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OCCUPATIONAL THERAPY
249 in the circulation an unpredictable amount is lost by passive transfer to adjacent tissues; this would lead to an overestimate of cardiac output by the temperature-sensitive sensing device downstream. Despite Dr. Khalil’s reluctance to accept the adequacy of more firmly established methods, and the technical difficulties and theoretical uncertainties of heat transfer methods, the close agreement which he found for values of cardiac output by the direct Fick method and by his modification of the thermal dilution method is almost
incredible. Department of Medicine, West Virginia University, Morgantown, West Virginia.
ROBERT
J. MARSHALL.
INTRAPERITONEAL TRANSFUSION OF BLOOD IN NEWBORN BABIES SIR,-I sympathise with Professor Rendle-Short’s dislike (July 20) of intraperitoneal blood-transfusion when his personal experience is limited to 2 cases with 100% mortality. This experience, however, is utterly at variance with that of other workers 1-4 who, in series of up to 800 such transfusions, have had no mortality attributable to using the peritoneal route. It seems unlikely, moreover, that the peritoneal adhesions which caused the death of the first child he mentions were due to a peritoneal transfusion given only four days previously, since there was hardly time for the sequence of events leading to death from intestinal obstruction from adhesions. If, as seems more likely, the adhesions were already formed or forming, peritoneal transfusion would in any case be contraindicated. Both the cases Professor Rendle-Short mentions are sufficiently unusual that I would welcome further clinical details. I also agree that I have never known it impossible to get blood into the vein of a newborn baby. There are, however, circumstances when intravenous transfusion of blood into babies is attended by considerable danger of heart-failure, and, when these circumstances apply, intraperitoneal transfusion is a safer alternative. Furthermore, in some parts of the world where it is difficult to provide adequate trained staff to supervise transfusion in babies, peritoneal transfusion may be a justifiable alternative to venous transfusion in selected babies where none of the contraindications aoolv. Nuffield Neonatal Research Unit,
Hammersmith Hospital,
London, W.12.
J. W. SCOPES.
OCCUPATIONAL THERAPY
SIR,-In the report of the International Hospita Congress held in Paris, Mr. R. L. Darch is stated to have suggested that the cost of providing occupational therapy, along with other services, could be out of proportion to the benefit derived (June 22, p. 1371). Occupational therapy is a young profession, and many of our members can remember the days when they were expected to retrieve, from the sale of articles made, most of the money spent on materials! Fortunately, it is now realised that treatment costs money; and with the growth of" industtial therapy " within psychiatric hospitals there is still need to emphasise the fact that every commercial aspect of occupational therapy should be secondary to the real needs of the patient. This treatment is largely concerned with realistic activities which will contribute towards the rehabilitation of patients 1. 2. 3. 4.
Procianoy, G. J. Pediat. Brazil, 1959, 24, 332. Niesert, F. J. Dtsch. med. Wschr. 1950, 75, 619. MacDougall, L. G. Brit. med. J. 1958, i, 139. Scopes, J. W. Lancet, 1963, i, 1027.
In many psychiatric hospitals domestic, industrial, and clerical units have been set up to help patients gain practical training and to give opportunity to resolve emotional difficulties before their discharge. Many departments are experimenting along these lines, to close the gap between hospital and community life. The service may be likened to occupational therapy in general hospitals, where disabled patients are taught to manage their lives more independently with the help of adaptations to furniture and household equipment. Furthermore, much is being done for the vast number of deteriorated psychotic patients, and many of the activities prescribed are outside the " traditional craft work " with which we are unfortunately so often associated in the minds of both lay and professional people. We are convinced that our present policy is realistic and of far greater help to patients, and, although the running of such departments costs more, it must be far below other services.
On behalf of the Association, I should like to thank the many doctors and hospital administrators who have shown a keen interest and concern in our forward-looking policy, and have supported many new ventures. B. M. STOW Association of Occupational Therapists, London, S.W.3.
Chairman of Council.
HUMAN RELATIONS IN HOSPITAL SiR,—Your leader of July 13 refers to the report by Lord Cohen’s subcommittee which proposed certain duties for " a doctor of comparatively junior status". These duties sound very like those assumed by any conscientious houseman. Another, I am sure he would add, is offering words of comfort to the relatives of deceased patients. This was certainly the teaching I
received. That such a recommendation was felt necessary illustrates the fact that many students fail to take advantage of the teaching offered. Yet one often sees statements that they had never seen many common conditions or performed minor operations and diagnostic procedures before qualifying. It seems fashionable to hurl brickbats at medical education. I submit that the fault often lies not with the educators but with the educated. F. WOODROFFE. London, N.4. FAT-EMBOLISM of SiR,—The hypothermia in the treatment of fat-embolism in four patients, described by Dr. Aladjemoff and her colleagues (July 6), represents a new and logical approach to an old and difficult problem. It will be interesting to review the results of treatment as the series of patients becomes larger. Without in any way criticising or diminishing the originality or value of the suggestion to use hypothermia in this condition, I should like to disagree with their view that a progressive reduction in the dose of drugs required for the control of hypothermia has a favourable use
prognostic significance. In the treatment of conscious and alert patients by prolonged mild hypothermia, it is not uncommon to find that on the first day of hypothermia pethidine and chlorpromazine (each 25-50 mg. by intramuscular injection) may be required as often as 2-3-hourly, but only 4-6-hourly on the second or third days, and less often on succeeding days. After stabilisation of temperature control it is often possible to discontinue the use of chlorpromazine, giving only pethidine 50 mg. intramuscularly, 6-hourly, in order to ensure comfort for the patient, particularly when active cooling is applied. In the anaesthetised or otherwise unconscious patient it is even more likely that hypothermia, once achieved, will require less in the way of active measures (drugs or ice) in order to maintain depression of temperature. I have observed one
incredible. Department of Medicine, West Virginia University, Morgantown, West Virginia.
