Monday, March 27, 2017

Empathy & Fragile Lives: NHS & Free Thinking!

When the book by Stephen Westaby turned up for reasons too complex to explain, the Cockcroach Catcher somehow managed to read the most important chapter that was quoted by many reviewers.

When I turned back to the beginning, I have to disagree with Westaby’s proud claim that he lacked empathy from lack of sleep as a Junior Doctor and that was why he became a heart surgeon.

Brought me back to how one could help people who has lost their life saving during the financial crises and became depressed and suicidal. Is empathy going to help? What about someone giving him back all the money he has lost? Would he still kill himself?

Well the “empathy-free” Westaby arrived in Australia for a conference only to receive a call asking him to go back to England as a mother of a 6 month old girl would only have him operate on her daughter to save her life. So Westaby immediately arranged to fly back and planned his operation/s on the long flight back. I call that real "empathy"!

Unfortunately what was planned did not work and the parents were counseled to say farewell. Westaby did not join in with the “empathy” as he did not try to comfort the parents. It was left to the others.

No, he decided to try something that has never been tried. As the parents went in afterwards thinking that they were going to say goodbye, mother felt the girl's feet which was the warmest it has been, she realised that her faith in Westaby was totally justified.

The girl is still alive today. Westaby was threatened with the sack for doing something that has never been done before.

Well, that is my kind of “empathy”!

It was great to see him in person at Sage, Gateshead for the BBC Free Thinking event. The book is for all of you that loved the NHS, the NHS Original, the NHS born in the same month and year Westaby was born. We need to bring it back and we need to let good doctors do what they think is best, even if it is not NICE approved. Free thinking indeed!

Gateshead © Am Ang Zhang 2017

Westaby must have the last words:

Who would be a heart surgeon now? With long, taxing operations, anxious relatives, the nights and weekend on call. Worse still, a health system entrenched in nonsensical bureaucracy with the reward of public exposure for a run of bad luck. Already 60 per cent of our children’s heart surgeons are overseas graduates.

In the final analysis, a profession that dwells upon death is unlikely to prosper – undertakers and the military aside. As Dr Kirklin emphasised, some deaths in cardiac surgery are inevitable. When a surgeon is focused on helping as many patients as his ability will allow, some will die. But we should not accept inconsistent teams, substandard facilities or lack of vital equipment. Otherwise patients die needlessly.

The answer? Bury the blame-and-shame culture and give us the tools to do the job.

Thursday, March 9, 2017

Obstacle to Knowledge: Barry Marshall

“The greatest obstacle to knowledge

is not ignorance;

it is the illusion of knowledge”.

Barry Marshall

I was visiting my good friend in Fremantle in Perth. He was apologetic that Perth is not really near anywhere and all they have is beach and mining.

Sharks too.

He need not have apologised. I was happy to be near where one of the greatest medical breakthrough since Koch’s TB  over a hundred years ago: Helicobacter pylori.

The temperature was in the mid 40s and the plants were unusual!

© Am Ang Zhang 2013

© Am Ang Zhang 2013

© Am Ang Zhang 2013

© Am Ang Zhang 2013

The Nobel Prize in Physiology or Medicine 2005: "for their discovery of the bacterium Helicobacter pylori and its role in gastritis and peptic ulcer disease"


Peptic ulcer – an infectious disease!
This year's Nobel Prize in Physiology or Medicine goes to Barry Marshall and Robin Warren, who with tenacity and a prepared mind challenged prevailing dogmas. By using technologies generally available (fibre endoscopy, silver staining of histological sections and culture techniques for microaerophilic bacteria), they made an irrefutable case that the bacterium Helicobacter pylori is causing disease. By culturing the bacteria they made them amenable to scientific study.
In 1982, when this bacterium was discovered by Marshall and Warren, stress and lifestyle were considered the major causes of peptic ulcer disease. It is now firmly established that Helicobacter pylori causes more than 90% of duodenal ulcers and up to 80% of gastric ulcers. The link between Helicobacter pylori infection and subsequent gastritis and peptic ulcer disease has been established through studies of human volunteers, antibiotic treatment studies and epidemiological studies.
Helicobacter pylori causes life-long infection
Helicobacter pylori is a spiral-shaped Gram-negative bacterium that colonizes the stomach in about 50% of all humans. In countries with high socio-economic standards infection is considerably less common than in developing countries where virtually everyone may be infected.
Infection is typically contracted in early childhood, frequently by transmission from mother to child, and the bacteria may remain in the stomach for the rest of the person's life. This chronic infection is initiated in the lower part of the stomach (antrum). As first reported by Robin Warren, the presence of Helicobacter pylori is always associated with an inflammation of the underlying gastric mucosa as evidenced by an infiltration of inflammatory cells.
The infection is usually asymptomatic but can cause peptic ulcer
The severity of this inflammation and its location in the stomach is of crucial importance for the diseases that can result from Helicobacter pylori infection. In most individuals Helicobacter pylori infection is asymptomatic. However, about 10-15% of infected individuals will some time experience peptic ulcer disease. Such ulcers are more common in the duodenum than in the stomach itself. Severe complications include bleeding and perforation.
The current view is that the chronic inflammation in the distal part of the stomach caused byHelicobacter pylori infection results in an increased acid production from the non-infected upper corpus region of the stomach. This will predispose for ulcer development in the more vulnerable duodenum.

