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be this : it is the duty of the pioneer to teach thegeneral surgeon or physician as much of his art as thelatter- can reasonably be expected to acquire andpractise ; it is the duty of the general surgeon orphysician to learn that and use it so far as he can, toknow his own limitations, and to seek the expert’shelp, without fears for his own prestige, when facedwith a problem that goes beyond his competence.Collaboration must replace rivalry, and friendlycriticism. exercise its educative function in both direc-tions. The specialised surgeon or physician shouldalways be a jump ahead of his general colleague, evenof the general colleague who has a special interest inhis field, and the general colleague should be alwaysmaking to overtake him.

This sort of relationship between general medicineand surgery and their subdivisions will not developif the latter are organised into watertight compart-ments. On this, the pattern of any national serviceof specialists that may be instituted, and theofficialrecognition accorded to higher qualifications, will havean all-important influence. We would urge that the

categories in such a service be as few as possible.Medicine and surgery, as now generally recognised,should not be further subdivided. For the specialtieswithin each the normal general training and appro-priate qualification should be demanded ; beyondthat, those specialising, fully ’or partly, in narrowerfields should be left to achieve their status by theirperformance and secure appointments on the strengthof their record. If ’diplomas in these narrower fields{e.g., neurology, cardiology, orthopaedic surgery,physical medicine) are instituted, they should not haveofficial recognition. This would not apply, of course,to the already well-denned specialties which lie outsidegeneral medicine and surgery, or often bestride both ;obstetrics and gynaecology, ophthalmology, otorhino-laryngology, radiology, and anaesthetics should havetheir own basic training and their own officiallyrecognised higher qualifications. But this list shouldnot be readily extended ; whether, for example,paediatrics and psychiatry should be statutorilyrecognised as independent categories, requiring theirown basic training from the beginning, or whetherpaediatricians and psychiatrists should appear underthe heading of physicians, and first qualify as phy-sicians, is a matter for consideration.The biologists have taught us that man achieved

his superiority over the animals not merely by develop-ing a superior brain but also by preserving a general-’ised adaptable bodily structure :

" We are led bv theevidence of comparative anatomy to ponder upon thefreedom of the will, or at least freedom of action,which we have because our bodies are versatile,untrammelled by specialisation for extreme but parti-cular skill, and capable of any task the mind mayimagine." 1 The body politic of medicine is analog-ous ; overspecialisation in the long run will hindergrowth and adaptation, and is at this stage in develop-ment most carefully to be guarcled against.Another temptation to the planners is to place too

much faith in central direction. The nervous systemintegrates the activities of the human organismbecause it is played upon by influences from theperiphery, and much of the nervous system is itselfperipheral. The integration of the activities of

1. Corner, G. C., Ourselves Unborn, London, 1944, p. 174.

specialists and consultants must grow out of ’peri-pheral collaboration in every hospital, town, andregion; it cannot be achieved from Whitehall or

Edinburgh. -

Wherever possible, specialists should all work in onegeneral hospital, rather than in isolated units. Butthe traditional organisation of departments within ahospital is not necessarily the best. There is room for

experiment with new arrangements. Instead of themedical firm of roughly 50 beds under one chief andan assistant chief, it might be better to place say 150beds under a group of six physicians. This need notmean an authoritarian head and five assistants chafingin subservience ; the group might learn to govern itselfmore after the fashion of the directorate of a companyor the fellowship of an Oxford or Cambridge college.The joint control of wards by physician and surgeonhas been mooted and tried ; it should do much - toimprove the practice of both and to benefit the pa-tients. Attaching a medical registrar to an eye wardor an ear, nose, and throat ward is another device formaking ideas flow between one specialist compartmentand another.However high the standards of intellectual honesty

may be among hospital chiefs, they still work underthe disadvantage that their performance is not

subjected to the regular criticism of their equals andpeers ; the tacit comment of students and juniors in ateaching hospital is an imperfect substitute. Themore colleagues can look over one another’s shouldersthe better their work will be. Two obstacles stand inthe way of this-competition for private practice andcompetition for prestige. A national health servicemay reduce the former, but only the deliberate cul-tivation of a tradition of personal friendliness andunselfish cooperation will overcome the latter.

