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SCHOOL REFUSAL
1002 In a large injury, rigid fixing of the chest wall is very undesirable, since it is likely to lead to pulmonary collapse in the immobilised areas and is almost impossible to achieve. I cannot envisage an area so large as to require two limpets leaving enough chest well to support the plaster, unless it completely encircled the chest. Modern methods of management have been well documented,l and the problem now is not one of effective treatment, but of making this treatment available as widely as possible. Department of Anaesthetics, Royal College of Surgeons, London, W.C.2.
Research
MICHAEL BOOKALLIL.
REFLEX MEASUREMENTS IN THYROID DISEASE
’
SiR,ŃThe article by Dr. Sherman and others (Feb. 2) details the usefulness of reflex measurements in thyroid disease. We should like to point out, however, that abnormal values can, on occasion, be present in other conditions: in particular we refer to hypothyroid values in neurosyphilis, in a lobotomised schizophrenic, in myasthenia gravis, 23 and in sarcoidosis.4 Differences between the right and left leg have been described.3 We mention this, not to detract from this valuable sign, but to point out the possibility of the small number of false positives being indicative of other pathological changes. GEORGE M. SIMPSON Rockland State Hospital, Orangeburg, New York.
JOHN H. BLAIR.
SCHOOL REFUSAL
SiR,ŃThough merely descriptive and non-technical, " school refusal " seems preferable to " school phobia " for a "syndrome which can reflect a readily reversible reaction, or which may be associated with severe neurotic or even psychotic disturbance ".5 This title highlights the common feature in that special dispensation has to be obtained for non-attendance at school, as well as hinting at the home tuition and psychiatric or legal actions that may ensue. Dr. Kahn’s first suggestion (April 13), however, for this name covers only one group, since he himself points out that the peak incidence is at 11 years. Many of the school refusals have in fact passed " the point from life predominantly in the family to life in the outside world " apparently successfully. Dr. Kahn later comes back to the central feature and elaborates that it occurs at " crisis points ", and he further lists a number of these, illuminatingly going well beyond the present discussion of school adjustment. Child psychiatry is increasingly taking account of the total family and the social setting. In this instance further insight into the problem might be obtained by viewing school refusal from the social aspect. Sociology has something to teach us here. " Crisis points " or, more optimistically, " steppingstones " are a feature in all societies, and individuals have at all times had difficulties in the role-changing periods hence the rituals (often extreme) of the " rites of passage ". Contemporary society with its ill-defined and often changing roles and frequent changes of fashion has largely dispensed with rituals without in fact facing the underlying problems. School refusal presents as an individual problem to the psychiatrist, and the extraction of a psychopathology is essential in the elucidation of a particular personality and its problems for treatment, as Dr. Kahn emphasises. Yet it might be helpful to consider school refusal as a social malady well worthy of an epidemiological study. Dr. Kahn’s list of individuals involved in the treatment 1. 2.
Windsor, H. M., Dwyer, B. Thorax, 1961, 16, 3. Simpson, G. M., Blair, J. H., Nartowicz, G. R. New Engl. J.
Med.
1963, 268, 89. 3. Simpson, G. M., Blair, J. H., Nartowicz, G. R. N.Y. St. J. Med. 1963, 63, 1148. 4. Richards, A. G. Canad. med. Ass. J. 1962, 86, 32. 5. Rodriguez, A., Rodriguez, M., Eisenberg, L. Amer. J. Psychiat. 1959, 116, 540 (quoted by Cameron in Medical Annual, 1961).
sort of liaison which is needed and which probably exists in few parts of the country. Contact between them must be fostered to avoid the complication of transferral after failure by an earlier agency, as well as to help identify the
indicates the
vulnerable individuals who need
special attention
at
crisis
periods. As a first step and a baseline for further study and evaluation of treatments, it might be fruitful for all disciplines concerned to undertake, possibly under the aegis of the Ministry of Education, a national survey. Unlike many psychiatric conditions the actual incidence and case ascertainment can be established. It is no less of a problem for the education authorities than for the psychiatric clinics, where it has been suggested that it is on the increase and already forms 5% of referrals.R
Birmingham.
