- Email: [email protected]
VARIATIONS ON A NEUROSOPHICAL THEME
597
(i.e., in conditions such as asthma, diffuse lupus erythematosus, periarteritis nodosa, and similar conditions,
into the renal effect on the
where most other forms of treatment fail or are disappointing and the outcome may be serious) should not, it is reasonable to suggest, be confused with the use of these substances in mild disorders with the object merely of improving symptoms or dispelling a rather disfiguring rash. The apophthegm of Francis Bacon seems singularly inappropriate here: " He that will not apply new remedies must expect new evils ; for time is the greatest innovator." FRANK MARSH.
smaller branches of the aorta but with no ill effects, and in view of Gtyliss and Laws’s work,l we are inclined to believe that aortic dissection is probably responsible for many of the complications so frequently labelled " chemotoxic." ERIC SAMUEL MICHAEL DENNY
artery is likely to have a lesser chemotoxio kidney than an injection of a higher percentage strength of contrast medium into the aorta. We have, as Dr. Gregg suggests, on occasions filled
VARIATIONS ON A NEUROSOPHICAL THEME SiR,ŇIn your leading article of Sept. 7 you comment
THE WOLFENDEN REPORT SIR,-The letter from Dr. Learoyd (Sept. 14) may well prove to be the opening round of an extensive correspondence on the Wolfenden report. May we take this opportunity of appealing to those members of the profession who intend to enter the debate to make it clear in what capacity they express their views ? In this respect Dr. Learoyd is honest. He states that he is a general practitioner ; is it in this capacity that he makes the rather wild generalisation that psychiatrists are unfit to deal with practical affairs ?If Dr. Learoyd has extensive knowledge of psychiatrists in general and those in particular who gave evidence to the committee, let him say so. If he has extensive knowledge of homosexuality, again let him say so. If, on the other hand, his views are the expression of outraged emotions let us know that too, so that we may judge just how valid his opinions are likely to be. Such phrases as the coal face of psychiatry " (whatever that may mean) ill become the columns of a scientific journal. It is not the purpose of this letter to point out all the fallacies in Dr. Learoyd’s communication. Ile states that the committee seems to have the haziest idea of the natural history of homosexuality." ; it is clear from what Dr. Learoyd goes on to write that he has even less. On what grounds, for instance, does he state that there is little animosity against necrophilia and bestiality because these practices are not likely to appeal to many, and that the habit of homosexuality is likely to spread? Are these views based on personal work on the subject of "
"
"
homosexuality ? We are psychiatrists engaged in the treatment of convicted homosexuals. Whilst we do not pretend that (despite our training) we are completely free of prejudice or unconscious bias in relation to this emotionally charged topic, we can at least honestly say that we have some experience of the subject. May we express- the hope that others who intend to state their views will consider soberly on what experience their opinions are based ? LEOPOLD H. FIELD R. CEDRIC SIMPSON. RENAL FAILURE FOLLOWING AORTOGRAPHY
SiR,-Dr. Gregg, in his letter of July 27, mentions some interesting aspects of renal aortography. Whilst r ot denying that the contrast obtained by accurate placement of the catheter tip in the renal artery is superior to that obtained by other methods, this method suffers from its failure to demonstrate aberrant renal vessels and as a primary arterial investigation it is inadvisable. In the investigation of the renal aspects of hypertension, no angiogram can be regarded as complete until the whole pattern of both renal vessels is demonstrated. With further reference to the placement of the catheter tip, it has been our practice to place the catheter above the origin of the renal vessels, since we have found that by placing the catheter below, retrograde filling occasionfails to occur in patients with a rapid circulation. Furthermore, we are not entirely convinced that a small quantity of contrast medium introduced directly
ally
upon Dr. Gooddy’s comparison between the circulation of the nerve impulse and the circulation of the blood. Whatever the scientific evidence in favour of his thesis, you clearly regard it with abhorrence because it smacks of physical determinism, which, in your own words, " is an implicit rejection of the notion of free-will." I venture to think that the reason for your aversion from determinism is notjustified by logical analysis. Perhaps your aversion is aggravated by the use, when referring to the course of a nerve impulse, of the word circle which suggests the rigid repetition of the geometrical figure. Dr. Gooddy doubtless used this word to facilitate comparison with Harvey’s concept of the movement of the blood, but if we substitute circuit we retain the property of regular succession and necessary connection implied by circle without accepting