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TREATMENT OF SEVERELY DISTURBED CHILDREN
445 cedure should not be undertaken unless the potential advantages the natient outweieh these armreciable hazards.
UNION OF FRACTURES
to
p. 305) and I are agreed R. W. AINSWORTH stimulates callus. Our fracture that DOUGLAS GAIRDNER to that whereas I be fundamental difference seems regard J. H. RACK callus as the means to an end (union) he regards it as the MARY WEBB. end itself. United Cambridge Hospitals. I believe callus to be the physiological reaction to a TREATMENT OF SEVERELY DISTURBED dangerous stimulus, much as I regard leucocytosis as the CHILDREN reaction to an infection. The purpose of both is to abolish the stimulus, and they are usually successful without any Kahan SIR,-Dr. (Feb. 9) makes some interesting a aid from the doctor. When rigid plate reduces the need comments on the residential treatment of severely disfor a large quantity of callus I am as satisfied as when an turbed children. We seem to be learning the same antibiotic reduces the need for a very high leucocytosis. lessons at Queen Mary’s Hospital for Children, where a I would no more give provocative movements to stimulate short-stay psychiatric unit was opened in May, 1962. excess callus formation than I would inject more staphyThese are: lococci into an area of cellulitis to provoke a higher (1) The smooth adjustment of a disturbed child to the ward callus and leucocytosis accord to my environment is hindered by the conventional rotation of leucocytosis. Both cir- nursing staff. Indeed, the appropriate correction was made description of " desirable reactions to undesirable " cumstances ". Sometimes, I believe, the undesirable within the first twelve weeks of the unit’s life. (2) The demands and impact of a group of disturbed circumstances" can be overwhelming-even for the have an almost specific fatigue-inducing effect on the children cave-man. The infection is too vigorous or the movement staff. They are more or less relieved of patient care nursing is too powerful, as the case may, be, to be controlled by during school hours when the children are taken for classes on the defence mechanism, and in fractures this means the ward by two teachers employed by the local education non-union. It is in these few cases that outside help is authority. The maximum number of the group has never needed, but the help required is to abolish the " un- exceeded fifteen. desirable circumstance ", not add to it. This is why (3) Severely disturbed children by virtue of their effect on less disturbed children and staff need in a found to used for the worst cases is excruciating series, rigidity, make a separate homogeneous group. The segregation. They a of union. give greater reliability continuous scream of a psychotic child, and the boost grating Of course, if Mr. Strange convinces us that he has no it receives from primitive ward acoustics, can quickly upset the cases (whether they pass under the name of problem balance of the group as a whole. " non-union " or of " refracture ") then he has succeeded precarious Compared with Dr. Kahan’s group, our children are in showing that this danger is purely hypothetical. But at less disturbed and in hospital for a shorter time. With the Birmingham Accident Hospital we have not succeeded his conclusion about the recruitment of staff in reducing our bone-graft rate for tibias (a severe testing regard to " a (that strong desire for the work often outweighs lack ground for a treatment) below 2B% and, although this of professional training "), our findings are that some is lower than the figures from three of the conservative student psediatric nurses who were introduced to the schools, it is not low enough to satisfy us. Before preunit as part of their general training, and who had never senting his figures, however, Mr. Strange must realise that his criteria for union are insufficiently strict to meet consciously had a strong desire for this type of work, made exceptionally good house-mothers. We also find our standards. Two final points not relevant to the immediate dis- that, although junior nurses and house-mothers derive some insight from discussion groups and seminars, they cussion. Firstly, the dangers of internal fixation are substantial, and it should not be used except by those gain much more from their experience of the pattern of who know how to minimise the and can child care set by the mature key figures of the senior
SlR,—Mr. Strange (Feb. 9, movement at a
complications
for certain deal with them when they arise. Secondly, of rigid fixation in up to half of our fracture cases genuinely arises from a desire to improve results and not
our use
nursing staff. Queen Mary’s Hospital for Children, Carshalton, Surrey.
