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INFORMAL ADMISSION OF MENTAL DEFECTIVES
316
Letters
to
the Editor
removing the protection previously afforded him by powers designed to safeguard the interests of the patient and the general public.
while
INFORMAL ADMISSION OF MENTAL DEFECTIVES
W. A. HEATON-WARD.
Bristol.
SiR,—Iwrite as the medical officer of a large and, I like to think, progressive hospital for mental defectives, whose policy is to train as many patients as possible to take their place in the community as soon as their rehabilitation is complete. In this post I have often found myself caught in the cross-fire between the forces of the " Civil-Liberty Guards on the one hand and those of the " Protect-the-Public-at-all-Costs Brigade on the other. The main strength of each force appears to be such that they might appropriately be called the reds " and the blues respectively, with supernumerary strength derived from the less responsible sections of the press, both national and local, vaccilating apparently according to the circulation-appeal of either cause at a particular time. It is not surprising, therefore, that I should feel considerable concern at the publication of a Ministry of Health circular recommending the informal admission of mental defectives to mental-deficiency hospitals and at the uncritical enthusiasm with which politicians and press have welcomed this allegedly great advance. "
"
"
"
"
REDUCTION OF INDIRECT BILIRUBINÆMIA IN VIVO
SIR,-Indirect bilirubin is believed to be neurotoxic in high concentration, and current theory attributes the kernicterus associated with hxmolytic disease of the newborn to such injury. Kernicterus is also seen in some cases of physiological icterus associated with hyperbilirubinsemia, especially in premature infants. Exchange transfusion, now widely practised to treat these conditions, is a cumbersome procedure, not entirely without risk.1 We have such cases
attempted to reduce the indirect bilirubineemia in by the oral administration of glucuronic acid. It
The modern concept of mental deficiency is that of social incapacity of such a degree as to render an individual in need of care, supervision, and control for his own protection or for the protection of others. Mental illness, on the other hand, in almost all cases, arises in individuals previously able to lead a fully independent existence. However, examination of the circular suggests that the Ministry of Health regards the mental defective as more capable of self-care than the voluntary patient with mental illness, in that he is to be allowed to leave hospital immediately (i.e., without the seventy-two hours’ notice at present required of the voluntary patients in a mental hospital) should he not respond to persuasion from the medical officer to remain. I visualise persuasion " becoming the signal for the " reds " to load and for the warreporters to hasten to the scene. On the other hand, let one of these patients wander away from hospital and be involved in injury to a member of the public and the blues will "
"
"
attack with full press support. It is true that the more severely handicapped mental defective could be admitted informally, provided that the medical officer of the hospital were given power to detain him for a prescribed period pending provision for alternative care, should this prove necessary, without the risk of allegations of wrongful detention being subsequently levelled. However, this seems to offer no advantage over an extension to all grades of mental defectives of the present arrangements under which the parents of these patients may place them under hospital care and retain the right to withdraw them on giving notice, so long as they are able to provide a satisfactory home for them. On the other hand, the admission of the higher-grade patients to mental-deficiency hospitals results from their failure in the outside world, and any successful rehabilitation and training, which is of necessity prolonged in most cases, will be impossible if they are to be allowed to leave hospital whenever they wish. It is unrealistic to believe that they will be sufficiently self-critical to appreciate their own shortcomings and the benefits to be derived from further stay in hospital, particularly if, they are encouraged in their resolve by the outside influences I have mentioned. I believe that for these reasons detention orders will be necessaary in a higher proportion of these cases than the circular would
suggest.
The new recommendation will, I believe, expose the medical officer to even more concentrated cross-fire,
Change
in
serum-bilirubin in
one
patient
on
glucuronic-acid
treatment.
thought that this might favour the conversion of the relatively toxic indirect bilirubin to the less toxic and more readily excreted direct bilirubin, which is known to be a glucuronicacid conjugate. Considerable success has been achieved by this measure. In 16 out of 27 cases we have observed a sharp drop in the level of indirect bilirubin, which persisted as long as the oral medication (1 g. per hour by mouth) was continued (see figure). In some instances, but not in all, this was associated
was
with a simultaneous but smaller rise in the concentration of direct bilirubin. In 11 patients no definite response was obtained. 1 of these, a premature infant, was subsequently given intravenous glucuronic acid with a striking response.
These preliminary observations suggest that oral therapy with glucuronic acid may prove beneficial in the prevention of kernicterus in a considerable proportion of cases and may serve to replace exchange
transfusion.
I
Department of Pediatrics, New York University College of Medicine. 1.
STUART DANOFF CHARLOTTE GRANTZ AUDREY BOYER L. EMMETT HOLT, JR.