its unvarying repetition. This substitution does not affect Dr. Gooddy’s meaning as far as my argument goes, because the properties of endlessness and dependence are still present, but it is easier to envisage the complex interconnection of ten thousand million nerve-cells as a circuit instead of a circle or even a circulation. Now in Dr. Gooddy’s view the neuronal circuit would be closed " (to use the terminology of the physicists) because no external control is incorporated. Each event is succeeded by another event in infinite sequence. At this point you raise your hands in horror and say " But this is determinism-how can a man be responsible for his actions if each action is the result of an infinite chain of inevitable events" Determinism it is, Sir, but his actions are entirely his own. The only exclusive alternative (and, therefore, the one which you would favour) to Dr. Gooddy’s hypothesis is a nervous-system in which the circuit is not endless and dependent, because some external factor is able to control the sequential passage of the nerve impulse. By external factor I do not mean the external world of which we are aware through our sensory nerve-endings because (to take an extreme example) to torture a person until he confesses to a crime he did not commit negates his freewill however his nervous system functions. I refer to an extrasensory factor of which we are unaware and which can only operate if the circuit is discontinuous. Whether this factor is chance (the random selection of nerve impulses from a store, for instance) or an omnipotent, omnipresent deity does not affect the conclusion that because of it a person’s actions are not wholly his own, and his responsibility for them is correspondingly decreased. The influence of blind chance upon cerebral processes is also exemplified by an epileptic discharge, and it is precisely under such circumstances as epileptic automatism that a patient is held not to be responsible for his actions. No, Sir, it seems to me that determinism is not only compatible with free-will, but is necessary for it. Freedom of choice is an everyday experience, and, even though the choice is an event in the passage of a nerve impulse through an endless circuit, it is none the less our own. In
’
1.
Gayliss, H., Laws, J. W.
Brit. med. J. 1956, ii, 1141.
598
theory our choice might be predictable by a superintellect which could determine the pathways of our nerve impulses and interpret their significance without affecting their course, or (to express the same thing in another way) which could predict our decision by discovering all the factors, conscious and unconscious, which had influenced us, without
our
being
of the
investigation. impossible, but if we
aware
event we believe to be that it could be achieved it is clear that such suppose theoretical predictability does not reduce our moral responsibility in making a decision any more than my feeling, from my knowledge of him, that a man is going to cheat at cards excuses him when, in fact, he does cheat. In conclusion it may be stated that if the activity of the brain is composed of nerve impulses in endless and dependent circuit, then the mind that is that brain is able to reach its decision by a process of logical thought in which, because it is not subject to external control, we recognise free-will. The philosophical implications of determinism are not to be feared. J. HOWELL EVANS.
Such
an
TRANSMISSION OF YAWS afraid that Dr. Cicely Williams’s answer SIR, -I to my question about the geographical range of (Sept. 7) does not really answer it. Most of the conditions yaws which, she says, encourage the spread of yaws occur (or have occurred within living memory) in co. Kerry and Tierra del Fuego. I wonder if Trepoibema pertenue is near enough to a free-living parasite to demand a minimum atmospheric temperature for successful transmission. Treatment is so damnably efficient that we shall nrobablv never know. " HARRY HAWKE." am
UNUSUAL URINE PROTEIN IN MYELOMATOSIS
SiR,-The two electrophoretic patterns shown in the accompanying figure are those of the serum and urine of a patient with multiple myelomatosis. The serum-protein pattern is typical of this condition, but that of the urine protein, with the three bands in the yglobulin region, is unique in my experience. Identical patterns were obtained from urine specimens collected at intervals spread over ten days. The urine contained an average of 1-5 g. protein per iitre, and was concentrated by dialysis against a gum-
The
electrophoretic patterns of serum (a) and case of multiple myeloma.
urine
(b) proteins in
a
acacia solution. Electrophoresis was carried out in a barbitone buffer, pH 8-6, at 100 volts for 15 hours. In the examination of some 40 cases of myelomatosis I have never encountered a Bence Jones protein which gave other than a single band upon electrophoresis under the above conditions, neither have I seen any report of more than one band being obtained, except at an acid pH. I shall be interested to hear of any similar results which may have been obtained in other laboratories. Llandough Hospital, Penarth, Glam.
