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SOME LIMITATIONS OF PSYCHIATRY
881
conjoined ureters face the small opening in the bowel mucosa. Two or three fine silk sutures fix the ureteric loop in position. The seromuscular edges at each end of the gutter are now picked up and held in apposition by two Babcock’s forceps. A little tension on these forceps facilitates the closure of the seromuseular incision and the burying of the ureteric loop by two continuous sutures of fine silk. About 2 in. of the ureteric loop is buried. The incision in the posterior peritoneum is closed so that the anastomosis is almost extraperitoneal, and the wound is closed with a fine drainage tube down to the ureterocolostomy. The advantages of this technique over the Coffey and similar techniques may be summarised as follows. There is
only
one
site to
plan
on
the colon for the
proposed
anastomosis, whereas with a short sigmoid the placing of two may be awkward. Moreover, the optimum site can be quickly judged from the position of the junction of the two ureters when the loop is made to lie parallel with the adjacent segment of sigmoid. There is only one opening made in the colon, and the technique does not involve the additional procedure of threading the ureter into its lumen. These points contribute to a more simple operation and a much shorter operating-time. The loop transplantation also gives an excellent functional result with immediate drainage. It is noticeable that sometimes drainage is delayed in the Coffey 11 transplantation, presumably because of some slight temporary obstruction. I have always held that ascending infection is more likely if the ureter is drawn into the lumen’of the bowel. A small hole in the mucosa at least simulates a ureteric orifice, and would seem to be more likely to prevent intimate contact with the faecal contents even if an actual valvular effect cannot be attained. Coffey probably had this in mind when he devised his no. in technique. Also it is possible that the combined efflux of urine at the one orifice may be a further safeguard against infection. D. LANG STEVENSON. Chigwell, Essex.
that these people will often remain surprisingly free from the relapses which are sometimes too freely ascribed to them. In spite of my- disagreements, I should like to congratulate Dr. Haldane on his courageous challenge to physicians and surgeons. We must ask ourselves what exactly we want from the psychiatrists to whom we refer patients, and-perhaps more importanthow we expect these patients to benefit from such reference. The time has indeed come when psychiatrists should protest against the tendency to use their departments as therapeutic dustbins. Ashford Hospital, A. BARHAM CARTER. ,
Ashford, Middlesex.
FAMILIAL
GLOMERULONEPHRITIS
SIR,—Ishared Viscount Addison’s beliefthat it cost five guineas to register. I tried it last week ; I received five shillina-s change. King’s College Hospital, DAVID ADDERLEY.
SIR,—The recurrence of glomerulonephritis in several members of a family must arouse suspicions of the presence either of some inherited intrinsic renal weakness or alternatively of a common extrinsic factor. Certainly the presence of the condition in successive generations, together with other undoubted congenital abnormalities, as described by Dr. Hawkins last week, leaves little doubt about the hereditary origin of some cases. However, instances do occur from time to time in which the presence of a common infecting organism would appear to be the most important factor in aetiology. In May, 1946, I had under my care at St. Georgein-the-East Hospital 3 members of a family of 8. These 3, who belonged to the same generation, were suffering from acute diffuse glomerulonephritis, Ellis type i. The family, consisting of mother, father, 4 children, and 2 grandchildren, all living together, had shortly before coming under observation been treated at a nearby municipal clinic for suspected scabies. When seen by me, 2 of the affected members of the family and the 2 grandchildren had typical impetiginous skin lesions from which haemolytic streptococci were grown. The same organism was obtained from the throat of the 3rd affected member. No congenital abnormalities were present in any of the family, nor was there any history of allergic illnesses. R. TEPPER. West Middlesex Hospital, Isleworth.
