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INADEQUATE MOTHERS
1451 in which
graphy
iopanoic acid (’ Telepaque ’) for oral cholecystoingested, there is no evidence of associated
was
drug therapy. In all cases for which I have sufficient information, the history fits the stress syndrome. I believe those patients who have inherited this disease risk in situations other than anaathesia, because it is made worse by emotional excitement and it must be recognised in order to advise them about medical care. are at
Department of Anesthesiology, University of Nebraska Medical Center, 42nd and Dewey Avenue, Omaha, Nebraska 68105, U.S.A.
‘
Radnor House,
Hay
on
Wye,
JAMES MATHERS.
Hereford HR3 5DQ.
ARTIFICIAL KIDNEY AND ARTIFICIAL DANIEL W. WINGARD.
INADEQUATE MOTHERS SiR,—Ifind it somewhat surprising that a letter from an institute of family psychiatry (Nov. 30, p. 1322) should advocate separation of the child from its inadequate mother. For one thing, it presupposes an inexhaustible supply of long-term foster parents, a condition which perhaps prevails in the Ipswich area, but certainly does not in this residential outer London borough. Baby-battering, like parasuicide, with which it is in many ways comparable, has no one single cause, and the study our controls, the more we realise that there few mothers indeed who are not potential babybatterers : there are rather high-risk and low-risk groups. But unhappy women have not been slow to learn that to admit to baby-battering or a fear of battering is to ensure immediate and continuing attention to their distress. All too often these young mothers have themselves been disadvantaged by parental loss or rejection from an early age and seem to choose as consorts men who, equally, are indifferent or uninvolved. The " remoteness from, and unresponsiveness to, the infant even from its birth " commented on by Dr Eickhoff (Nov. 9, p. 1152) is often determined by pre-existing depression, puerperal breakdown, or illness in the child which prevents normal bonding. In one case, for example, a harness fitted for correction of congenital dislocation of the hip made it impossible for the mother to nurse or breast-feed her baby. The aim is not, to quote Ms Osborn (Nov. 30, p. 1322), " to alter a woman’s personality overnight ": indeed, in a day-hospital setting, it can take months of skilled nursing supervision to bring about any appreciable improvement in mother/child relationship. But this gives time to treat any puerperal illness, and, working in close liaison with the health visitor and social services, to involve other members of the family; meanwhile these inexperienced mothers and their children get the mothering they need, while contact with staff and less disturbed mothers provides a useful model of mothering behaviour. To keep staff anxiety at tolerable levels, we have to limit our number to six such mothers at a time, but, despite the slow gains, we feel this method preferable to the inevitable succession of short-term placements in care which merely serve to perpetuate the cycle of deprivation.
more we
are
Day Hospital, 77 Woodcote Road,
Wallington,
JOY WEST.
Surrey.
Sm,—Few would dissent from the proposition that when baby is battered it means that something is wrong with a parent, usually mother, even if mother’s disability is only given the imprecise label of inadequacy ". So what are the ethical and practical grounds on which Mrs Osborn (Nov. 30, p. 1322) recommends separation of the child from the mother-but only offers " love and care to the child ? Separation should surely be prescribed, if at all, a
"
"
1. Gelles, R. J.
only after the mother and child together have been thoroughly assessed, as inpatients if necessary, and a more precise diagnosis made of mother’s long-term incapacity. ’ During the assessment process, at least, one hopes that substitute love and care would be provided for them both.
Am. J. Orthopsych. 1973, 43/4,
611.