A. J. CUMMINGS.
MATRIARCHY
SiR,-Your correspondent has made some penetratinr observations on the nurse-patient relationship in his Personal Paper (Aug. 24). What would he have concluded had his ward been staffed in part by male nurses!ItIt is notorious that these individuals tend to display amusement, if not impatience, at the
"
I
I
I
of authority’ female of their certain colleagues. It is ? generated by are often efficient ! same men that these notorious equally nurses, with a talent for gaining hospital prizes and the 1 ! respect of their patients. the this to resentment explain helps Perhaps may women feel on encountering this male invasion of "their" (What happened when women invade profession. Medicine ’?) They have tried to make a corner," ’ and establish matriarchal authority over both sexes but the tide is bound to as the essence of nursing ; run against them as the individual nurse becomes increasingly a specialist in inter-personal relation. the recent emphasis on psychology for ships." (Observe aura
"
"
general nurses.) Your correspondent has aptly stated the paradox’; of a job that seems to attract by virtue of its dis. j advantages. He might care to be reminded that this attraction can persist, for women as well as men, even where the matriarchal subsociety is cracking. I must confess to prejudice in this matter, and sign myself ’
"
"
MALE S.RX THE LIVER IN HÆMOCHROMATOSIS
SIR,—In their letter of July 20, Professor Gillman and his associates state that " the findings of Higginson et al. in their 1957 studies seem, to contradict those of their 1953 report and, moreover, are apparently not in con. formity with the reports of other workers in the Union, all of whom seem to agree that portal cirrhosis associated with severe siderosis is the most common variety of cirrhosis encountered among Africans in the Union." As one of the other workers whose name has been quoted in this letter, I should like to reply briefly to some of the points mentioned in his letter : (1) The concept of what constitutes a cirrhosis of liver in contradistinction to hepatic fibrosis has undergone a radical change since Strachan,1 Becker,2 Gillman and Gillman, 3-5 or Higginson published their surveys. I classified casesas " early cirrhosis in 1944, which I would now regardas simple portal fibrosis. The criteria for a true cirrhosis have been clarified and so to a certain extent have the possible pathogenetic pathways. At any rate, in my necropsy liver material from both Europeans and Africans on the Witwaters. rand (and basing one’s classification on the morphological criteria proposed by Himsworthand Goldblatt 8) the corrr nzorzest variety of cirrhosis encountered amongst both Europeans and Africans in this part of South Africa, is post-necrotic This type of cirrhosis is quite unrelated to the cirrhosis. presence or degree of siderosis. (2) I have recently had the privilege of a visit from Prof. Paul Steiner, who independently reviewed my material. With his permission, I quote from his report on the African cases: " The post-necrotic type comprised about two-fifths of all cases The Laennee type, which is probably related to the post-necrotic type, accounted for another two-fifths. A small proportion were classified as pigmentary. Many other cases had appreciable amounts of pigment but it did not appear to be related to the fibrous tissue. Most of the cases classified as pigmentary were of the monolobular type, and if the pig "
1. Strachan, A. S. M.D. thesis, Glasgow, 1929. 2. Becker, B. J. P. Leech, 1944, 15, 15. 3. Giliman, J., Gillman, T. Arch. Path. 1945, 40, 239. 4. Gillman, J., Gillman, T. Lancet, 1948, i, 169. 5. Gillman, J., Gillman., T. Perspectives in Human Malnutrition. New York, 1951. 6. Higginson, J., Gerritsen, T., Walker, A. R. P. Amer. J. Path. 1953, 29, 779. 7. Himsworth, H. P. Lectures on the Liver and Its Diseases. Oxford, 1947. 8. Goldblatt, H. Transactions of the 6th Conference on Liver Injury. Josiah Macy, jun., Foundation. New York, 1947. p. 9.
