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water was poured into this machine by me the red warninglight did not go on.There are obviously many hazards that can result from

over-heating the donor blood-hxmolysis of cells, possiblyrelease of nitrogen gas which, if present in small bubbles,could be missed by the operator-quite apart from thepossibility of toxic substances that may be released fromthe tubing heated to a high temperature.

Professor Rickham and I will be publishing a shortpaper on our cases of ileocolitis. This hazard is, I think, ofsuch importance that I felt there should be no delay indirecting the attention of paediatricians to this risk.

I have spoken to the makers of the Grant warmingmachine, and they will be able to rewire this apparatus toexclude this possible complication. In the meantime a

large notice has been put on my machine stating clearlythat cold water only must be used.

Department of Child Health,University of Liverpool,

Alder Hey Children’s Hospital,Eaton Road, Liverpool L12 2AP. A. E. MCCANDLESS.

BEHAVIOURAL SCIENCES IN THE MEDICALCURRICULUM

SIR,-Professor Black and Dr. Cairns 1 have raisedseveral important issues concerning the place of thebehavioural sciences, and in particular of psychology,within the preclinical medical curriculum. The generaldesirability of introducing instruction in psychology intothe medical course is widely accepted, but it is perhapspertinent to inquire what precise purpose such instructionis intended to serve, for upon the answer to such a questionwill depend the nature of the medical psychology course,its content, and its duration. If it is intended purely tobroaden the general education of the medical student onmatters touching upon human nature, then few problemsarise: a course might fairly easily be designed which wouldpresent a reasonably comprehensive, though superficial,picture of the present state of academic psychology. If,on the other hand, the psychology taught to medicalstudents is intended to have practical implications for theway in which patients are to be treated (and both ProfessorBlack and Dr. Cairns seem to have this in mind), then thesituation is quite different. Behaviour modification tech-

niques (referred to quaintly and somewhat euphemisticallyby Black as

" persuasion technology ") are numerous anddiffer widely in both general and specific characteristics.They are, moreover, conceptually very complex, and indeedthere is considerable ongoing debate 2,3 among psycho-logists concerning the relationship between behaviour

changes brought about within the clinical therapeuticcontext and formalised statements of learning theoryderived from controlled laboratory investigations. Itwould be unreasonable to expect that a clinician couldeffectively employ a behaviour modification technique, andevaluate its outcome, without being fully aware of thearguments and counter-arguments lying behind its use.

It is difficult to see how, in the necessarily cursory coveragewhich can be afforded to psychology within an alreadycrowded medical curriculum, the required level of sophisti-cation may be attained. This point may be emphasised bynoting that clinical psychologists now typically undertaketwo years’ postgraduate training following their first degreein psychology in order to reach an acceptable standard ofcompetence. Any psychology course designed for medicalstudents must take considerations such as these intoaccount.

1. Cairns, H. Lancet, Jan. 8, 1972, p. 93.2. Porter, R. The Role of Learning in Psychotherapy. London, 1968.3. Bergin, A. E., Garfield, S. L. Handbook of Psychotherapy and

Behavior Change: An Empirical Analysis. New York, 1971.

The psychological education of our future general prac-titioners is perhaps best predicated upon the assumptionthat the provision of specialised clinical psychologicalservices is likely to undergo at least a moderate expansionin the near future, and that the purpose of preclinicalpsychology teaching should, therefore, be primarily to

alert the medical profession to the nature, availability, anddesirability of utilising these behaviour modificationservices.

In addition, it is arguable that those who lecture onpsychology to medical students should be less concernedwith presenting a balanced overall (and hence inevitablylow-level) coverage of psychology, than with indicatingthe full range of problems and complexities which besetany attempt to provide a psychological analysis of humanbehaviour: such an approach might at least forestall a

too-ready use of facile, quasi-psychological diagnosesmore often than not couched in debased psychoanalyticjargon.