LIVER
SiR,—Iam writing to comment on your editorial on artificial liver (Oct. 26, p. 992) and also on Dr Oreopoulos’s letter (Sept. 28, p. 779) about your editorial on tomorrow’s artificial kidney (Aug. 24, p. 446). The charcoal artificial kidney to which Dr Oreopoulos referred is not the same as the microcapsule artificial kidney referred to in the editorial. The original charcoal artificial kidney consisted in perfusion of blood directly over charcoal granules,]. whereas the microcapsule artificial kidney depends on the principle of artificial cells using semipermeable microcapsules, studied in our laboratory since 1956.2-4 In the latter case, ultrathin biocompatible semipermeable membranes are made to envelop or coat various types of biologically active material, including enzymes, ion-exchange resin, and activated The enveloping biocompatible membranes charcoal. prevent the enclosed materials from having any adverse effects on the body, but at the same time allow permeant toxins or metabolites to enter the microcapsules to be acted on by the enclosed materials. Furthermore, because of the ultrathin membrane (300 A) and the high surface area (300 ml.) semipermeable microcapsules have a potential transport rate which is about 100 times that of the standard haemodialysers.2-4 We use charcoal as one of the microencapsulated materials because activated charcoal granules are effective in adsorbing many toxic materials, but when used for direct blood perfusion give off embolising particles and remove platelets. Microencapsulation of active charcoal granules by coating with biocompatible membranes eliminates the problems of embolism and platelet removal and at the same time makes use of the adsorbing properties of charcoal, thus allowing clinical use in patients with renal failure, drug overdose, and hepatic failure. In animal experiments, we have also studied the microcapsule artificial kidney constructed from microencapsulated enzymes, ionexchange resin, and other adsorbents for the removal of other toxins or waste metabolites.2-4 In all these cases, we made use of the artificial-cell approach to contain biologically active material. If Dr Oreopoulos refers to the chapter on the microcapsule artificial kidney in the book on Renal Dialysis,5 the book on Artificial Cells,4 or detailed papers from this laboratory, he will find full credit attributed to Dr Yatzidi’s group for their use of direct charcoal ha:moperfusion and at the same time an account of our reasons for using the principle of artificial cells in the form of semipermeable microcapsules to envelop or coat the charcoal to avoid the adverse effects of direct perfusion. As discussed in your editorial on an artificial liver, the microcapsule approach in the form of coated charcoal is also being assessed for the treatment of hepatic failure at McGill6 and more recently at King’s.’I A complete artificial liver 1. Yatzidis, H. Eur. Dial. Transplant. Ass. Proc. 1964, 1, 83. 2. Chang, T. M. S. Trans. Am. Soc. artif. intern. Organs, 1966, 12, 13. 3. Chang, T. M. S. Science, 1964, 146, 524. 4. Chang, T. M. S. Artificial Cells. Springfield, Illinois, 1972. 5. Renal Dialysis (edited by D. Whelpton). London, 1974. 6. Chang, T. M. S. Lancet, 1972, ii, 1371. 7. Gazzard, B. G., Weston, M. J., Murray-Lyon, I. M., Flax, H., Record, C. D., Portmann, B., Langley, P. G., Dunlop, E. H.,
Mellon, P. J., Ward, M. D., Williams, R. ibid. 1974, i, 1301.
graphy
iopanoic acid (’ Telepaque ’) for oral cholecystoingested, there is no evidence of associated
was
drug therapy. In all cases for which I have sufficient information, the history fits the stress syndrome. I believe those patients who have inherited this disease risk in situations other than anaathesia, because it is made worse by emotional excitement and it must be recognised in order to advise them about medical care. are at
Department of Anesthesiology, University of Nebraska Medical Center, 42nd and Dewey Avenue, Omaha, Nebraska 68105, U.S.A.
‘
Radnor House,
Hay
on
Wye,
JAMES MATHERS.
Hereford HR3 5DQ.
ARTIFICIAL KIDNEY AND ARTIFICIAL DANIEL W. WINGARD.
INADEQUATE MOTHERS SiR,—Ifind it somewhat surprising that a letter from an institute of family psychiatry (Nov. 30, p. 1322) should advocate separation of the child from its inadequate mother. For one thing, it presupposes an inexhaustible supply of long-term foster parents, a condition which perhaps prevails in the Ipswich area, but certainly does not in this residential outer London borough. Baby-battering, like parasuicide, with which it is in many ways comparable, has no one single cause, and the study our controls, the more we realise that there few mothers indeed who are not potential babybatterers : there are rather high-risk and low-risk groups. But unhappy women have not been slow to learn that to admit to baby-battering or a fear of battering is to ensure immediate and continuing attention to their distress. All too often these young mothers have themselves been disadvantaged by parental loss or rejection from an early age and seem to choose as consorts men who, equally, are indifferent or uninvolved. The " remoteness from, and unresponsiveness to, the infant even from its birth " commented on by Dr Eickhoff (Nov. 9, p. 1152) is often determined by pre-existing depression, puerperal breakdown, or illness in the child which prevents normal bonding. In one case, for example, a harness fitted for correction of congenital dislocation of the hip made it impossible for the mother to nurse or breast-feed her baby. The aim is not, to quote Ms Osborn (Nov. 30, p. 1322), " to alter a woman’s personality overnight ": indeed, in a day-hospital setting, it can take months of skilled nursing supervision to bring about any appreciable improvement in mother/child relationship. But this gives time to treat any puerperal illness, and, working in close liaison with the health visitor and social services, to involve other members of the family; meanwhile these inexperienced mothers and their children get the mothering they need, while contact with staff and less disturbed mothers provides a useful model of mothering behaviour. To keep staff anxiety at tolerable levels, we have to limit our number to six such mothers at a time, but, despite the slow gains, we feel this method preferable to the inevitable succession of short-term placements in care which merely serve to perpetuate the cycle of deprivation.
more we
are
Day Hospital, 77 Woodcote Road,
Wallington,
JOY WEST.