BERNARD BARNETT.
VENTILATION OF OPERATING-ROOM SUITES Sirshould like to comment on the letter from Dr. Blowers and others (Jan. 19) supporting the recommendation made by the operating-theatre hygiene committee that filtration of input air down to 5 microns is
bacteriologically adequate. It is known that filters which are 99% efficient against the relatively large test dust particles down to 5 microns in diameter (Test Dust no. 2 B.s.2831) will allow to pass at least 50% of the
particles normally occurring as atmospheric pollution. Whilst most airborne microorganisms may tend to be carried by the larger pollution particles and will thus be removed by a 5-micron filter, a significant proportion of them will pass the filter on fine dust particles (Dr. Blowers found 2%) and enter the theatre. This surely is undesirable and should be avoided. But I suggest that a low, or even zero, bacteriological count in the incoming air is not the sole criterion on which to base a standard for efficiency, since it takes no account of the very large numbers of sterile airborne dust particles which will pass a 5-micron filter and enter the theatre. Most of these particles will, or should, pass out of the theatre by ventilation, but many will be deposited and will aggregate on vertical and horizontal surfaces and will become potential hosts for the microorganisms which are, at present, unavoidably brought into the theatre— for example, by the operating staff—and which cannot be removed with absolute certainty by ventilation. stated in the letter by Mr. Sutherland and cost of filters of very high efficiency is low compared with the cost of infection of even one patient, the case for using filters of the highest possible efficiency
Since,
as
Mr. Firman,7 the
seems
irrefutable.
Salisbury, Wilts.
C. G. TROTMAN.
HYPONATRÆMIA IN INFANTILE MALNUTRITION SIR,-Since Dr. Smith’s excellent work while he was in this unit, we have been aware of the danger of pulmonary oedema in malnourished infants, referred to in his letter of April 6. The unit’s views are expressed in a recent review of treatment and prognosis in malnutri-
tion : " The most dangerous pitfall is fluid into a wasted child."1
to
infuse
too
much
Of the last 13 children who died, only 1 had severe puloedema, while 5 more had minimal fluid in the lower lobes at postmortem. 9 of these children were admitted with signs of failure of hepatic function (i.e., bilirubin above 1 mg. per 100 ml. or serum glutamic-pyruvic transaminase over 250 V.. per 0.1 ml.), and of these, 5 had serum-sodium levels of 125 mEq. per litre or less. The question now is not " Do the babies die of hyponatræmia or of hyperbilirubinæmia ? " but " What cell functions 6. Coulsting, H. Brit. J. Psychiat. 1961, 107, R.M.P.A. supplement monary
7. 8.
(April), p. 25. Lancet, 1962, ii, 1169. Garrow, J. S., Picou, D., Waterlow, J. C. 11, 217.
W. Indian
med. J. 1962,
Research
MICHAEL BOOKALLIL.
REFLEX MEASUREMENTS IN THYROID DISEASE
’
SiR,ŃThe article by Dr. Sherman and others (Feb. 2) details the usefulness of reflex measurements in thyroid disease. We should like to point out, however, that abnormal values can, on occasion, be present in other conditions: in particular we refer to hypothyroid values in neurosyphilis, in a lobotomised schizophrenic, in myasthenia gravis, 23 and in sarcoidosis.4 Differences between the right and left leg have been described.3 We mention this, not to detract from this valuable sign, but to point out the possibility of the small number of false positives being indicative of other pathological changes. GEORGE M. SIMPSON Rockland State Hospital, Orangeburg, New York.
JOHN H. BLAIR.