Professor Black and Dr. Cairns have both pointed outthat formal teaching in psychology as part of the pre-clinical curriculum can hardly be expected greatly to

enhance human sympathy and warmth in a general prac-titioner. This is undoubtedly true. It is equally unlikelythat it will provide the clinician with the necessary skillsto become an effective behavioural technologist. Suitablydesigned, however, a preclinical psychology course couldplay a most valuable role in enhancing the general prac-titioner’s awareness of the complexities of human be-

haviour, and in emphasising the need for specialisedhandling of those disorders possessing a clear psychologicalcomponent.

University Department of Psychology,P.O. Box 363,

Birmingham B15 2TT. F. N. JOHNSON.

SIR,-Professor Black believes that the behaviouralsciences should have an important role in medical educa-tion. But here there may be something of a paradox. Ifthese subjects were allowed substantial admission to thecrowded preclinical syllabus, they could go far to defeattheir own purpose by reducing still further the student’sopportunities for gaining experience of life outside his

profession." A man who is nothing but a lawyer ", remarked Lord

Goodman recently, " is not much of a lawyer ". It is evenmore certain that a good doctor must know and care formuch more than medicine. And for this he needs time-time to read more than his technical books, time to diverthimself vigorously in the open air, time to travel brieflyoutside his own country, time above all to meet old friendswhose hopes and endeavours in other fields may be no lessimportant, and perhaps more testing, than his own. Such

activities, already valid in themselves, may also teach himmore than can be learnt from academic instruction.By comparison, of the three new sciences considered by

Professor Black, sociology would appear to offer littlemore than ill-founded statistics manipulated at best bythe ingenuous and all too often by the politically motivated.It can surely do nothing to illuminate the infinite variety ofindividual human distress. Nor need we pay much atten-tion to the animals, except to agree with the unhappyDuchess of Orleans, the neglected wife of Louis XIV’svery odd brother. Grieving for her ravaged Palatinate, shedeclared the behaviour of her dogs and her tame duck tobe greatly preferable to the calculated savageries of Man.Human psychology may take us some way, while serving

as an introduction to the psychoses. But often it is the

layman, perhaps unwittingly, who turns it to the best

advantage. The good battalion commander draws upon a

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score of scarcely conscious perceptions to judge the moraleof his troops in battle, and in 1940 the will of this countryto survive was summoned and expressed by a Prime Minis-ter who thought very little of psychology; practising it, tosupreme effect, he yet continued to fancy that it all camenaturally.

So " life ", perhaps, and " literature " too, as Pro-fessor Black suspected of the days before anyone hadheard of the behavioural sciences, may still have theirplace in the medical curriculum.

Victoria Hospital,Whinney Heys Road,Blackpool FY3 8NR. I. MCD. G. STEWART.

SIR,-I feel that Professor Black’s article (Dec. 18,p. 1366) illuminates, and perhaps contributes to, three oithe major problems disturbing medical education in thiscountry. In our institution, as in many others, curriculaxchanges are requiring that rapidly expanding areas oi

knowledge be taught in shrinking periods of time. WhileI do not see this as necessarily incompatible with a goodmedical education, it does create a demand for selectivity,which seems to be both beneficial to the recipients of thecurriculum and frustrating to its organisers. It is especiallythis frustration that Professor Black, as well as many others,seems to heighten.

Professor Black: (1) recommends that human psychologyand (with less conviction) sociology should occupy anexpanded role in both the preclinical and clinical curriculaof the medical student; (2) recommends that humanpsychology should be taught in the preclinical years by an" academic psychologist "; and (3) fails to explain con-vincingly why either should be done. I do not argue thatthe behavioural sciences should not occupy an expandedrole in the medical-school curricula, nor do I fault ProfessorBlack for recommending such; I simply point out that,taken in the light of similar recommendations by proponentsof dozens of other areas related to medicine, many non-existent a few years ago, the resulting frustrations of such arecommendation to those charged with organising medical-school curricula must be obvious. While my concern mayresult in part from my failure to understand the designation" academic psychologist ", whatever its meaning, I wouldstill be disturbed by Professor Black’s emphasis on specialtyteaching by narrow specialists.

