THE NEUROLOGICAL APPROACH TO MENTAL DISORDER

430 of the

system the samples were taken, but these twelve analyses suggest that the water is poor and subject to frequent high pollutions. Chester is a small town of only 4142 acres and 44,280 inhabitants, or nearly 11 persons Its birth-rate in 1939 was 15-6 ; death-rate 13-8 ; infantile mortality 77-3 and maternal mortality 5-4. There were 37 deaths from all tuberculosis, giving a mortality-rate of 0-84 based on the population of 45,090the number given by the Registrar General for estimating death-rates. This is not a good health record for 1939. The endemic infectious diseases were not particularly troublesome in the year, the only one calling for comment was diphtheria with 135 notifications and 10 deaths.

per

acre.

Letters

to

the Editor

HOSPITALS RADON CENTRE SiR.-As the result of a generous gift from the British War Relief Society of New York further supplies of radon are now assured. The gift was made to the British Hospitals Association, who have asked the Middlesex. Hospital to administer it. This new supply is intended for the use of hospitals throughout the country and no distinction will be made between requisitions for paying and non-paying patients. It is hoped to increase the amount of radium in solution at this new centre when the demand warrants it. In the first instance it will be necessary to charge all hospitals for supplies of radon, and it has been decided to charge for it at the lowest basic rates obtaining at the Medical Research Council radon centre-namely. one shilling a millicurie-with a reduction to sixpence a millicurie for any quantity in excess of fifty millicuries ; the minimum charge for any radon requisition will be one guinea. It is hoped that in the near future some arrangement will be possible whereby the burden of such payments may be lightened. Applications for radon may now be sent to the Hospitals Radon Centre, c/o Barton Lime Co., Bartonin-the-Clay, Beds (telephone Hexton 210). SIDNEY RUSS. Middlesex Hospital, W.1. ’

EXETER

Exeter is another small ciy, but its population of 70,000 being more than half as large again as that of Chester gives it a density of nearly 17 to the acre. Most of our older cities, though not seriously overcrowded, are cramped, retaining some of the pattern of the fortified

walled cities of medieval times. Modern conditions would be served better if we cleared the centres of our cities antl dispersed the population in the peripheries. At present the enemy is doing the former for us, though hardly with discrimination ; but whether we shall seize the opportunity to do our own part remains to be seen. Of the 212 persons on the blind register of Exeter at the end of 1939 all but one were over 50 years of age. Owing to the Blind Persons Act, we have nearly complete records of the prevalence of blindness, and these show strikingly how prevention has reduced this calamity. It is unfortunate that we have no such information of the deaf and do not know whether we have reduced deafness by preventive measures. Dr. G. B. Page’s report indicates the extent to which tuberculosis is found in animals slaughtered for human consumption, not because the findings are exceptional at Exeter, but because they In carcases of cattle other than cows, 4-5% are average. show evidence of tuberculosis. Cows show definite lesions to the extent of 11-8%, and pigs 1-7%. In calves tuberculosis is rare and in ovines a curiositv. Of 34 tons 13 cwt. of all foods condemned, 19 tons 5 cwt. owed their condemnation to tuberculosis. Infectious Disease in

England and Wales

WEEK ENDED MARCH

15

JVot/tcoM.—The following cases of infectious disease were notified during the week : smallpox, 0 ; scarlet fever, 1221 ; whooping-cough, 3338 ; diphtheria, 1033 ; enteric fever, 28 ; measles (excluding rubella), 15,056 ; pneumonia (primary or influenzal), 1318 ; puerperal pyrexia, 141 ; cerebrospinal fever, 330 ; poliomyelitis, 5 ; polio-encephalitis, 2 ; encephalitis lethargica, 7 ; dysentery, 146 ; ophthalmia neonatorum, 77. No case of cholera, plague or typhus fever was notified during the week.

The number of civilian and service sick in the Infectious Hospitals of the London County Council on March 14 was 1837, including : scarlet fever, 230 ; diphtheria, 338 ; measles, 451 ; whooping-cough,

253 ; enteritis, 20 ; chicken-pox, 121 ; erysipelas, 38 ; mumps, 3 ; poliomyelitis, 2 ; dysentery, 26 ; cerebrospinal fever, 85 ; puerperal .’epsis, 14 ; enteric fev ers, 4 ; german measles, 9 ; other diseases mon-infectious), 135 ; not yet diagnosed, 107. Deaths.-In 126 great towns there was no death from smallpox, enteric fever or scarlet fever, 38 (2) from whooping-cough, 25 (1) from measles, 31 (0) from diphtheria, 36 (4) from diarrhoea and enteritis under 2 years, and 132 (15) from influenza. The figures in parentheses are those for London itself. There were 7 deaths from whooping-cough at Birmingham and 6 at Liverpool, and in the same week at Glasgow there were 15. Liverpool reported 5 fatal cases of diphtheria. Bradford had 9 deaths from influenza, Birmingham 6, no other great town more than 4.