AMNION IMPLANTATION IN PERIPHERAL VASCULAR DISEASE
from iov in ooeratins-.
J. H. HICKS.
Birmingham Accident Hospital.
UMBILICAL ARTERY FOR TRANSFUSION
SIR,-We should
like to comment on Dr. Cottom’s the use of the umbilical artery for fluid replacement " and for arterial sampling,
letter (Feb. 9) "
prolonged
on
by means of an indwelling catheter. We have in the past two years catheterised by this route 50 newborn babies, a large proportion being prematures with respiratory failure. 20 of them died, and a characteristic finding at necropsy (performed in every case) was that the passage of the catheter had caused extensive haemorrhage into the outer part of the arterial wall. In addition there was some thrombus at the junction of the iliac and umbilical arteries in 2 cases. In 2 of the survivors cyanosis of one leg developed, presumably owing to arterial spasm; removal of the catheter restored the
circulation. In to
no case
has
catheterisation contributed amongst survivors. thrombosis can occur, the pro-
umbilical-artery
death, and there have been
But since arterial spasm
or
no
sequelae
G. CROSSE.
Sirwas very interested in Mr. Pringle’s observations (Jan. 12), since he states that " amnion implantation has no demonstrable effect on the course of peripheral vascular disease ". This coincides with my observations in a limited series. My purpose, however, is to call attention to the possible value of this treatment in acrocyanosis. I referred1 to the use of this material in the following words: "
I have noted over the years that whereas the varix becomes in early pregnancy, the acrocyanotic limb may often improve. For this reason I implanted amnion in a series of limbs. Some of the patients were much improved. Results were too variable, however, for us to recommend this treatment. However, when stripping the limb which is the seat of both varicose and acrocyanotic trouble, the question of an amnion implant may be considered. It can do no harm, and on occasions the results are good. It should be remembered that incompetent varices cause more symptoms in a worse
1. Varicose
Veins; p. 264. Bristol, 1960.
UNION OF FRACTURES
to
p. 305) and I are agreed R. W. AINSWORTH stimulates callus. Our fracture that DOUGLAS GAIRDNER to that whereas I be fundamental difference seems regard J. H. RACK callus as the means to an end (union) he regards it as the MARY WEBB. end itself. United Cambridge Hospitals. I believe callus to be the physiological reaction to a TREATMENT OF SEVERELY DISTURBED dangerous stimulus, much as I regard leucocytosis as the CHILDREN reaction to an infection. The purpose of both is to abolish the stimulus, and they are usually successful without any Kahan SIR,-Dr. (Feb. 9) makes some interesting a aid from the doctor. When rigid plate reduces the need comments on the residential treatment of severely disfor a large quantity of callus I am as satisfied as when an turbed children. We seem to be learning the same antibiotic reduces the need for a very high leucocytosis. lessons at Queen Mary’s Hospital for Children, where a I would no more give provocative movements to stimulate short-stay psychiatric unit was opened in May, 1962. excess callus formation than I would inject more staphyThese are: lococci into an area of cellulitis to provoke a higher (1) The smooth adjustment of a disturbed child to the ward callus and leucocytosis accord to my environment is hindered by the conventional rotation of leucocytosis. Both cir- nursing staff. Indeed, the appropriate correction was made description of " desirable reactions to undesirable " cumstances ". Sometimes, I believe, the undesirable within the first twelve weeks of the unit’s life. (2) The demands and impact of a group of disturbed circumstances" can be overwhelming-even for the have an almost specific fatigue-inducing effect on the children cave-man. The infection is too vigorous or the movement staff. They are more or less relieved of patient care nursing is too powerful, as the case may, be, to be controlled by during school hours when the children are taken for classes on the defence mechanism, and in fractures this means the ward by two teachers employed by the local education non-union. It is in these few cases that outside help is authority. The maximum number of the group has never needed, but the help required is to abolish the " un- exceeded fifteen. desirable circumstance ", not add to