SOME LIMITATIONS OF PSYCHIATRY
THE MENTALLY HANDICAPPED CHILD
SIR,—I enjoyed reading Dr. Haldane’s thoughtful article in your last issue. Whether psychiatrists will agree with him or not, the physician who interests himself in neuropsychiatric illness will appreciate only too well what Dr. Haldane means when he says that the psychoneurosis is only one manifestation-one outward expression-of the patient’s personality. Where, however, I differ from Dr. Haldane is in his conclusion, as I understand it, that superficial therapy -what he calls a " psychiatric placebo "-is not really worth while, because it is not likely to effect any very fundamental change in a psychoneurotic patient. His conclusion that " the symptoms of a psychoneurosis are themselves of minor import relative to the underlying disorder " has not engendered in me the feelings of therapeutic impotence that make him end his paper with the words " we must also be still more realistic and realise that at present, apart from a little palliation, many- cannot be treated at all." On the contrary, this conclusion has stimulated me in the past to concentrate more than ever on attempting to relieve the symptoms of, for example, an hysteric, rather than on trying to .change the rigid attitude of mind which I have no doubt he possesses. Often all that is needed for the patient to return to a useful job of work is relief from his symptoms, and I am convinced
SIR,—I have read with great interest the article of another mother on this theme. When my boy was born he had the cord tight around his neck. He was asphyxiated; and it took 15 minutes to revive him and make him cry. When he " did not do the things which a normal baby did at his age I knew that he had suffered a brain injury. At 2 years the boy learned to -walk and to talk, and at
COST OF MEDICAL REGISTRATION
London, S.E.5.
-
3 years had a good vocabulary and liked to make conversation, but was completely unable to use his hands for any purposeful activity, and showed no interest in playing or in doing anything for himself. At 5 he learnt to feed himself with a spoon and also started to dress himself, but it took 3 more years before he could be induced to try buttoning-up things. His disability became more obvious as time went on, whereas his speech, apart from a certain abruptness, developed quite normally. He was 9 when he came to England, and quickly learned to speak English without forgetting his German. He also learned, in a few months, to read English ; but he was never able to write, or to draw even a simple geometrical figure, and he remained unable to imitate movements or to do anything with his hands, no matter how often one showed it to him. Apart from a few simple movements, which he learned by having his hand guided over and over again, he was almost helpless. But he was not paralysed, and his arms and hands were well formed and well developed. Besides his physical disability he showed strange menta limitations. He could not solve a simple form-board test, and was unable to build with bricks or to accomplish even the most simple constructional task. Labelled as doubly "
1. See
Lancet, April 29,
p. 825.
conjoined ureters face the small opening in the bowel mucosa. Two or three fine silk sutures fix the ureteric loop in position. The seromuscular edges at each end of the gutter are now picked up and held in apposition by two Babcock’s forceps. A little tension on these forceps facilitates the closure of the seromuseular incision and the burying of the ureteric loop by two continuous sutures of fine silk. About 2 in. of the ureteric loop is buried. The incision in the posterior peritoneum is closed so that the anastomosis is almost extraperitoneal, and the wound is closed with a fine drainage tube down to the ureterocolostomy. The advantages of this technique over the Coffey and similar techniques may be summarised as follows. There is
only
one
site to
plan
on
the colon for the
proposed
anastomosis, whereas with a short sigmoid the placing of two may be awkward. Moreover, the optimum site can be quickly judged from the position of the junction of the two ureters when the loop is made to lie parallel with the adjacent segment of sigmoid. There is only one opening made in the colon, and the technique does not involve the additional procedure of threading the ureter into its lumen. These points contribute to a more simple operation and a much shorter operating-time. The loop transplantation also gives an excellent functional result with immediate drainage. It is noticeable that sometimes drainage is delayed in the Coffey 11 transplantation, presumably because of some slight temporary obstruction. I have always held that ascending infection is more likely if the ureter is drawn into the lumen’of the bowel. A small hole in the mucosa at least simulates a ureteric orifice, and would seem to be more likely to prevent intimate contact with the faecal contents even if an actual valvular effect cannot be attained. Coffey probably had this in mind when he devised his no. in technique. Also it is possible that the combined efflux of urine at the one orifice may be a further safeguard against infection. D. LANG STEVENSON. Chigwell, Essex.
that these people will often remain surprisingly free from the relapses which are sometimes too freely ascribed to them. In spite of my- disagreements, I should like to congratulate Dr. Haldane on his courageous challenge to physicians and surgeons. We must ask ourselves what exactly we want from the psychiatrists to whom we refer patients, and-perhaps more importanthow we expect these patients to benefit from such reference. The time has indeed come when psychiatrists should protest against the tendency to use their departments as therapeutic dustbins. Ashford Hospital, A. BARHAM CARTER. ,
Ashford, Middlesex.