How to prove it: He drank the bacteria!

You could say that. I drank the bacteria and at first I was okay. But instead of being perfectly well and having a silent infection, after about five days I started having vomiting attacks. Typically at dawn I would wake up, run to the toilet and vomit. And it was a clear liquid, as if you had drunk a pint of water and regurgitated it straight back. Not only that, there was no acid in it. I remembered from my medical student days that if you have a meal where you drink so much beer that it’s coming back up straight away, it doesn’t have any acid in it. I knew there was something unusual about vomiting and not having acid.

                                                                                        Barry Marshall   

Difficult 10 years:
The medical establishment was difficult to persuade - everyone accepted that ulcers were caused by acid, stress, spicy foods, and should be treated by drugs blocking acid production. The big Pharmas were not happy to see any change as patients will have to take medication for life.

He went to the US to try and persuade the US doctors.

A big battle was still going on. I went to America to fight the battle there, because unfortunately the American medical profession was extremely conservative: ‘If it hasn’t happened in America, it hasn’t happened’. We needed people in the United States to take the treatment which we had developed.

Getting Personal:

The personal stuff was usually said behind my back, and my wife used to catch a bit of it. For example, I was at a conference, presenting our work. By then I had a few converts, who would be saying, ‘Oh, Barry, this is exciting. What are you going to do next?’ So they would talk to me, but 90 per cent of the audience wouldn’t know enough about it. And my wife would be on the bus tour with all the other wives, sitting in behind some of them. One wife would be saying to another one, ‘My husband said he couldn’t believe it. They had that guy from Australia talking about bacteria in the stomach. What a load of rubbish. This drug company’s reputation is mud’ ‑ because that company would be funding the bus tour at the conference. So things like that used to go on behind the scenes.


It wasn’t settled until people did a truly double-blind study, using an acid blocker and also amoxicillin and a third antibiotic called tinidazol. All of those antibiotics could be given in a placebo, so one group of patients could take the ‘real’ antibiotics and the others would take antibiotics that were absolutely identical but were ‘fake’, and even the doctors didn’t know which patient was getting which treatment. That trial was done in Austria and was then published in America, in the New England Journal [of Medicine], which would have the most stringent criteria for medical research.
One year later, at a big think-tank in Washington to which I was invited, it was declared proven: ‘The treatment for ulcers is now antibiotics.’ That was vindication, in effect. The implication, once you say that in the United States and the NIH [National Institutes of Health] or somebody like that puts a document out and everyone accepts it, is that you have to follow it. In 1994 there were thousands of professors and scientists in the US making a living off Helicobacter.
“Ideas without precedent are generally looked upon with disfavour 
and men are shocked if 
their conceptions of an orderly world are challenged.” 

Bretz, J Harlen 1928. Dry Falls-Thinking Outside The Box

Also, thinking out of the box can be a good idea. Sometimes it’s better not to know all the dogma, all the things about a very difficult disease. If it’s very difficult, that means people have been working on it for years and they haven’t figured out the cure, which means they haven’t figured out the cause. So having all that knowledge that’s been accumulated in the last 10 or 20 years is really not an advantage, and it’s quite good to go and tackle a problem with a fresh mind when no-one else has had any luck.
                                                                                      Barry Marshall

Tuesday, March 7, 2017

New Encounter with Mondrian

Some different Mondrians at the Guggenheim Museum, Manhattan.