ROBERT
J. MARSHALL.
INTRAPERITONEAL TRANSFUSION OF BLOOD IN NEWBORN BABIES SIR,-I sympathise with Professor Rendle-Short’s dislike (July 20) of intraperitoneal blood-transfusion when his personal experience is limited to 2 cases with 100% mortality. This experience, however, is utterly at variance with that of other workers 1-4 who, in series of up to 800 such transfusions, have had no mortality attributable to using the peritoneal route. It seems unlikely, moreover, that the peritoneal adhesions which caused the death of the first child he mentions were due to a peritoneal transfusion given only four days previously, since there was hardly time for the sequence of events leading to death from intestinal obstruction from adhesions. If, as seems more likely, the adhesions were already formed or forming, peritoneal transfusion would in any case be contraindicated. Both the cases Professor Rendle-Short mentions are sufficiently unusual that I would welcome further clinical details. I also agree that I have never known it impossible to get blood into the vein of a newborn baby. There are, however, circumstances when intravenous transfusion of blood into babies is attended by considerable danger of heart-failure, and, when these circumstances apply, intraperitoneal transfusion is a safer alternative. Furthermore, in some parts of the world where it is difficult to provide adequate trained staff to supervise transfusion in babies, peritoneal transfusion may be a justifiable alternative to venous transfusion in selected babies where none of the contraindications aoolv. Nuffield Neonatal Research Unit,
Hammersmith Hospital,
London, W.12.
J. W. SCOPES.
OCCUPATIONAL THERAPY
SIR,-In the report of the International Hospita Congress held in Paris, Mr. R. L. Darch is stated to have suggested that the cost of providing occupational therapy, along with other services, could be out of proportion to the benefit derived (June 22, p. 1371). Occupational therapy is a young profession, and many of our members can remember the days when they were expected to retrieve, from the sale of articles made, most of the money spent on materials! Fortunately, it is now realised that treatment costs money; and with the growth of" industtial therapy " within psychiatric hospitals there is still need to emphasise the fact that every commercial aspect of occupational therapy should be secondary to the real needs of the patient. This treatment is largely concerned with realistic activities which will contribute towards the rehabilitation of patients 1. 2. 3. 4.
Procianoy, G. J. Pediat. Brazil, 1959, 24, 332. Niesert, F. J. Dtsch. med. Wschr. 1950, 75, 619. MacDougall, L. G. Brit. med. J. 1958, i, 139. Scopes, J. W. Lancet, 1963, i, 1027.
In many psychiatric hospitals domestic, industrial, and clerical units have been set up to help patients gain practical training and to give opportunity to resolve emotional difficulties before their discharge. Many departments are experimenting along these lines, to close the gap between hospital and community life. The service may be likened to occupational therapy in general hospitals, where disabled patients are taught to manage their lives more independently with the help of adaptations to furniture and household equipment. Furthermore, much is being done for the vast number of deteriorated psychotic patients, and many of the activities prescribed are outside the " traditional craft work " with which we are unfortunately so often associated in the minds of both lay and professional people. We are convinced that our present policy is realistic and of far greater help to patients, and, although the running of such departments costs more, it must be far below other services.
On behalf of the Association, I should like to thank the many doctors and hospital administrators who have shown a keen interest and concern in our forward-looking policy, and have supported many new ventures. B. M. STOW Association of Occupational Therapists, London, S.W.3.
Chairman of Council.
HUMAN RELATIONS IN HOSPITAL SiR,—Your leader of July 13 refers to the report by Lord Cohen’s subcommittee which proposed certain duties for " a doctor of comparatively junior status". These duties sound very like those assumed by any conscientious houseman. Another, I am sure he would add, is offering words of comfort to the relatives of deceased patients. This was certainly the teaching I
received. That such a recommendation was felt necessary illustrates the fact that many students fail to take advantage of the teaching offered. Yet one often sees statements that they had never seen many common conditions or performed minor operations and diagnostic procedures before qualifying. It seems fashionable to hurl brickbats at medical education. I submit that the fault often lies not with the educators but with the educated. F. WOODROFFE. London, N.4. FAT-EMBOLISM of SiR,—The hypothermia in the treatment of fat-embolism in four patients, described by Dr. Aladjemoff and her colleagues (July 6), represents a new and logical approach to an old and difficult problem. It will be interesting to review the results of treatment as the series of patients becomes larger. Without in any way criticising or diminishing the originality or value of the suggestion to use hypothermia in this condition, I should like to disagree with their view that a progressive reduction in the dose of drugs required for the control of hypothermia has a favourable use
prognostic significance. In the treatment of conscious and alert patients by prolonged mild hypothermia, it is not uncommon to find that on the first day of hypothermia pethidine and chlorpromazine (each 25-50 mg. by intramuscular injection) may be required as often as 2-3-hourly, but only 4-6-hourly on the second or third days, and less often on succeeding days. After stabilisation of temperature control it is often possible to discontinue the use of chlorpromazine, giving only pethidine 50 mg. intramuscularly, 6-hourly, in order to ensure comfort for the patient, particularly when active cooling is applied. In the anaesthetised or otherwise unconscious patient it is even more likely that hypothermia, once achieved, will require less in the way of active measures (drugs or ice) in order to maintain depression of temperature. I have observed one