A Doctor's Journal
Mind and Body
By MILES HOWARD EIGHT years ago, Ronald Mac- Keith, of Guy's, examined a consecutive series of children sent up to his out-patient clinic because of recurrent attacks of abdominal pain. Out of twenty- five, only one had any physi- cal disorder adequate . to account for the pain; in three the cause of it was quite obscure; and in fifteen of the remainder emotional excitation was the principal cause. In the other six it was one among several causes. The moral was clear : faced with any child who has recurrent abdominal pain, the doctor should look for a reason in the emotional field first, though he will, as a matter of course, review his patient's bodily state as well. One form of this disorder that I see more often nowadays than formerly is the 'migraine equivalent'—discom- fort, cramp or even quite acute colicky pain in the abdomen, with nausea and wretchedness, but no headache. if the pain is severe enough and the patient is admitted to hospital, someone may be tempted to open the abdominal cavity and take a look inside; he will find nothing wrong there, for the trouble isn't a disorder of the gut, but of life.
MacKeith's researches, as I say, were done eight years ago; but all the same I was delighted to read a first-class paper in the Lancet by Tizard. Stapleton and their colleagues on the role and functions of the child specialist in the diagnosis and handling of disorders not of bodily origin. 'In the past,' as the authors say, 'a pediatrician could earn an honourable living without knowing anything of psychiatry. But now serious organic disease, which used to present the most immediate and pressing problems, has declined . . . emo- tional disorders must be his major preoccupation.'
Unluckily for him, standard medical training has given him little or nothing in the way of preparation—in his approach, in techniques of exploration or in methods of therapy—for deal- ing with those manifold illnesses of childhood of which stress is a major cause, or with the emo- tional aspect of physical disease, that make up at least half his work. If he turns with relief and en- thusiasm to the child with a rare disease, it's not only because this kind of disease has some in- trinsic interest and importance, but also because he feels more at ease and more comfortable in his approach to it than he does with the all-too- common, but troublesome, 'psychosomatic' dis- order. (I've got into the way, lately, of putting this word in quotation marks—it frets me : my offer of fifty guineas to anyone who can think of a better term still stands.) `In most British medical schools . . . the in- terest of the student in personality is suppressed, while his mind is burdened with detail that should concern only a specialist.' I couldn't agree more : most students of medicine are very good with people, until their natural humanity of outlook has been distorted by undue emphasis on detail, number-worship and physical data. It may take three or four years of experience before the would-be doctor can resume his normal vision.
That a team of doctors of such skill and ex- perience as this should recognise so clearly, and set out so well, the urgent need for more aware- ness and better training in their own field is in- deed a landmark in medicine. For myself, I'm with them almost all the way: one minor bone I'd pick with them is choice of title—`Role of the Pediatrician in Mental Illness'—`mental' isn't the term, for it clearly implies, to most readers, an illness with psychiatric symptoms, or insanity, and that's not what they are talking about. Apart from this small point, I give the paper full marks and a gold medal.
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