Tableau No. 2/Composition No. VII

Composition 8 Compositie 8 )

Solomon R. Guggenheim Museum Website: (Photos)
When Mondrian saw Cubist paintings by Georges Braque and Pablo Picasso at a 1911 exhibition in Amsterdam, he was inspired to go to Paris. Tableau No. 2/Composition No. VII, painted a year after his arrival in 1912, exemplifies Mondrian’s regard for the new technique. With a procedure indebted to high Analytic Cubism, Mondrian broke down his motif—in this case a tree—into a scaffolding of interlocking black lines and planes of color; furthermore, his palette of close-valued ocher and gray tones resembles Cubist canvases.

First Encounter with Mondrian

In my book The Cockroach Catcher I described how I was suddenly confronted with a piece of work by Mondrian. I have to confess it was not an artist I have heard of at the time. I did not think it was a favourite for most others at the clinic. In a sense I inherited it by accident. Having stared at it for the better part of two and a half years and then spending the next thirty plus years comparing it with other modern art in museums round the world, I have come to appreciate it more and more.
Composition with Yellow, Blue and Red (currently on display at Tate Liverpool)

This is how the scene was described in the book:
“Very neat,” I said.
“It is rather, I think you should have it in your room.” Miss Frys replied.
“Thanks.” Had I managed to resolve some irresolvable conflict or had I been categorised already? In any case the Mondrian would be fine on its own.
Years later I found out that even the Tate rejected Mondrian, but then the Tate also rejected Picasso………”
The Tate now of course has several Mondrian works.

Saturday, July 25, 2015

Art Institute & Mondrian:Thumb Sucking & Winnicott.

It was such a pleasure to encounter Mondrian at the Chicago Art Institute that I am reprinting my blog from earlier days.

Lozenge Composition with Yellow,Black, Blue, Red, and Gray1921
Art Institute Chicago 

Now you can read the whole chapter here:

Chapter 10  First Encounter

In the winter of 1972, something happened that sealed my fate to stay in England forever.  I was appointed Registrar to a world famous clinic.
         By then I already had one of my higher qualifications (D.P.M. – Diploma in Psychological Medicine) and was in the process of sitting the first ever examination of the Royal College of Psychiatrists. At last we could achieve the same standing as colleagues in most other disciplines - a membership, not just a diploma.  I had moved to London to take the examination for this most prestigious psychiatry qualification. My wife had accompanied me for what we thought was a year abroad.
         On a cold October morning I made my way to one of these old mental hospitals which was running the first ever training course for the RoyalCollege Membership examination. It would be foolish not to be there as most of those who ran the new College were on the teaching panel.
         As you drove into the main gate of this rather imposing Victorian beauty or monstrosity, you got the same feel as in most mental hospitals of the same era. There was the odd one working the kerbs and gardens. A small group might be shepherded by a nurse to cross a road on their way to their morning’s appointment. Many had the typical shuffling gaits from the antipsychotics they were on.
         The last of the summer’s Hydrangea flowers still tried to hang on. They looked tired and ugly. I would never have hydrangea in my garden.
         The Post-grad place was easy enough to find as you just followed the majority of the cars.  Wow, with half an hour to go, the car park was already nearly full.  I suppose we all wanted to have a nearby spot to park on such a chilly morning.
         I liked to be nearer the front as chances of falling asleep would be much reduced. I spotted a gap, made my way in and before I could sit down, someone offered me a hand.

