BRITISH MEDICAL JOURNAL
12 FEBRUARY 1977
It has been stressed that there can be a high failuie rate when attempts are made to obtain healing in compound tibial fractures with free grafts or flaps once infection and sequestration have become established: a failure rate of 34 6°o in 52 patients.1 However, at the same time it was found that of the 11 patients who had received primary or delayed primary full-thickness skin cover, healing was obtained in all. It was therefore advised at that time that primary flat cover (cross-leg or transposition flap) should be provided more often in such circumstances. Others2 $ have advised against the use of an immediate cross-leg flap as failure would result in the loss of a valuable flap site. However, not only is the abdominal tube pedicle available for later reconstruction if necessary but free flap transfer is now a practical alternative to conventional flap cover, so that the failure of a cross-leg flap would not now be as serious as formerly. (Indeed, the first reported successful transfer of a free groin flap4 was in a patient with compound lower limb trauma.) Once non-union and infection are established attempts at flap cover and bone grafting (with or without internal fixation) may prove difficult and likely to involve a protracted series of hospital admissions. Patients with established sepsis, sequestration, and nonunion after compound tibial fracture are all too common. Thus providing primary cover at the fracture site, likely as it is to give swifter healing in a proportion of patients, should be considered at the time of initial assessment so that liaison between the two specialties concerned may occur in the acute as well as the later stage of management. RICHARD W GRIFFITHS Wessex Plastic and Oral Surgery Centre, Salisbury, Wilts
Odstock Hospital,
3
Harrison, S H, British Journal of Plastic Surgery, 1968, 21, 262. Pick, J F, Journal of the International College of Surgeons, 1947, 10, 281. Brown, R F, British J'ournal of Plastic Surgery, 1965, 18, 26. Daniel, R K, and Taylor, G I, Plastic and Reconstructive Suirgery, 1973, 52, 1 1 1.
Staffing of hospital laboratories SIR,-It was with some concern that we read the recent policy statement by the Institute of Medical Laboratory Sciences (late Laboratory Technicians) on the future staffing of the hospital laboratory service.' It would serve no useful purpose to itemise the many assumptions and inaccuracies contained in this document. It is important, however, that it should be considered by all medical and nonmedical heads of departments and their trainees in all branches of pathology. It seems evident that the institute is attempting to elevate the status of its members at the expense of both the medically qualified and the non-medically qualified graduate specialising in laboratory medicine. It is often the case that documents of this type are regarded as statements of fact rather than opinion or wishful thinking; it is therefore important that inaccurate statements or policies not in the interests of patients should be refuted. We hope that this will be done by bodies representing both medical and non-medical graduate scientists. The interests of patients are best served when the medical consultant is head of a pathology laboratory, as only he can undertake
441
many of the diagnostic, therapeutic, and advisory functions of laboratory practice. Medical knowledge is also essential for forward planning. It is equally true that in certain disciplines and in some circumstances a senior and properly trained graduate scientist may be an acceptable alternative, but even he may not be able to undertake all of the functions or activities of a registered medically qualified pathologist. Undoubtedly technical staff should be involved in decision-making and administration. This is achieved by their representation on most cogwheel divisions and on pathological and scientific advisory committees at all levels. It seems a pity that the IMLS should have produced such a divisive document which could sour the currently good relationships built up over the years between all grades of laboratory staff. It is also important that the Department of Health and Social Security in future discussions with professional bodies about laboratory management is not unduly influenced by the hypothetical schemes of advancement advocated by the IMLS but that the advice given in HSC(lS)16 continues to be followed-that is, the manager of the laboratory should be a medical consultant or non-medical scientist of equivalent standing.
W A J CRANE G D POWELL I M P DAWSON V W PUGH J A H FINBOw H G H RICHARDS M L GHOSH R D C SINCLAIR J S P JONES W WAGSTAFF A MACFARLANE F WALKER G W PENNINGTON Consultant Pathologists, Trent Region
Institute of Medical Laboratory Sciences, Future Staffing in the Medical Laboratory Service, A Policy Statement. London, IMLS, 1976.
