1340

,co-existent but unrelated tuberculosis in the skin arevery great.

Sarcoid lesions appear in some other systemic-diseases-for example, chronic berylliosis,13 chronicbrucellosis,14 and histoplasmosis.I5 But only someexamples of berylliosis seem at present to come withinthe definition of sarcoidosis. To include in sarcoidosis," dis-ease " caused by tubercle bacilli or beryllium isnot irrational; nor is it confusing, unless we continueto believe in the anthropomorphic concept of

" the

independent self-sufficiency of diseases." 1

13. Hardy, H. L. Amer. Rev. Tuberc. 1955, 72, 129.14. Barrett, G. M., Rickards, A. G. Quart. J. Med. 1953, 22, 23.15. Pinkerton, H., Iverson, L. Arch. intern. Med. 1952, 90, 456.16. Neuroses in General Practice. By C. A. H. WATTS, M.D. Royal

College of Physicians of Edinburgh Publications no. 6. Edin-burgh: T. & A. Constable. 1956. Pp. 31. 3s. 6d.

17. Meares, A. Lancet, 1954, ii, 592.18. Hopkins, P. Ibid, Sept. 1, 1956, p.455.19. Ryle, A. Ibid, Dec. 1, 1956, p. 1162.

Psychotherapy in General PracticeALMOST every specialty of today began in a small

-way as part of the work of the general practitioner.The newer the specialty the more it should reflect thetype of practice from which it came ; but this doesnot always happen, and psychiatry is a case in point.In the 2nd John Matheson Shaw lecture of the RoyalCollege of Physicians of Edinburgh Dr. C. A. H.WATTS 16 divides psychiatry into three " grades " of,complexity and discusses the reaction of the familydoctor to this one of the many specialties to which hiswork has given birth. How much psychiatry is

practised by family doctors ? Is it as little as it seemsto be ?The routine of a consultation begins with listening

as the patient’s history is told, and making a

clinical examination. These steps, either in thedoctor’s surgery or the patient’s home, are by no meansdevoid of emotional content, as MEARES17 has illus-trated ; and when advice or reassurance is added, withor without medication, rapport between patient anddoctor has been built up-by nothing more or lessthan the practice of unacknowledged psychotherapy.The rapport situation is WATTS’S first and most

elementary grade of psychotherapy ; but, because heuses each day new physical methods and techniquesand powerful new remedies, the general practitionermay forget the impact of the treatment on the mindsof his patients, and may only grudgingly admit thatboth his and his patient’s confidence in it will add

greatly to its potency.If basic psychotherapy, the rapport technique, is

practised unawares by the many, "

second-grade "

(but not second-rate) psychiatry is followed only bythe few in general practice. Yet with its help, as

HOPKINS18 puts it, " the doctor can unquestionablyget nearer the ideal of treating patients and not merelytheir symptoms." To attempt a reasoned assessmentof the emotional disorder, arrive at a diagnosis, andundertake treatment with deliberate aimed psycho-therapy is a distinct advance on the first " grade " :it is no longer empirical, and it is in fact undertakenwith efficiency and success (though, as RYLE 19 haslately remarked, with little recognition) by an increas-ing number of family doctors. They know that theyare practising psychiatry as they work, though ofcourse it is a different psychiatry from that of the

specialist. For one thing, there is the importantquestion of the right time to start psychotherapy;and BALINT20 has pointed out how little the specialistknows about this problem-yet it faces the generalpractitioner almost every day. Few practitioners havehad special training in psychiatry or psychotherapy,and many have learnt by trial and error how to helppatients to regain their emotional balance. WATTShas illustrated how the range of mental illness whichthe general practitioner sees is also different from thatof hospital or clinic practice : schizophrenia and otherpsychoses are rare ; hysteria, anxiety states, andendogenous depressions are common. The familydoctor, too, must live with the chronic psychiatricpatients in his practice, as well as with those who havechronic organic disease. It is among them that he willfind the patients-and he must recognise them

correctly-who need the " third grade " of psychiatry;and these he will refer to a psychiatrist.The proper management of mental illness (and it

must be managed while we develop the means toprevent it 21) requires more family doctors to learntheir own " grade " of directed and reasoned psychiatry- and to be given the time in which to do it.

(SNOWDEN 22 has described a short method of psycho-therapy which aims at understanding and explainingthe patient’s symptoms, and which, he feels, is withinthe compass of all general practitioners.) But theyand their hospital colleagues have much to learn fromone another. At present even the nomenclature ofmental illness differs between psychiatric clinic and

general practice, and neither worker knows the back-ground against which the other sees his patients northe scope of his opportunity to help them. Meansmust be found, by postgraduate courses, informal

meetings, and domiciliary consultations, to supple-ment improved undergraduate teaching. Each mustlearn and each must teach ; for at present there is adanger that a third of psychiatry will remain

unacknowledged, a further third wither from lack ofsupport and teaching, while the rest becomes anesoteric mystery remote from the world of generalpractice.

20. Balint, M. Ibid, 1955, i, 683.21. See leading article, Ibid, Nov. 24, 1956, p. 1087.22. Snowden, E. N. Ibid, 1954, ii, 376.

Lungs of Foundry WorkersLUNG disease from dust has been a curse of metal

workers from early times: In the lst century A.D.,PLINY mentioned that metal refiners wore bladdersover their faces as a protection. During the 19thcentury the mortality amongst metal workers wassurely at its highest, for a Sheffield grinder aged 30was, among his fellows, an old man. His conditionwas vividly described by EBENEZER ELLIOT, theRotherham poet :

" There draws the grinder his uneasy breath,There, coughing, at his deadly trade he bends,Born to die young, he fears not man nor death,Scorning the future, what he earns he spends,Debauch and riot are his bosom friends.

And, old at two and thirty, meets his doom."In the past twenty-five years the pulmonary diseases

of foundry workers have been much investigated;but, though some of the studies have included clinical