Surrey.
Sm,—Few would dissent from the proposition that when baby is battered it means that something is wrong with a parent, usually mother, even if mother’s disability is only given the imprecise label of inadequacy ". So what are the ethical and practical grounds on which Mrs Osborn (Nov. 30, p. 1322) recommends separation of the child from the mother-but only offers " love and care to the child ? Separation should surely be prescribed, if at all, a
"
"
1. Gelles, R. J.
only after the mother and child together have been thoroughly assessed, as inpatients if necessary, and a more precise diagnosis made of mother’s long-term incapacity. ’ During the assessment process, at least, one hopes that substitute love and care would be provided for them both.
Am. J. Orthopsych. 1973, 43/4,
611.
LIVER
SiR,—Iam writing to comment on your editorial on artificial liver (Oct. 26, p. 992) and also on Dr Oreopoulos’s letter (Sept. 28, p. 779) about your editorial on tomorrow’s artificial kidney (Aug. 24, p. 446). The charcoal artificial kidney to which Dr Oreopoulos referred is not the same as the microcapsule artificial kidney referred to in the editorial. The original charcoal artificial kidney consisted in perfusion of blood directly over charcoal granules,]. whereas the microcapsule artificial kidney depends on the principle of artificial cells using semipermeable microcapsules, studied in our laboratory since 1956.2-4 In the latter case, ultrathin biocompatible semipermeable membranes are made to envelop or coat various types of biologically active material, including enzymes, ion-exchange resin, and activated The enveloping biocompatible membranes charcoal. prevent the enclosed materials from having any adverse effects on the body, but at the same time allow permeant toxins or metabolites to enter the microcapsules to be acted on by the enclosed materials. Furthermore, because of the ultrathin membrane (300 A) and the high surface area (300 ml.) semipermeable microcapsules have a potential transport rate which is about 100 times that of the standard haemodialysers.2-4 We use charcoal as one of the microencapsulated materials because activated charcoal granules are effective in adsorbing many toxic materials, but when used for direct blood perfusion give off embolising particles and remove platelets. Microencapsulation of active charcoal granules by coating with biocompatible membranes eliminates the problems of embolism and platelet removal and at the same time makes use of the adsorbing properties of charcoal, thus allowing clinical use in patients with renal failure, drug overdose, and hepatic failure. In animal experiments, we have also studied the microcapsule artificial kidney constructed from microencapsulated enzymes, ionexchange resin, and other adsorbents for the removal of other toxins or waste metabolites.2-4 In all these cases, we made use of the artificial-cell approach to contain biologically active material. If Dr Oreopoulos refers to the chapter on the microcapsule artificial kidney in the book on Renal Dialysis,5 the book on Artificial Cells,4 or detailed papers from this laboratory, he will find full credit attributed to Dr Yatzidi’s group for their use of direct charcoal ha:moperfusion and at the same time an account of our reasons for using the principle of artificial cells in the form of semipermeable microcapsules to envelop or coat the charcoal to avoid the adverse effects of direct perfusion. As discussed in your editorial on an artificial liver, the microcapsule approach in the form of coated charcoal is also being assessed for the treatment of hepatic failure at McGill6 and more recently at King’s.’I A complete artificial liver 1. Yatzidis, H. Eur. Dial. Transplant. Ass. Proc. 1964, 1, 83. 2. Chang, T. M. S. Trans. Am. Soc. artif. intern. Organs, 1966, 12, 13. 3. Chang, T. M. S. Science, 1964, 146, 524. 4. Chang, T. M. S. Artificial Cells. Springfield, Illinois, 1972. 5. Renal Dialysis (edited by D. Whelpton). London, 1974. 6. Chang, T. M. S. Lancet, 1972, ii, 1371. 7. Gazzard, B. G., Weston, M. J., Murray-Lyon, I. M., Flax, H., Record, C. D., Portmann, B., Langley, P. G., Dunlop, E. H.,
Mellon, P. J., Ward, M. D., Williams, R. ibid. 1974, i, 1301.