Behaviourism SIR,-While welcoming your leading article (2 October, p 776) pointing out the impressive accomplishments of behaviour therapy in the treatment of neurotic reactions, I would like to draw attention to a number of erroneous statements. Firstly, you give the impression that the method of gradual desensitisation of animal neuroses emerged in Masserman's experiments.' In fact, the method was introduced in the course of experiments I performed2 on cats, having produced their neuroses by a method similar to that described by Masserman. Secondly, it is true that neurotic animals do not recover (and do not eat), when they are kept "in prolonged contact with the food in the absence of any noxious stimulus." This is demonstrably because the anxiety prevents eating in the experimental cage. If eating is brought about, as it may be, by special measures2 3recovery does occur. Thirdly, contrary to a widespread impression, human neuroses, like those of animals, do not as a rule recover on the basis of maximal exposure to anxiety-evoking stimuli. Flooding works best when the anxiety-evoking stimuli are presented in "large step" hierarchical order.4 In some cases, not surprisingly, it does not work at all. Fourthly, except in the case of obsessivecompulsive neuroses, most of the evidence5 is contrary to the view of Marks6 that flooding
is in general more effective than desensitisation. In Marks's own comparative studies the relaxation training was hopelessly inadequate, consisting of a single training session given by psychiatric residents who had themselves had only one session of training. Fifthly, your statement that "when behaviour therapists have required treatment themselves they have not yet considered behaviour therapy to be indicated" is very damaging and based on a very misleading paper by Lazarus.7 This reported the selfreferral practices of 23 so-called "behaviour therapists" who, being associated with Lazarus, would probably be eclectics who use some behaviour therapy techniques. In a much more extensive study by Foa8 it was found that, whereas, in general, eclectics who use behaviour therapy do not seek behaviour therapy for themselves, 90)3O" of those who practise behaviour therapy exclusively do. J WOLPE Behavior Therapy Unit, Temple University School of Medicine, c 'o Eastern Pennsylvania Psychiatric Institute, Philadelphia, Pennsylvania Masserman, J H, Behavior and Neurosis. Chicago, University of Chicago Press, 1943. Wolpe, J, British Journal of Psychiatry, 1952, 43, 243. 3Wolpe, J, Psychotherapy by Reciprocal Inhibition. Stanford, Stanford University Press, 1958. 'Wolpe, J, The Practice of Behavior Therapy, 2nd edn. New York, Pergamon Press, 1973. Mathews, A M, et al, British Jrournal of Psychiatry, 1974, 125, 256. Marks, I M, American J'ournal of Psychiatry, 1976, 133, 253. 7Lazarus, A A, Behavior Therapy and Beyond. New York, McGraw-Hill, 1971. 8Foa, E B, Journal of Behaviour Therapy and Experimental Psychiatry. In press. 2
**Masserman's cats were made neurotic in their home cages, while Professor Wolpe's were taken to special cages for the experimental procedure; although both experimenters used methods of gradual desensitisation, Professor Wolpe's design was more felicitous in that it included a clear spatial dimension in the treatment, the cats being brought gradually nearer to the experimental cages from their home cages. With regard to Professor Wolpe's second point, Masserman induced his cats to eat in the cages in which they had been exposed to noxious stimuli by stroking the animals and feeding them by hand. Much more work needs to be done on the relative effectiveness of desensitisation and flooding and on the particular indications for each. It is remarkable that two apparently opposite methods should both be effective. But if "large step" hierarchical procedures are used in flooding are the two methods really so different ? Our leading article did not acknowledge Professor Wolpe's great and pioneering influence on the application of behavioural methods to the treatment of human neuroses.-ED, BMJ. Suppressing lactation SIR,-Your leading article on this subject (22 January, p 189) left me with a sense of wonderment, rather as if I had been reading a discussion on the advantages of leeches in the treatment of vapours in the 19th century. Why is it that we must continue to invent diseases where none exist? Why do we continue to compare one therapeutic agent with another when none is necessary, some are dangerous, and almost all are expensive? After a double blind trial in this hospital in 1965 it was concluded that routine treatment
12 FEBRUARY 1977