FAMILIAL
GLOMERULONEPHRITIS
SIR,—Ishared Viscount Addison’s beliefthat it cost five guineas to register. I tried it last week ; I received five shillina-s change. King’s College Hospital, DAVID ADDERLEY.
SIR,—The recurrence of glomerulonephritis in several members of a family must arouse suspicions of the presence either of some inherited intrinsic renal weakness or alternatively of a common extrinsic factor. Certainly the presence of the condition in successive generations, together with other undoubted congenital abnormalities, as described by Dr. Hawkins last week, leaves little doubt about the hereditary origin of some cases. However, instances do occur from time to time in which the presence of a common infecting organism would appear to be the most important factor in aetiology. In May, 1946, I had under my care at St. Georgein-the-East Hospital 3 members of a family of 8. These 3, who belonged to the same generation, were suffering from acute diffuse glomerulonephritis, Ellis type i. The family, consisting of mother, father, 4 children, and 2 grandchildren, all living together, had shortly before coming under observation been treated at a nearby municipal clinic for suspected scabies. When seen by me, 2 of the affected members of the family and the 2 grandchildren had typical impetiginous skin lesions from which haemolytic streptococci were grown. The same organism was obtained from the throat of the 3rd affected member. No congenital abnormalities were present in any of the family, nor was there any history of allergic illnesses. R. TEPPER. West Middlesex Hospital, Isleworth.
SOME LIMITATIONS OF PSYCHIATRY
THE MENTALLY HANDICAPPED CHILD
SIR,—I enjoyed reading Dr. Haldane’s thoughtful article in your last issue. Whether psychiatrists will agree with him or not, the physician who interests himself in neuropsychiatric illness will appreciate only too well what Dr. Haldane means when he says that the psychoneurosis is only one manifestation-one outward expression-of the patient’s personality. Where, however, I differ from Dr. Haldane is in his conclusion, as I understand it, that superficial therapy -what he calls a " psychiatric placebo "-is not really worth while, because it is not likely to effect any very fundamental change in a psychoneurotic patient. His conclusion that " the symptoms of a psychoneurosis are themselves of minor import relative to the underlying disorder " has not engendered in me the feelings of therapeutic impotence that make him end his paper with the words " we must also be still more realistic and realise that at present, apart from a little palliation, many- cannot be treated at all." On the contrary, this conclusion has stimulated me in the past to concentrate more than ever on attempting to relieve the symptoms of, for example, an hysteric, rather than on trying to .change the rigid attitude of mind which I have no doubt he possesses. Often all that is needed for the patient to return to a useful job of work is relief from his symptoms, and I am convinced
SIR,—I have read with great interest the article of another mother on this theme. When my boy was born he had the cord tight around his neck. He was asphyxiated; and it took 15 minutes to revive him and make him cry. When he " did not do the things which a normal baby did at his age I knew that he had suffered a brain injury. At 2 years the boy learned to -walk and to talk, and at
COST OF MEDICAL REGISTRATION
London, S.E.5.
-
3 years had a good vocabulary and liked to make conversation, but was completely unable to use his hands for any purposeful activity, and showed no interest in playing or in doing anything for himself. At 5 he learnt to feed himself with a spoon and also started to dress himself, but it took 3 more years before he could be induced to try buttoning-up things. His disability became more obvious as time went on, whereas his speech, apart from a certain abruptness, developed quite normally. He was 9 when he came to England, and quickly learned to speak English without forgetting his German. He also learned, in a few months, to read English ; but he was never able to write, or to draw even a simple geometrical figure, and he remained unable to imitate movements or to do anything with his hands, no matter how often one showed it to him. Apart from a few simple movements, which he learned by having his hand guided over and over again, he was almost helpless. But he was not paralysed, and his arms and hands were well formed and well developed. Besides his physical disability he showed strange menta limitations. He could not solve a simple form-board test, and was unable to build with bricks or to accomplish even the most simple constructional task. Labelled as doubly "
1. See
Lancet, April 29,
p. 825.