it. This is why (3) Severely disturbed children by virtue of their effect on less disturbed children and staff need in a found to used for the worst cases is excruciating series, rigidity, make a separate homogeneous group. The segregation. They a of union. give greater reliability continuous scream of a psychotic child, and the boost grating Of course, if Mr. Strange convinces us that he has no it receives from primitive ward acoustics, can quickly upset the cases (whether they pass under the name of problem balance of the group as a whole. " non-union " or of " refracture ") then he has succeeded precarious Compared with Dr. Kahan’s group, our children are in showing that this danger is purely hypothetical. But at less disturbed and in hospital for a shorter time. With the Birmingham Accident Hospital we have not succeeded his conclusion about the recruitment of staff in reducing our bone-graft rate for tibias (a severe testing regard to " a (that strong desire for the work often outweighs lack ground for a treatment) below 2B% and, although this of professional training "), our findings are that some is lower than the figures from three of the conservative student psediatric nurses who were introduced to the schools, it is not low enough to satisfy us. Before preunit as part of their general training, and who had never senting his figures, however, Mr. Strange must realise that his criteria for union are insufficiently strict to meet consciously had a strong desire for this type of work, made exceptionally good house-mothers. We also find our standards. Two final points not relevant to the immediate dis- that, although junior nurses and house-mothers derive some insight from discussion groups and seminars, they cussion. Firstly, the dangers of internal fixation are substantial, and it should not be used except by those gain much more from their experience of the pattern of who know how to minimise the and can child care set by the mature key figures of the senior
SlR,—Mr. Strange (Feb. 9, movement at a
complications
for certain deal with them when they arise. Secondly, of rigid fixation in up to half of our fracture cases genuinely arises from a desire to improve results and not
our use
nursing staff. Queen Mary’s Hospital for Children, Carshalton, Surrey.
AMNION IMPLANTATION IN PERIPHERAL VASCULAR DISEASE
from iov in ooeratins-.
J. H. HICKS.
Birmingham Accident Hospital.
UMBILICAL ARTERY FOR TRANSFUSION
SIR,-We should
like to comment on Dr. Cottom’s the use of the umbilical artery for fluid replacement " and for arterial sampling,
letter (Feb. 9) "
prolonged
on
by means of an indwelling catheter. We have in the past two years catheterised by this route 50 newborn babies, a large proportion being prematures with respiratory failure. 20 of them died, and a characteristic finding at necropsy (performed in every case) was that the passage of the catheter had caused extensive haemorrhage into the outer part of the arterial wall. In addition there was some thrombus at the junction of the iliac and umbilical arteries in 2 cases. In 2 of the survivors cyanosis of one leg developed, presumably owing to arterial spasm; removal of the catheter restored the
circulation. In to
no case
has
catheterisation contributed amongst survivors. thrombosis can occur, the pro-
umbilical-artery
death, and there have been
But since arterial spasm
or
no
sequelae
G. CROSSE.
Sirwas very interested in Mr. Pringle’s observations (Jan. 12), since he states that " amnion implantation has no demonstrable effect on the course of peripheral vascular disease ". This coincides with my observations in a limited series. My purpose, however, is to call attention to the possible value of this treatment in acrocyanosis. I referred1 to the use of this material in the following words: "
I have noted over the years that whereas the varix becomes in early pregnancy, the acrocyanotic limb may often improve. For this reason I implanted amnion in a series of limbs. Some of the patients were much improved. Results were too variable, however, for us to recommend this treatment. However, when stripping the limb which is the seat of both varicose and acrocyanotic trouble, the question of an amnion implant may be considered. It can do no harm, and on occasions the results are good. It should be remembered that incompetent varices cause more symptoms in a worse
1. Varicose
Veins; p. 264. Bristol, 1960.