It has been stressed that there can be a high failuie rate when attempts are made to obtain healing in compound tibial fractures with free grafts or flaps once infection and sequestration have become established: a failure rate of 34 6°o in 52 patients.1 However, at the same time it was found that of the 11 patients who had received primary or delayed primary full-thickness skin cover, healing was obtained in all. It was therefore advised at that time that primary flat cover (cross-leg or transposition flap) should be provided more often in such circumstances. Others2 $ have advised against the use of an immediate cross-leg flap as failure would result in the loss of a valuable flap site. However, not only is the abdominal tube pedicle available for later reconstruction if necessary but free flap transfer is now a practical alternative to conventional flap cover, so that the failure of a cross-leg flap would not now be as serious as formerly. (Indeed, the first reported successful transfer of a free groin flap4 was in a patient with compound lower limb trauma.) Once non-union and infection are established attempts at flap cover and bone grafting (with or without internal fixation) may prove difficult and likely to involve a protracted series of hospital admissions. Patients with established sepsis, sequestration, and nonunion after compound tibial fracture are all too common. Thus providing primary cover at the fracture site, likely as it is to give swifter healing in a proportion of patients, should be considered at the time of initial assessment so that liaison between the two specialties concerned may occur in the acute as well as the later stage of management. RICHARD W GRIFFITHS Wessex Plastic and Oral Surgery Centre, Salisbury, Wilts
Odstock Hospital,
3
Harrison, S H, British Journal of Plastic Surgery, 1968, 21, 262. Pick, J F, Journal of the International College of Surgeons, 1947, 10, 281. Brown, R F, British J'ournal of Plastic Surgery, 1965, 18, 26. Daniel, R K, and Taylor, G I, Plastic and Reconstructive Suirgery, 1973, 52, 1 1 1.
Staffing of hospital laboratories SIR,-It was with some concern that we read the recent policy statement by the Institute of Medical Laboratory Sciences (late Laboratory Technicians) on the future staffing of the hospital laboratory service.' It would serve no useful purpose to itemise the many assumptions and inaccuracies contained in this document. It is important, however, that it should be considered by all medical and nonmedical heads of departments and their trainees in all branches of pathology. It seems evident that the institute is attempting to elevate the status of its members at the expense of both the medically qualified and the non-medically qualified graduate specialising in laboratory medicine. It is often the case that documents of this type are regarded as statements of fact rather than opinion or wishful thinking; it is therefore important that inaccurate statements or policies not in the interests of patients should be refuted. We hope that this will be done by bodies representing both medical and non-medical graduate scientists. The interests of patients are best served when the medical consultant is head of a pathology laboratory, as only he can undertake
441
many of the diagnostic, therapeutic, and advisory functions of laboratory practice. Medical knowledge is also essential for forward planning. It is equally true that in certain disciplines and in some circumstances a senior and properly trained graduate scientist may be an acceptable alternative, but even he may not be able to undertake all of the functions or activities of a registered medically qualified pathologist. Undoubtedly technical staff should be involved in decision-making and administration. This is achieved by their representation on most cogwheel divisions and on pathological and scientific advisory committees at all levels. It seems a pity that the IMLS should have produced such a divisive document which could sour the currently good relationships built up over the years between all grades of laboratory staff. It is also important that the Department of Health and Social Security in future discussions with professional bodies about laboratory management is not unduly influenced by the hypothetical schemes of advancement advocated by the IMLS but that the advice given in HSC(lS)16 continues to be followed-that is, the manager of the laboratory should be a medical consultant or non-medical scientist of equivalent standing.
W A J CRANE G D POWELL I M P DAWSON V W PUGH J A H FINBOw H G H RICHARDS M L GHOSH R D C SINCLAIR J S P JONES W WAGSTAFF A MACFARLANE F WALKER G W PENNINGTON Consultant Pathologists, Trent Region
Institute of Medical Laboratory Sciences, Future Staffing in the Medical Laboratory Service, A Policy Statement. London, IMLS, 1976.