(i.e., in conditions such as asthma, diffuse lupus erythematosus, periarteritis nodosa, and similar conditions,
into the renal effect on the
where most other forms of treatment fail or are disappointing and the outcome may be serious) should not, it is reasonable to suggest, be confused with the use of these substances in mild disorders with the object merely of improving symptoms or dispelling a rather disfiguring rash. The apophthegm of Francis Bacon seems singularly inappropriate here: " He that will not apply new remedies must expect new evils ; for time is the greatest innovator." FRANK MARSH.
smaller branches of the aorta but with no ill effects, and in view of Gtyliss and Laws’s work,l we are inclined to believe that aortic dissection is probably responsible for many of the complications so frequently labelled " chemotoxic." ERIC SAMUEL MICHAEL DENNY
artery is likely to have a lesser chemotoxio kidney than an injection of a higher percentage strength of contrast medium into the aorta. We have, as Dr. Gregg suggests, on occasions filled
VARIATIONS ON A NEUROSOPHICAL THEME SiR,ŇIn your leading article of Sept. 7 you comment
THE WOLFENDEN REPORT SIR,-The letter from Dr. Learoyd (Sept. 14) may well prove to be the opening round of an extensive correspondence on the Wolfenden report. May we take this opportunity of appealing to those members of the profession who intend to enter the debate to make it clear in what capacity they express their views ? In this respect Dr. Learoyd is honest. He states that he is a general practitioner ; is it in this capacity that he makes the rather wild generalisation that psychiatrists are unfit to deal with practical affairs ?If Dr. Learoyd has extensive knowledge of psychiatrists in general and those in particular who gave evidence to the committee, let him say so. If he has extensive knowledge of homosexuality, again let him say so. If, on the other hand, his views are the expression of outraged emotions let us know that too, so that we may judge just how valid his opinions are likely to be. Such phrases as the coal face of psychiatry " (whatever that may mean) ill become the columns of a scientific journal. It is not the purpose of this letter to point out all the fallacies in Dr. Learoyd’s communication. Ile states that the committee seems to have the haziest idea of the natural history of homosexuality." ; it is clear from what Dr. Learoyd goes on to write that he has even less. On what grounds, for instance, does he state that there is little animosity against necrophilia and bestiality because these practices are not likely to appeal to many, and that the habit of homosexuality is likely to spread? Are these views based on personal work on the subject of "
"
"
homosexuality ? We are psychiatrists engaged in the treatment of convicted homosexuals. Whilst we do not pretend that (despite our training) we are completely free of prejudice or unconscious bias in relation to this emotionally charged topic, we can at least honestly say that we have some experience of the subject. May we express- the hope that others who intend to state their views will consider soberly on what experience their opinions are based ? LEOPOLD H. FIELD R. CEDRIC SIMPSON. RENAL FAILURE FOLLOWING AORTOGRAPHY
SiR,-Dr. Gregg, in his letter of July 27, mentions some interesting aspects of renal aortography. Whilst r ot denying that the contrast obtained by accurate placement of the catheter tip in the renal artery is superior to that obtained by other methods, this method suffers from its failure to demonstrate aberrant renal vessels and as a primary arterial investigation it is inadvisable. In the investigation of the renal aspects of hypertension, no angiogram can be regarded as complete until the whole pattern of both renal vessels is demonstrated. With further reference to the placement of the catheter tip, it has been our practice to place the catheter above the origin of the renal vessels, since we have found that by placing the catheter below, retrograde filling occasionfails to occur in patients with a rapid circulation. Furthermore, we are not entirely convinced that a small quantity of contrast medium introduced directly
ally
upon Dr. Gooddy’s comparison between the circulation of the nerve impulse and the circulation of the blood. Whatever the scientific evidence in favour of his thesis, you clearly regard it with abhorrence because it smacks of physical determinism, which, in your own words, " is an implicit rejection of the notion of free-will." I venture to think that the reason for your aversion from determinism is notjustified by logical analysis. Perhaps your aversion is aggravated by the use, when referring to the course of a nerve impulse, of the word circle which suggests the rigid repetition of the geometrical figure. Dr. Gooddy doubtless used this word to facilitate comparison with Harvey’s concept of the movement of the blood, but if we substitute circuit we retain the property of regular succession and necessary connection implied by circle without accepting its unvarying repetition. This