Annotations

THE CLAIMS OF UNRRA

THE task of feeding Europe in the first winter afterthe war always promised to be heavy, and the leaders ofUNRRA have ,laid their plans with that in mind. It is

dismaying to learn that their estimates of the suppliesneeded have not been met. At the Council meeting,held in London on Aug. 8, Mr. Herbert Lehman, thedirector-general, reported that over and over againrequests of exceedingly modest proportions made tothe supply authorities have not been complied with, andseemingly firm commitments have disappeared when themoment for delivery came. He reviewed what hasbeen achieved already. ’UNRRA was not in a positionto press forward with its work until March or April ofthis year. The first job was to send supplies to liberatedareas unable to pay in foreign exchange, and by June 30supplies to the value of’295,000,000 (59,000,000), andweighing 1,250,000 tons, had been shipped. By the endof August it is hoped that the total will have reached1,800,000 tons. Much food was sent: but there werealso tractors, livestock, farm machinery, fertilisers andseeds, raw cotton, and wool. The contribution issmall when set against the ravages of war, but it is a

beginning. Medical supplies have included DDT powderto combat malaria and typhus, as well as sera, vaccines,-X-ray equipment, complete hospital units, sulphona-mides, and penicillin. The greatest difficulty has beento get transport. So far, about 20,000 lorries are

promised or are being shipped ; but, as Mr. Lehmansaid, these are not enough, and they have not comesoon enough. He forecast that UNRRA would have to

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ship, during the last 7 months of 1945, supplies worth$1,051,700,000 (225,340,000) ; and this would leaveonly$175,000,000 of the fund in hand for the needs ofnext year. He insisted that the resources providedat the Atlantic City meeting were wholly inadequateto give even minimal relief to the countries needing it.The requirements for 1946 were estimated before theSoviet had asked UNRRA for help to the value of$700,000,000 in the coming year ; and even withoutthis claim, at least$1,500,000,000 more will be needed.The money and goods must be found ; nearly the wholeof liberated Europe is facing prospects of famine and thebitter effects of cold. The peoples of the liberatedcountries will not be safe until they have harvestednext year’s crops. They need food, tractors, raw

materials, clothing, and coal ; to supply them UNRRAneeds shipping and supplies, especially fats, dairyproducts, meat, and lorries. To meet these bare needsthose of us who are better, off must give up a little more,and postpone our own hopes of an easier time to come.Mr. Lehman believes, and he will be widely supported,that it is a sacrifice which will be made willingly for thosewho suffered under the Nazis and resisted them so

capably in the underground armies. He insists thatthe supplying governments must be prepared to fulfiltheir promises rapidly and generously ; otherwisethey would do well to give no pledges, for if the promisedhelp is not forthcoming the name of the United Nationswill be defamed in Europe this winter.

GROUP PSYCHOTHERAPY

THE social aspect of neurotic conditions, which wasemphasised and studied by Burrows almost thirty yearsago, has received increasing recognition in the develop-ment and application of methods of group psycho-therapy. But more practical needs have stimulatedinterest in group treatment ; economy of therapeutictime is an urgent matter today, when the war has revealedthe shortage of trained psychiatrists. It is natural that

psychiatrists should bring, from individual psycho-therapy to group practice, different methods of approach,and that there should be several developments in grouptherapy.The inter-reactive tensions arising between people in

groups are a legitimate subject for study by those inter-ested in analytic methods and who view neurosis as adisturbance of social relationships. The group setting,however, has important features of its own which haveshown it to be more than a method of saving time ;significant symptoms are thrown into social relief, andfunctional diagnosis becomes easier and sounder than inshort interviews, while progress can be observed andprognosis made more sure. Foulkes believes also that aspecific therapeutic effect springs from the inter-reactivegroup situation, and shares the experience of Americantherapists that ego-strengthening and social adaptationare particular gains, even in short group treatment, whereinsight may not be reached. A deeper method, with thetherapist analysing the personal and group defences thatprevent free discussion and emotional interchange, hasbeen used in parallel with individual analytic treatment,but the need for short treatment has impelled the develop-ment of less interpretive practices. In these, the