Behaviourism SIR,-While welcoming your leading article (2 October, p 776) pointing out the impressive accomplishments of behaviour therapy in the treatment of neurotic reactions, I would like to draw attention to a number of erroneous statements. Firstly, you give the impression that the method of gradual desensitisation of animal neuroses emerged in Masserman's experiments.' In fact, the method was introduced in the course of experiments I performed2 on cats, having produced their neuroses by a method similar to that described by Masserman. Secondly, it is true that neurotic animals do not recover (and do not eat), when they are kept "in prolonged contact with the food in the absence of any noxious stimulus." This is demonstrably because the anxiety prevents eating in the experimental cage. If eating is brought about, as it may be, by special measures2 3recovery does occur. Thirdly, contrary to a widespread impression, human neuroses, like those of animals, do not as a rule recover on the basis of maximal exposure to anxiety-evoking stimuli. Flooding works best when the anxiety-evoking stimuli are presented in "large step" hierarchical order.4 In some cases, not surprisingly, it does not work at all. Fourthly, except in the case of obsessivecompulsive neuroses, most of the evidence5 is contrary to the view of Marks6 that flooding
is in general more effective than desensitisation. In Marks's own comparative studies the relaxation training was hopelessly inadequate, consisting of a single training session given by psychiatric residents who had themselves had only one session of training. Fifthly, your statement that "when behaviour therapists have required treatment themselves they have not yet considered behaviour therapy to be indicated" is very damaging and based on a very misleading paper by Lazarus.7 This reported the selfreferral practices of 23 so-called "behaviour therapists" who, being associated with Lazarus, would probably be eclectics who use some behaviour therapy techniques. In a much more extensive study by Foa8 it was found that, whereas, in general, eclectics who use behaviour therapy do not seek behaviour therapy for themselves, 90)3O" of those who practise behaviour therapy exclusively do. J WOLPE Behavior Therapy Unit, Temple University School of Medicine, c 'o Eastern Pennsylvania Psychiatric Institute, Philadelphia, Pennsylvania Masserman, J H, Behavior and Neurosis. Chicago, University of Chicago Press, 1943. Wolpe, J, British Journal of Psychiatry, 1952, 43, 243. 3Wolpe, J, Psychotherapy by Reciprocal Inhibition. Stanford, Stanford University Press, 1958. 'Wolpe, J, The Practice of Behavior Therapy, 2nd edn. New York, Pergamon Press, 1973. Mathews, A M, et al, British Jrournal of Psychiatry, 1974, 125, 256. Marks, I M, American J'ournal of Psychiatry, 1976, 133, 253. 7Lazarus, A A, Behavior Therapy and Beyond. New York, McGraw-Hill, 1971. 8Foa, E B, Journal of Behaviour Therapy and Experimental Psychiatry. In press. 2
**Masserman's cats were made neurotic in their home cages, while Professor Wolpe's were taken to special cages for the experimental procedure; although both experimenters used methods of gradual desensitisation, Professor Wolpe's design was more felicitous in that it included a clear spatial dimension in the treatment, the cats being brought gradually nearer to the experimental cages from their home cages. With regard to Professor Wolpe's second point, Masserman induced his cats to eat in the cages in which they had been exposed to noxious stimuli by stroking the animals and feeding them by hand. Much more work needs to be done on the relative effectiveness of desensitisation and flooding and on the particular indications for each. It is remarkable that two apparently opposite methods should both be effective. But if "large step" hierarchical procedures are used in flooding are the two methods really so different ? Our leading article did not acknowledge Professor Wolpe's great and pioneering influence on the application of behavioural methods to the treatment of human neuroses.-ED, BMJ. Suppressing lactation SIR,-Your leading article on this subject (22 January, p 189) left me with a sense of wonderment, rather as if I had been reading a discussion on the advantages of leeches in the treatment of vapours in the 19th century. Why is it that we must continue to invent diseases where none exist? Why do we continue to compare one therapeutic agent with another when none is necessary, some are dangerous, and almost all are expensive? After a double blind trial in this hospital in 1965 it was concluded that routine treatment