Gail: Thumb Sucking

 “I am Gail. I am from the Tavistock.”
         The Tavistock?  Many others would think this was the place they had pop concerts, and doctors would know that the British Medical Association was at Tavistock SquareLondon.  But I knew. I was too astonished. I did not know what to say. Then I managed to utter my name and said that I would be going to the Tavistock, and that I had just been appointed a Registrar there.
         Where I came from no longer seemed so important.
         Synchronicity[1], you see. Gail put her thumb in her mouth and started sucking it vigorously.
         “Sorry, my mother’s fault and she has already paid for my analysis for the last three years. Between you and me, I preferred my thumb. Who is your analyst?”
         “Haven’t got one.”
         “Oh, yes. Dr Collinwood is the odd one out. Her registrar does not need to be in analysis.  However, one good thing the thumb sucking did was to get me my job at the Tavi. I was already in analysis.”
         Analysis for thumb sucking? I thought to myself. Never! Whatever next? And a sought after job in London?
         What did I do wrong, or right to get my job?
         “Ah, you see you are Chinese. You don’t need analysis. Your predecessor was Greek. She had the collective culture of the Ancient Greeks.”
         Perhaps her next registrar would be Egyptian.
         Over the next six hours or so, I began to understand the scale of her problem. It was really like having sex in public and she could be so engrossed in it. It would be wrong to suggest that she tried to reach orgasm but sometimes from the sound she was producing it was not far off. Now and again she noticed that I was paying more attention to the thumb sucking than to the lectures. She stopped and apologised.
         It would be odd to have gone through years of training at a place where the perceived wisdom was that all problems big and small could be traced back to our childhood and more particularly to our sexual development that I should write about my work without any reference to these aspects.  It would also be peculiar if I, having been brought up in a Psychoanalytic Centre of world class reputation, could pretend that sex did not play a significant part in human psychopathology.
         My first encounter with my future colleague certainly shocked me. What was I getting myself into? Was I going to see even crazier people?
         The staff, not the patients.
         My start at the Tavistock was straightforward enough. They had a good introductory pack. I was first briefed by Miss Frys the social work team leader. She was the nicest person one could meet and work with. Warm, kind and she listened carefully. She looked normal enough. I found out later that she was a Quaker and she came from a family where every female member lived to over a hundred. She looked like she was heading that way too.
         She told me Dr Collinwood was very fond of her previous registrar who was a Greek girl.  She was going back to Greece to have her first child before starting a Child Psychiatric clinic there.
         “We are rather fond of Greeks here right now, as there are two others whom you will meet probably at lunch.”
         One later on became a Health Minister in charge of Psychiatry and the other started the Athens Psychoanalytic Society. I too became very fond of both of them and continued to meet them occasionally at international congresses.

Miss Frys had some impressionist prints on the wall and they just seemed to match the colour of her hair. A peculiar picture with coloured squares was by the cupboard and was obviously not hers.
         “Ah, an imposition here. You see, our local library is very good. They have all these prints they lend out to clinics and public offices. This one seemed to be the one left when everybody else have had their pick. I thought, well it is not my type of picture, but it is mathematical and perhaps a Chinese would appreciate it.”
         There were not as many Chinese in the U.K. in those days, and multicultural understanding was almost non-existent.
         Well, it is not in my nature to speak my mind, not at a first meeting with someone who seemed to ooze wisdom and kindness. I took another look and asked, “Who is the artist?”
         “Very neat,” I said.
         “It is rather, I think you should have it in your room.” Miss Frys replied.
         “Thanks.” Had I managed to resolve some irresolvable conflict or had I been categorised already?  In any case the Mondrian would be fine on its own.
         Years later I found out that even the Tate rejected Mondrian, but then the Tate also rejected Picasso.
         Now I am going to be cultured as well.
         “Do you like music? The library has a superb collection of records and they get every thing new as well. I live very close to the Festival Hall. I must take you to a concert there some time unless you have been already.”
         I must confess that with all that studying and preparing for the arrival of our first baby, concerts seemed like a lot of trouble; but I would certainly try and get the records as I had a very good sound system.  Radios and electronics had been my hobby from the age of nine, and over the years I had built at least eight systems of my own, starting with a simple crystal radio set, then graduating to a triple valved receiver system and ultimately to a high fidelity amplification system with EL84[2], which remains the gold standard of the industry.
         It was not until some years after her retirement that I finally took up her offer and met up with her at the Royal Festival Hall. There is no better place to be in London on a late June evening when the light never seems to want to disappear.
         “So you are having a new baby in March. Dr Collinwood is very pleased because you will be able to observe your own baby’s development. It will save a lot of time. But I shall arrange for you to do your nursery observation about three streets away.
         “Now here is Dr Collinwood, I can hear her coming down clanging two cups. She had this kidney stone problem years ago, and her doctor advised her to drink lots. So she takes two cups of coffee instead of one. Oh, I see the coffee lady is bringing down two more. I presume one is for you and one for me.
         “We have this coffee lady who comes in at ten to make coffee. I do not think they pay her very much, but the clinic is thinking about instant coffee and tea-bags so that they can save some money. She has been here twenty two years, as long as I have been, and is part of the fixture. We are all writing letters.”