therapist occupies a seat among a group of 8-10 patients,arranged roughly in a circle, and takes part in a groupdiscussion, steering it without controlling it, and allowingthe group to produce and resolve its own tensions,without necessarily demanding insight. Socialisation ofthe neurotic, rather than personal integration at a deeplevel, is the aim, but deeper changes in the personalitydo occur. It is an important point that the therapist isin no way the central pinion of the group, but rather isready to capitalise and help emotional interchange bycomment and remark from time to time. These groupsare free to raise topics of their own choice, and it is usual

to find that they raise and struggle usefully with the very :

bones of their own psychological skeletons.Group therapy is more widely practised, however, with

larger groups, and on a more superficial level, with thepsychiatrist in a didactic, persuasive, or hortative role.The patients meet in a group up to fifty strong, and thepsychiatrist opens a lecture-discussion on adjustmentproblems, or explains psychosomatic phenomena, andteaches sufficient anatomy and physiology from chartsfor the patient to grasp simple facts of the mind-bodyrelationships. This is an extension of the methods ofindividual explanation and persuasion, and retains theaim of furthering a patient’s understanding of his ownillness without freeing his deeper psychological forces.It is a system of education and informative discussion onthe intellectual level, with the psychiatrist as a self-

appointed leader, and is concerned with collections ofindividuals rather than with the dynamics of groupinterpersonal relations.At a recent conference of psychiatrists from the three

Canadian Services and the Department of VeteransAffairs, in Montreal, three papers on group psycho-therapy paid recognition to the difficulties that neuroticsfind in living harmoniously in groups, and to the reduc-tion in tension and the improvement in interpersonalreactions which follow group treatment. All speakersregarded a full activity programme, including physicaland recreational activities, as well as art, music, andcrafts, as an important extension to formal group psycho-therapy, stimulating interchange of ideas and reducingthe sense of isolation. Group activity is the natural

corollary of group treatment and helps the neurotic toovercome his difficulties and sense of guilt, and oneparticular variety of it—psychodramatics—is in increas-ing use. Moreno’s view, that an individual on a stageplays his own emotional role if placed in a dramaticsituation of emotional importance to himself, has beenconfirmed widely in practice, and the resultant emotionalcatharsis and liberation are regarded as valuable on bothsides of the Atlantic. When used in groups the increasein tolerance and reduction of guilt that follow psycho-dramatics foster the group identification that the neuroticfinds so difficult.

PENICILLIN FOR GONORRHŒA

THE practice of therapeutics has many disappoint-ments, and the cynical physician who remarked, "letus use this new drug before it ceases to cure," was smart-ing from the memory of past failures, and enthusiasmsdoomed to oblivion. Yet some remedies have provedso efficacious that even enthusiasts could not discreditthem ; and penicillin is one of these. Its promise forthe control of gonorrhoea is of vital importance to thecommunity in view of the wide prevalence of this diseasewhich has hitherto offered sturdy resistance to all themeans aimed at its extinction. Reports continue toclaim a remarkably high rate of cure and hopes run high,so that some epidemiologists are already prepared toturn a page and write off a major public health problem.Even the most careful clinician cannot but be impressedby the accumulating evidence of highly satisfactoryresults.Most of the initial work in this field has been done in

the Services, which combine prior claims on stocks ofpenicillin with plenty of suitable cases under ideal con-ditions for control and observation. The Army MedicalDepartment Bulletin for June, 1945, estimates that theroutine use of this drug for the treatment of gonorrhoeain one theatre of war in a single month saved 20,000"

man-days " and 800 hospital beds. The problem hasbeen not to establish the therapeutic value of the drugbut to find a standard dosage which will produce mostcures in the shortest time with the minimum amount ofpenicillin. Single large ’doses or large doses given atintervals of a day or two do not seem to have been so