The number of stillbirths notified during the week was 230 (corresponding to a rate of 42 per thousand total births), including 16 in London. INCIDENCE OF INFLUENZA

In the week ended March 15, 132 deaths were ascribed to influenza in the great towns, 67 fewer than in the previous week. Of these deaths 6-8% were at ages under 25 and 54’54% at ages over 65. In the county of London 15 deaths were registered (13 in the previous week). The proportion of total deaths coming from the South-Eastern Area was 28-36%. It would appear that the winter epidemic is now over.

NEUROLOGICAL APPROACH TO MENTAL DISORDER SiB,—In your issue of March 15 Group Captain Symonds puts forward a brilliant contribution to the understanding of mental disorder. The more’s the pity it is vitiated by its unadmitted philosophic bias. Distinguished members of our profession seem peculiarly apt to be unaware that any attitude,’ however well supported by observed facts, rests inevitably upon a philosophic basis ; and their unawareness leads to much debate, marked equally by erudition and irrelevance. Neuro-psychiatry 1.:ersus medical psychology, as rival approaches to mental disorder. is one of the most fascinating-and profound-of these philosophic cleavages. The mock-modest pretension of the scientist to have no time for philosophy does not absolve him from philosophic bias, but merely reveals his bias to be unconscious-or, as Group Captain Symonds may prefer to put it, forgotten. This avoidable occurrence is, in fact, responsible for most of the needless arguments between intelligent THE

men.

What is here suggested is that Group Captain Symonds is right, demonstrably and irrefutably right, in his conclusions. His world picture, in which his views on mental disorder have their inevitable setting, is consistent and " makes sense." From his neuro-psychiatric as he says fellows he should receive a magnificent endorsement of his opinions. In the intelligent world as a whole, however, the unanimity might be less marked, possibly by some fifty per cent. It is here suggested that the dissident half is not composed of merely ignorant and contumacious persons, but of persons whose world picture, in which their views on mental disorder have their inevitable setting, is equally consistent, and makes equal though very different sense. It is finally suggested that man is not adequately expressed in either world picture alone. The form-makers and the form-breakers-Abel and his brother Cain, the Aristotelians and the Platonists, the Apollonians and the Dionysians-these are the eternal prototypes through whose labours the world first moulds itself in lovely forms, then breaks through, painfully and often cruelly, to fresh beauty. Always it was, and it will always be, the tragedy of the form-making mind, striving to bring its well-loved order out of chaos, to see suddenly breaking from some unlooked-for covert Priapus with his imprudent gestures, Pan with his insulting pipes. We are still bound by these prototypal limitations, and till the spanning mind comes forward no honest truce is possible. What is, however, possible is for each to work in good-humoured self-awareness and equal rivalry. The kind offer of cooperation on the basis that" there is no justification whatever for psychotherapy as a special branch of medicine," and with insistence on an increased relative importance for neurology

431 in the psychological diploma is oddly reminiscent of a dictator’s idea of cooperation with a small state, or a boa constrictor’s hope of cooperation with a lamb. In all three cases there is the same engaging naivete.

Group Captain Symonds is ungenerously in error in accusing the psychotherapist of trying to elbow his way unnecessarily into the sphere of mental disorder. The psychotherapist, though not always himself aware of it, is in this sphere the authentic voice of that other half of man, which, though it may be driven into the wilderness of medical disrepute, will not and cannot be completely silenced. ALAN MCGLASHAN.

SaR,-3mong various circles of psychiatrists Dr.

address must have had the effect Were it not for the fact that acute controversy on general subjects is now the height of bad form, we might expect bitter protests from those students of the mind who prefer to ignorethe activities of its cerebral basis. As it is, Dr. Symonds’s materialist bomb will no doubt be treated as an unfortunate brick unworthy of notice. Nevertheless the address marks the beginning of the end of " pure " psychiatry, particularly of that section which treats psycho-analysis as the core of all wisdom. Pigeon-hole methods of classifying mental conditions likewise receive notice to quit in an address which forsakes " fixed clinical syndromes " for those manifold and mutable abnormal reactions that express a disordered mind. In the subject of mental disorder, brain activity and its abnormal disturbances are now being studied from that materialist point of view which recognises the brain to be the physical basis of mind. From this point of view, every case of mental disorder is part of a dynamic " eternal triangle " consisting of the brain and body as a whole, of the mind which is dependent on the brain, and of that external environment which the mind reflects and reacts to through the activities of the The treatment of mental disorder will nervous system. therefore embrace not only a consideration of the relationship between the mind and the external environment, but also of the various cerebral activities which relate the individual to the environment. It is an axiom that all mental disorder must be based on some corresponding cerebral disorder, and clinical science now begins to utilise in practice this principle of modern materialism. At the same time clinicians will not fall into the old error of regarding the external environment as unalterable and " normal," whatever its character, to which the patient must necessarily adapt himself like a prisoner in a cell. War, hunger and social disorganisation give an external ehvironment to which a great many individuals are unable or unwilling to adapt themselves indefinitely, and if clinicians have only " adaptation " to urge upon patients about to leave the mental hospitals the sheep if not the goats among them will surely bolt back to the security of padded cells. But in all seriousness, the sociological side of the question cannot be neglected, and the baredoctrine of adaptation to the environment whatever its character is one which has nothing in common with a scientific outlook on society. Only a devotee of the blitzkrieg can present today’s environment as a state of affairs to which men and women must merely adapt themselves indefinitely. Between the abnormalities of psychotics and the " normalities " of modern society there is a closer connexion than one might gather from most textbooks of psychiatry-a connexion not to be disposed of by the simplicities of convulsion therapy.. R. L. WORRALL.