         I greeted Dr Collinwood, my consultant. She put the coffees down and shook my hand. She looked less scary than the first time I met her. There were now more smiles. What was she making of this young Chinese doctor from across the globe, I wondered.
         Her first concern was the baby. Well she was a real children’s doctor. I later found out that she had worked for years with Winnicott. Winnicott is someone I still have a lot of time for. He was really a paediatrician but his psychological understanding of children and mothers was nearer to my heart than many of the Viennese psychoanalysts such as Sigmund Freud, Anna Freud, and Melanie Klein etc.  Dr Collinwood continued to show great interest in both our children and after she retired the whole family had spent quite a number of summer holidays at her retreat in Suffolk. One time the grand parents came with us too.
         I knew straight away that I would be fine at the Tavistock.
         “There is this case I need to talk to you about.  We missed the last two case presentations (maternity leave and all that) and I promised that we would try and do one six to eight weeks after your arrival.
         “I do not normally give my new junior any old case to take over but this is a nice boy and you might get on with him. I shall continue to see his mother.”
         Meeting with the psychotherapist was another really nice experience. There was so much gesturing that I later discovered was a Jewish thing. But Miss Horowitz you cannot fault. Her father was a famous child psychiatrist and she was really an Anna Freudian[3]. Not so much of the penis envy or bad breast good breast stuff that Gail kept talking about.
         We had twelve cupboards all with individual keys.  Each therapy patient got assigned one and they could put their first name on it. There were packs of toys that the other psychotherapist sorted out and it included drawing material. Drawing paper was multicoloured and we tried not to let the children take their drawings home as a rule, as they were important material for analysis.

All that medical training and exams and so on had not prepared me for what I had to do. I had to start from scratch. I was not even going to take a history. The first session with Michael would be a play oh, sorry psychotherapy session.
         “You will be fine, although it would have been better to learn on a new case.”
         All the Nation’s pride and glory was up to me now. I could only succeed.
         Michael turned out to be a very nice boy as I was promised. He had two problems: nightmares and soiling.
         The nightmares annoyed mum but she really could not stand the soiling.
         “There must be something physical, Dr Collinwood. He has already seen the Greek doctor for six months and now you want him to see this Chinaman?”
         “Oh, very nice to meet you,” she said, putting her unlit cigarette back in her big handbag. She had a very Jewish look with a very Cockney accent. If I knew what I know now, she looked exactly like one of those handing out drinks in one of the New York Hassidic Jewish camera stores. The way her eyes were scanning she did not miss a thing.
         “I brought his pants from school.  He soiled it again.  I thought the doctor might want to see it.”
         I was beginning to “like” her.  Such consideration!
         “Sorry mummy.”
         “There is no need to show Dr Zhang. I hope with a few more sessions we may get to the bottom of the problem.”
         Dr Collinwood was confident. I was not sure if I was.  But my tough medical training saved me – the important rule of using long words and never expressing doubt.  I did not hesitate and said, “Sure we are going to.”
         Mrs Green was evacuated during the war. Dr Collinwood and Miss Frys were trying to put a series together on the effect of evacuation on problems for mothers with the next generation. It was quite unique in its way as hopefully there was not going to be another war and perhaps evacuation would not be used if there was one.
         Her husband was probably Jewish as well and was on Incapacity Benefit as a result of some illness or other.
         Michael soiled only at school and almost always just before going home or coming to the clinic. He often woke up screaming in the middle of the night and insisted that mother should go and see him. She now put him in bed with her to save getting up, she told Dr Collinwood. Mother cleaned for the school so Michael stayed at home with father.
         Mrs Green was so fed up that the previous week she took Michael up Archway Bridge ready to jump. She called Dr Collinwood instead.
         At least in those days we did not have tons of local authority social workers around you once something like that happened. Nowadays Michael would probably have been placed with another family at some point.
         Michael got into a routine pretty quickly. First, we played football - a soft ball. I kept goal three times and he three times. Then we wrote the score on the little black board. He wrote his name on the card provided for the cupboard but insisted on putting three black lines round it.  What would Miss Horowitz say? Then he played with the animals and then arranged the family dolls around the table. Mother, father and a little girl. A boy would probably be too close to home.
         Though he was eight, he was more like six in size and was very timid. He asked permission for just about everything.
         He would then finish with a game of draughts. I made the mistake of leaving the pieces as they were. He saw me three times a week, and he was my first and only patient then.  He asked if I saw anyone else. I quickly learned to put some names on the other cupboards and tidied up the draughts. An obstetrician delivering his first baby must not let the mother know it was his first.
         He soon started drawing. Mother, father, and a baby girl in the middle. We religiously put all these in his cupboard.
         “I like that drawing,” he pointed to the Mondrian, “So neat.” He was right.
         We saw mother and son separately at the same time for fifty minutes twice a week.   Mum always said goodbye to Michael outside my door, with a kiss and darling this and that.  One day after a few sessions, as she walked with Dr Collinwood to her consulting room, she said very loudly, “Is your new doctor any good?  He seemed quiet and sensible, but Michael tells me he only plays football and draughts with him.”
         It was much later that I realised that children are equipped with defences so varied that it sometimes takes one a while to understand what has happened. Michael was an intelligent boy. He had set up decoys. He had now established with mum that I only played football and draughts with him. No wonder we only ever played for a few minutes each time and no wonder it did not matter if the draughts game finished.
         Now instead of putting the girl in the family group, it was a boy, and he no longer drew a girl on his pictures. He drew a boy.
         He kept putting the father in the toilet in the doll’s house.
         One day Michael drew me a picture that I could no longer hold back from Dr Collinwood until supervision time. I intruded into her fluid loading time.
         Michael drew a naked mummy complete with big boobs and pubic hair. The boy in the middle was naked too and had a rather large tool on him. Father was in his pyjamas and Michael drew tears down his face.
         We made the case presentation. It was well attended by nearly everybody including those from the other teams. Word must have got out that Dr Collinwood had a case that had sex features.
         Father suffered from severe diabetes and had been impotent for years.  Mother had very bad abuse history from the evacuation days and had become rather needy of sexual gratification. In a desperate attempt to shame her husband she slept stark naked and put Michael in the middle. She would get Michael to have an erection and then say to her husband, even your eight year old can do better than that. She would not contemplate leaving him, as the benefits were good and she got to drive his car. Dr Collinwood did not mince words on erotic stimulation etc. etc.  All the way through, Gail never sucked her thumb. We passed around the drawings. Freudians made their bid with Oedipus and all that. Kleinians[4] insisted on bad breast. To me it was just an abused mum having a bad time and using the boy to get back at her husband.  But it was only my first case.
         Gail gave me a thumbs up (the other thumb) approvingly afterwards and said I passed the test. I told her that attending Dr Collinwood’s case meetings could save her lots of money. “It’s my mother’s anyway,” she said.
         Michael continued to see me for the best part of the rest of my stay at the Tavistock.  His nightmares disappeared and he stopped soiling.  Nobody knew if his mother stopped fiddling with his penis but to me it was an eye-opener. At least being Jewish she had no qualms about bringing Michael to the clinic three times a week for his therapy sessions. Since then, I have collected quite a few other similar cases, but I shall always remember Michael and Mondrian.