Walker, W., Mollison, P. L. Lancet, 1957, i,
1309.
Letters
to
the Editor
removing the protection previously afforded him by powers designed to safeguard the interests of the patient and the general public.
while
INFORMAL ADMISSION OF MENTAL DEFECTIVES
W. A. HEATON-WARD.
Bristol.
SiR,—Iwrite as the medical officer of a large and, I like to think, progressive hospital for mental defectives, whose policy is to train as many patients as possible to take their place in the community as soon as their rehabilitation is complete. In this post I have often found myself caught in the cross-fire between the forces of the " Civil-Liberty Guards on the one hand and those of the " Protect-the-Public-at-all-Costs Brigade on the other. The main strength of each force appears to be such that they might appropriately be called the reds " and the blues respectively, with supernumerary strength derived from the less responsible sections of the press, both national and local, vaccilating apparently according to the circulation-appeal of either cause at a particular time. It is not surprising, therefore, that I should feel considerable concern at the publication of a Ministry of Health circular recommending the informal admission of mental defectives to mental-deficiency hospitals and at the uncritical enthusiasm with which politicians and press have welcomed this allegedly great advance. "
"
"
"
"
REDUCTION OF INDIRECT BILIRUBINÆMIA IN VIVO
SIR,-Indirect bilirubin is believed to be neurotoxic in high concentration, and current theory attributes the kernicterus associated with hxmolytic disease of the newborn to such injury. Kernicterus is also seen in some cases of physiological icterus associated with hyperbilirubinsemia, especially in premature infants. Exchange transfusion, now widely practised to treat these conditions, is a cumbersome procedure, not entirely without risk.1 We have such cases
attempted to reduce the indirect bilirubineemia in by the oral administration of glucuronic acid. It
The modern concept of mental deficiency is that of social incapacity of such a degree as to render an individual in need of care, supervision, and control for his own protection or for the protection of others. Mental illness, on the other hand, in almost all cases, arises in individuals previously able to lead a fully independent existence. However, examination of the circular suggests that the Ministry of Health regards the mental defective as more capable of self-care than the voluntary patient with mental illness, in that he is to be allowed to leave hospital immediately (i.e., without the seventy-two hours’ notice at present required of the voluntary patients in a mental hospital) should he not respond to persuasion from the medical officer to remain. I visualise persuasion " becoming the signal for the " reds " to load and for the warreporters to hasten to the scene. On the other hand, let one of these patients wander away from hospital and be involved in injury to a member of the public and the blues will "
"
"
attack with full press support. It is true that the more severely handicapped mental defective could be admitted informally, provided that the medical officer of the hospital were given power to detain him for a prescribed period pending provision for alternative care, should this prove necessary, without the risk of allegations of wrongful detention being subsequently levelled. However, this seems to offer no advantage over an extension to all grades of mental defectives of the present arrangements under which the parents of these patients may place them under hospital care and retain the right to withdraw them on giving notice, so long as they are able to provide a satisfactory home for them. On the other hand, the admission of the higher-grade patients to mental-deficiency hospitals results from their failure in the outside world, and any successful rehabilitation and training, which is of necessity prolonged in most cases, will be impossible if they are to be allowed to leave hospital whenever they wish. It is unrealistic to believe that they will be sufficiently self-critical to appreciate their own shortcomings and the benefits to be derived from further stay in hospital, particularly if, they are encouraged in their resolve by the outside influences I have mentioned. I believe that for these reasons detention orders will be necessaary in a higher proportion of these cases than the circular would
suggest.
The new recommendation will, I believe, expose the medical officer to even more concentrated cross-fire,
Change
in
serum-bilirubin in
one
patient
on
glucuronic-acid
treatment.
thought that this might favour the conversion of the relatively toxic indirect bilirubin to the less toxic and more readily excreted direct bilirubin, which is known to be a glucuronicacid conjugate. Considerable success has been achieved by this measure. In 16 out of 27 cases we have observed a sharp drop in the level of indirect bilirubin, which persisted as long as the oral medication (1 g. per hour by mouth) was continued (see figure). In some instances, but not in all, this was associated
was
with a simultaneous but smaller rise in the concentration of direct bilirubin. In 11 patients no definite response was obtained. 1 of these, a premature infant, was subsequently given intravenous glucuronic acid with a striking response.
These preliminary observations suggest that oral therapy with glucuronic acid may prove beneficial in the prevention of kernicterus in a considerable proportion of cases and may serve to replace exchange
transfusion.
I
Department of Pediatrics, New York University College of Medicine. 1.
STUART DANOFF CHARLOTTE GRANTZ AUDREY BOYER L. EMMETT HOLT, JR.
Walker, W., Mollison, P. L. Lancet, 1957, i,
1309.