substitution does not affect Dr. Gooddy’s meaning as far as my argument goes, because the properties of endlessness and dependence are still present, but it is easier to envisage the complex interconnection of ten thousand million nerve-cells as a circuit instead of a circle or even a circulation. Now in Dr. Gooddy’s view the neuronal circuit would be closed " (to use the terminology of the physicists) because no external control is incorporated. Each event is succeeded by another event in infinite sequence. At this point you raise your hands in horror and say " But this is determinism-how can a man be responsible for his actions if each action is the result of an infinite chain of inevitable events" Determinism it is, Sir, but his actions are entirely his own. The only exclusive alternative (and, therefore, the one which you would favour) to Dr. Gooddy’s hypothesis is a nervous-system in which the circuit is not endless and dependent, because some external factor is able to control the sequential passage of the nerve impulse. By external factor I do not mean the external world of which we are aware through our sensory nerve-endings because (to take an extreme example) to torture a person until he confesses to a crime he did not commit negates his freewill however his nervous system functions. I refer to an extrasensory factor of which we are unaware and which can only operate if the circuit is discontinuous. Whether this factor is chance (the random selection of nerve impulses from a store, for instance) or an omnipotent, omnipresent deity does not affect the conclusion that because of it a person’s actions are not wholly his own, and his responsibility for them is correspondingly decreased. The influence of blind chance upon cerebral processes is also exemplified by an epileptic discharge, and it is precisely under such circumstances as epileptic automatism that a patient is held not to be responsible for his actions. No, Sir, it seems to me that determinism is not only compatible with free-will, but is necessary for it. Freedom of choice is an everyday experience, and, even though the choice is an event in the passage of a nerve impulse through an endless circuit, it is none the less our own. In
’
1.
Gayliss, H., Laws, J. W.
Brit. med. J. 1956, ii, 1141.
598
theory our choice might be predictable by a superintellect which could determine the pathways of our nerve impulses and interpret their significance without affecting their course, or (to express the same thing in another way) which could predict our decision by discovering all the factors, conscious and unconscious, which had influenced us, without
our
being
of the
investigation. impossible, but if we
aware
event we believe to be that it could be achieved it is clear that such suppose theoretical predictability does not reduce our moral responsibility in making a decision any more than my feeling, from my knowledge of him, that a man is going to cheat at cards excuses him when, in fact, he does cheat. In conclusion it may be stated that if the activity of the brain is composed of nerve impulses in endless and dependent circuit, then the mind that is that brain is able to reach its decision by a process of logical thought in which, because it is not subject to external control, we recognise free-will. The philosophical implications of determinism are not to be feared. J. HOWELL EVANS.
Such
an
TRANSMISSION OF YAWS afraid that Dr. Cicely Williams’s answer SIR, -I to my question about the geographical range of (Sept. 7) does not really answer it. Most of the conditions yaws which, she says, encourage the spread of yaws occur (or have occurred within living memory) in co. Kerry and Tierra del Fuego. I wonder if Trepoibema pertenue is near enough to a free-living parasite to demand a minimum atmospheric temperature for successful transmission. Treatment is so damnably efficient that we shall nrobablv never know. " HARRY HAWKE." am
UNUSUAL URINE PROTEIN IN MYELOMATOSIS
SiR,-The two electrophoretic patterns shown in the accompanying figure are those of the serum and urine of a patient with multiple myelomatosis. The serum-protein pattern is typical of this condition, but that of the urine protein, with the three bands in the yglobulin region, is unique in my experience. Identical patterns were obtained from urine specimens collected at intervals spread over ten days. The urine contained an average of 1-5 g. protein per iitre, and was concentrated by dialysis against a gum-
The
electrophoretic patterns of serum (a) and case of multiple myeloma.
urine
(b) proteins in
a
acacia solution. Electrophoresis was carried out in a barbitone buffer, pH 8-6, at 100 volts for 15 hours. In the examination of some 40 cases of myelomatosis I have never encountered a Bence Jones protein which gave other than a single band upon electrophoresis under the above conditions, neither have I seen any report of more than one band being obtained, except at an acid pH. I shall be interested to hear of any similar results which may have been obtained in other laboratories. Llandough Hospital, Penarth, Glam.