[1] Synchronicity – In The Structure and Dynamics of the Psyche Jung describes how, during his research into the phenomenon of the collective unconscious, he began to observe coincidences that were connected in such a meaningful way that their occurrence seemed to defy the calculations of probability. Unfortunately it is often quoted as a scientific basis for astrology and other improbabilities.
[2] EL84 - a vacuum tube (a.k.a. valve) of the power pentode type. It has a 9 pin miniature base and is found mainly in the final output stages of amplification circuits, most commonly now in guitar amplifiers, but originally in radios and many other devices of the pre-transistor era.  However, even now, hi-fi connoisseurs still prefer sounds produced by valve amplifiers to digital transistor sound.

[3] Anna Freud - Anna Freud moved away from the classical position of her father, who was concentrating on the unconscious Id (a perspective she found to be restrictive) and instead emphasized the importance of the ego, the constant struggle and conflict it is experiencing by the need to answer contradicting wishes, desires, values and demands of reality. By this, she established the importance of the ego functions and the concept of defense mechanisms. Focusing on research, observation and treatment of children, Freud established a group of prominent child developmental analysts (which included Erik Erikson, Edith Jacobson and Margaret Mahler) who noticed that children's symptoms were ultimately analogue to personality disorders among adults and thus often related to developmental stages. At that time, these ideas were revolutionary and Anna provided us with a comprehensive developmental theory and the concept of developmental lines.
   As such, the formation of the fields of child psychoanalysis and child developmental psychology can be attributed to Anna Freud.
“……I think that a psychoanalyst should have...interests...beyond the limits of the medical facts that belong to sociology, religion, literature, ,[and] history,...[otherwise]his outlook on...his patient will remain too narrow. This point contains...the necessary preparations beyond the requirements made on candidates of psychoanalysis in the institutes. You ought to be a great reader and become acquainted with the literature of many countries and cultures. In the great literary figures you will find people who know at least as much of human nature as the psychiatrists and psychologists try to do.”        Anna Freud

[4] Melanie Klein - child psychoanalyst who worked in London (as the US required a MD degree to practise psychoanalysis) had a strong following and some severe critics too. Her theories – (as portrayed in Nicholas Wright’s 1988-Mrs Klein) include references to: "good breast" and "the bad breast"; "symbolic urine"; playing the violin as "a repressed masturbation fantasy"; automobiles  being penises and mountains being breasts.