Symonds’s presidential of a landmine.

ANDROGENS

IN

GYNÆCOLOGY

SiB,—Your leading article of March 15 (p. 351) remarks on the masculinising activity of testosterone and its propionate when given for various gynaecological disorders. This unwanted action will undoubtedly dissuade many practitioners from availing themselves of an otherwise apparently harmless and effective therapeutic procedure. In three of the four complaints mentioned (functional uterine haemorrhage, dysmenorrhcea and chronic mastitis) the action of testosterone seems to depend on the direct antagonism which it possesses to endogenous oestrogens. It has been shown (Emmens, C. W. and Bradshaw, T. E. T. J. Endocrinol. 1939, 1, 378)

that androstenedione and androstanediol are as potent testosterone in inhibiting the response of spayed mice to oestrone, yet possess only a fraction of its androgenic activity in mammals ( and respectively). It might. accordingly, be worth while to give these compounds a clinical trial in such disorders, in the hope that they would be as efficient as testosterone in the desired direction, without the same tendency to produce masculinisation in effective doses. The inhibitory effect of testosterone on lactation may be due to an indirect action on the pituitary body, and there is no evidence that the other androgens mentioned would be as effective. It might nevertheless be again worth while to put to direct test, by clinical trial, the question whether one of the other androgens would not produce the desired effect, without the undesired concomitant actions of testosterone. C. W. EMMENS. National Institute for Medical Research, N.W.3. as

THE RIVER EMERGENCY SERVICE the M.O. of an ambulance ship in the River Service I had recently been anxiously waiting for a relief M.O. to take on my duties, so that I could have seven days’ leave still due to me from last year (we are magnanimously given two weeks in the year). At last he arrived and I was all set to get away, as I thought. We introduced ourselves. He has named me McCork in your journal (March 15, p. 359), so I shall return the compliment and call him Bull, but of the Ferdinand instead of the John family. He looked over the ambulance ship and wasn’t impressed, as there was no private cabin for the M.O. He saw some V.A.D. nurses doing Thomas splint drill and, informing me that he hadn’t seen a Thomas for twenty years, didn’t believe in it and always used a Liston, he said he didn’t think much of their efforts. Having remained on board for fifteen minutes we went up to our billets. He was very upset at the apparent lack of comforts and conveniences, and said, " This is a dreadful place. Your P.M.O. told me it was comfortable. I must telephone him immediately. I’ll just stay two days until you get away, and then clear out." When I told him that I would not leave knowing that he wasn’t going to stay until I returned, he said, " Well, I’ll go straight away," and departed bag and baggage, having been with us exactly half an hour. It was with mixed feelings that I watched him jump. on a bus ; I felt depressed as I saw my week’s visit to my family vanishing into the future, but glad that I wasn’t leaving the sisters. V.A.D.’s and stretcher-bearers (the ambulance officer who is an Ulsterman is able to take care of himself)whom I have come to regard with some affection, having seen them stand up to five months of the blitz in this dreary dockland-to his mercies. Perhaps it was as well that he left the docks and the uncomfortable billets to the " Neutral " and went back to sniff his crocuses and tomasinianus. McCORK.

. SiR,-As Emergency

SiB,—Now that one of your peripatetic correspondents has concluded his extremely brief experiment with time and with the Thames and has fled back to his garden, perhaps you will allow one of the medical officers who has been with the River Emergency Service for many months to reply to some of his strictures. The giving of lectures, which are more like the chats one used to give to one’s clinical clerks or surgical and the practices, are real and of value. The dressers, " comfortable billets " are real no longer, for they have mostly been bombed out of existence. Had our critic been with us during the early autumn I doubt if he would have written so lightly of a " blitz on the river." Trying to rescue people from burning wharves, getting a small peace-time pleasure steamer alongside flaming barges whilst avoiding those that had broken -adrift (reminding one of heroes on their way to Valhalla), and trying in the heat and the smoke and the flame to stop pain and stay haemorrhage has perhaps little in common with the Crocus tornasinianus even in its folded-up umbrella stage. When incendiaries rained on a certain dockyard and the sequela of H.E. was punctually noted, my sisters and nursing auxiliaries in their " natty uniforms " (what ought they to wear-crinolines or gardening aprons P) put out dozens of burning bombs and by so doing saved