A. J. CUMMINGS.
MATRIARCHY
SiR,-Your correspondent has made some penetratinr observations on the nurse-patient relationship in his Personal Paper (Aug. 24). What would he have concluded had his ward been staffed in part by male nurses!ItIt is notorious that these individuals tend to display amusement, if not impatience, at the
"
I
I
I
of authority’ female of their certain colleagues. It is ? generated by are often efficient ! same men that these notorious equally nurses, with a talent for gaining hospital prizes and the 1 ! respect of their patients. the this to resentment explain helps Perhaps may women feel on encountering this male invasion of "their" (What happened when women invade profession. Medicine ’?) They have tried to make a corner," ’ and establish matriarchal authority over both sexes but the tide is bound to as the essence of nursing ; run against them as the individual nurse becomes increasingly a specialist in inter-personal relation. the recent emphasis on psychology for ships." (Observe aura
"
"
general nurses.) Your correspondent has aptly stated the paradox’; of a job that seems to attract by virtue of its dis. j advantages. He might care to be reminded that this attraction can persist, for women as well as men, even where the matriarchal subsociety is cracking. I must confess to prejudice in this matter, and sign myself ’
"
"
MALE S.RX THE LIVER IN HÆMOCHROMATOSIS
SIR,—In their letter of July 20, Professor Gillman and his associates state that " the findings of Higginson et al. in their 1957 studies seem, to contradict those of their 1953 report and, moreover, are apparently not in con. formity with the reports of other workers in the Union, all of whom seem to agree that portal cirrhosis associated with severe siderosis is the most common variety of cirrhosis encountered among Africans in the Union." As one of the other workers whose name has been quoted in this letter, I should like to reply briefly to some of the points mentioned in his letter : (1) The concept of what constitutes a cirrhosis of liver in contradistinction to hepatic fibrosis has undergone a radical change since Strachan,1 Becker,2 Gillman and Gillman, 3-5 or Higginson published their surveys. I classified casesas " early cirrhosis in 1944, which I would now regardas simple portal fibrosis. The criteria for a true cirrhosis have been clarified and so to a certain extent have the possible pathogenetic pathways. At any rate, in my necropsy liver material from both Europeans and Africans on the Witwaters. rand (and basing one’s classification on the morphological criteria proposed by Himsworthand Goldblatt 8) the corrr nzorzest variety of cirrhosis encountered amongst both Europeans and Africans in this part of South Africa, is post-necrotic This type of cirrhosis is quite unrelated to the cirrhosis. presence or degree of siderosis. (2) I have recently had the privilege of a visit from Prof. Paul Steiner, who independently reviewed my material. With his permission, I quote from his report on the African cases: " The post-necrotic type comprised about two-fifths of all cases The Laennee type, which is probably related to the post-necrotic type, accounted for another two-fifths. A small proportion were classified as pigmentary. Many other cases had appreciable amounts of pigment but it did not appear to be related to the fibrous tissue. Most of the cases classified as pigmentary were of the monolobular type, and if the pig "
1. Strachan, A. S. M.D. thesis, Glasgow, 1929. 2. Becker, B. J. P. Leech, 1944, 15, 15. 3. Giliman, J., Gillman, T. Arch. Path. 1945, 40, 239. 4. Gillman, J., Gillman, T. Lancet, 1948, i, 169. 5. Gillman, J., Gillman., T. Perspectives in Human Malnutrition. New York, 1951. 6. Higginson, J., Gerritsen, T., Walker, A. R. P. Amer. J. Path. 1953, 29, 779. 7. Himsworth, H. P. Lectures on the Liver and Its Diseases. Oxford, 1947. 8. Goldblatt, H. Transactions of the 6th Conference on Liver Injury. Josiah Macy, jun., Foundation. New York, 1947. p. 9.