Is such an approach really to the medical student’s

advantage ? The hazards of creating a product who is welltrained in dozens of narrow disciplines, but who has littleconcept of the use of this training in an integrated fashionin clinical medicine, seem quite real. Again, the frustrationafforded the organisers of medical-school curricula bysuch recommendations is obvious.

The major new demand made on those responsible forthe streamlined medical-school curricula is justification ofthe material taught, and it is this requirement that seems tooffer the greatest advantage to the student. Therefore, itseems that any proponent of additions to medical curri-cula should have, as his first task, the complete justificationof his recommendations, in terms of the needs of the com-pleted product. Otherwise, I can see such recommendationsas only adding to the confusion which exists in medicaleducation. While Professor Black did mention the recom-mendations of a commission and a council, and he did referto the need of medical practitioners to be able to answertheir patients’ questions, these justifications seem ratherunsatisfying, and there was no acceptable justification forthe suggestion that an

" academic psychologist " providethe preclinical teaching. I realise the requirements of thearticle’s brevity, but unless I am told in far more preciseterms why the behavioural sciences should be expanded and

why they should be taught by behavioural scientists, I findthat my confusion and frustration are only increased.

Division of Clinical Immunology andRheumatology,

Department of Medicine,University of Alabama in Birmingham,

1919 Seventh Avenue South,Birmingham, Alabama 35233, U.S.A. JOE G. HARDIN, JR.

PRESCRIPTION CHARTS

SIR,-Dr. Spencer (Jan. 15, p. 144) comments on thecontinued use of Latin abbreviations (o.m., p.r.n., &c.) forthe frequency of drug administration. Robb 1 has shownthat many nurses (and some doctors) do not know themeanings of such terms. It seems, therefore, a matter ofsome urgency that a drug chart is adopted, where times ofadministration can be indicated by a tick in the appropriatecolumn. Such a chart is already in use in some hospitals-e.g., at the Leeds General Infirmary, where there exists acommittee which reviews such items as the lay-out of drugcharts, record charts, and laboratory forms. When manyof the hospital staff in this country may not be fully con-versant with English (and presumably less so with Latin),such a revised prescription chart seems a logical innovation.I accept that without increasing the size of the form E.c.10such a format may not be appropriate in general practice.

Graylingwell Hospital,Chichester, Sussex. DAVID HARRIS.

PLANS FOR NEW PSYCHIATRICUNITS

SiR,—The plea of Dr. Crocket (Dec. 18, p. 1373),supported by Professor Carstairs and Professor Walton(Jan. 15, p. 143), that the design of new psychiatric unitsshould match modern treatment methods stimulates as

much surprise as agreement. Surprise that in the N.H.S. ofthe ’70s we still need to plead for close collaboration betweenplanners and clinicians.Some years ago I heard a regional-board architect scoff at

the desire of doctors and nurses to have a say in the plan-ning of a new hospital unit. " You don’t ask a bus conductorhow to build a bus ", he affirmed-quite wrongly, I sug-gested at the time. Nowadays, any designer of a bus knowshe has to ask not only the conductor, but also the driver andpassengers as well, if he expects the end-product of hisskill to secure consumer satisfaction.In a specialty in which the rate of change is steadily

accelerating it is important to look well ahead, to buildflexible units, and to match structure with function as faras all this is humanly possible. Are there really hospitalauthorities and architects unaware of such needs ? Or arethe problems Dr. Crocket cites merely illustrations of thedisadvantage of trying to practise modern psychiatry in ageneral-hospital setting ? Administered according to themedical model, the general hospital emphasises technicalcompetence and, to a large extent, still seems to ignoreinterpersonal relationships and the physical and socialstructure necessary for their therapeutic exploitation.

Ross Clinic,Cornhill Road,

Aberdeen AB9 2ZF. J. K. W. MORRICE.

SIR,-May I add some comments to Professor Carstairs’and Professor Walton’s letter supporting Dr. Crocket’splea for the provision of a room large enough to holdregular meetings of staff and patients in psychiatric units ingeneral hospitals ? It is equally important to provideseveral rooms large enough for small-group psychotherapyand a sufficient number of interview rooms for individualpsychotherapy.1. Robb, G. H. Lancet, 1971, ii, 700.