SCHOOL REFUSAL
SiR,ŃThough merely descriptive and non-technical, " school refusal " seems preferable to " school phobia " for a "syndrome which can reflect a readily reversible reaction, or which may be associated with severe neurotic or even psychotic disturbance ".5 This title highlights the common feature in that special dispensation has to be obtained for non-attendance at school, as well as hinting at the home tuition and psychiatric or legal actions that may ensue. Dr. Kahn’s first suggestion (April 13), however, for this name covers only one group, since he himself points out that the peak incidence is at 11 years. Many of the school refusals have in fact passed " the point from life predominantly in the family to life in the outside world " apparently successfully. Dr. Kahn later comes back to the central feature and elaborates that it occurs at " crisis points ", and he further lists a number of these, illuminatingly going well beyond the present discussion of school adjustment. Child psychiatry is increasingly taking account of the total family and the social setting. In this instance further insight into the problem might be obtained by viewing school refusal from the social aspect. Sociology has something to teach us here. " Crisis points " or, more optimistically, " steppingstones " are a feature in all societies, and individuals have at all times had difficulties in the role-changing periods hence the rituals (often extreme) of the " rites of passage ". Contemporary society with its ill-defined and often changing roles and frequent changes of fashion has largely dispensed with rituals without in fact facing the underlying problems. School refusal presents as an individual problem to the psychiatrist, and the extraction of a psychopathology is essential in the elucidation of a particular personality and its problems for treatment, as Dr. Kahn emphasises. Yet it might be helpful to consider school refusal as a social malady well worthy of an epidemiological study. Dr. Kahn’s list of individuals involved in the treatment 1. 2.
Windsor, H. M., Dwyer, B. Thorax, 1961, 16, 3. Simpson, G. M., Blair, J. H., Nartowicz, G. R. New Engl. J.
Med.
1963, 268, 89. 3. Simpson, G. M., Blair, J. H., Nartowicz, G. R. N.Y. St. J. Med. 1963, 63, 1148. 4. Richards, A. G. Canad. med. Ass. J. 1962, 86, 32. 5. Rodriguez, A., Rodriguez, M., Eisenberg, L. Amer. J. Psychiat. 1959, 116, 540 (quoted by Cameron in Medical Annual, 1961).
sort of liaison which is needed and which probably exists in few parts of the country. Contact between them must be fostered to avoid the complication of transferral after failure by an earlier agency, as well as to help identify the
indicates the
vulnerable individuals who need
special attention
at
crisis
periods. As a first step and a baseline for further study and evaluation of treatments, it might be fruitful for all disciplines concerned to undertake, possibly under the aegis of the Ministry of Education, a national survey. Unlike many psychiatric conditions the actual incidence and case ascertainment can be established. It is no less of a problem for the education authorities than for the psychiatric clinics, where it has been suggested that it is on the increase and already forms 5% of referrals.R
Birmingham.
BERNARD BARNETT.
VENTILATION OF OPERATING-ROOM SUITES Sirshould like to comment on the letter from Dr. Blowers and others (Jan. 19) supporting the recommendation made by the operating-theatre hygiene committee that filtration of input air down to 5 microns is
bacteriologically adequate. It is known that filters which are 99% efficient against the relatively large test dust particles down to 5 microns in diameter (Test Dust no. 2 B.s.2831) will allow to pass at least 50% of the
particles normally occurring as atmospheric pollution. Whilst most airborne microorganisms may tend to be carried by the larger pollution particles and will thus be removed by a 5-micron filter, a significant proportion of them will pass the filter on fine dust particles (Dr. Blowers found 2%) and enter the theatre. This surely is undesirable and should be avoided. But I suggest that a low, or even zero, bacteriological count in the incoming air is not the sole criterion on which to base a standard for efficiency, since it takes no account of the very large numbers of sterile airborne dust particles which will pass a 5-micron filter and enter the theatre. Most of these particles will, or should, pass out of the theatre by ventilation, but many will be deposited and will aggregate on vertical and horizontal surfaces and will become potential hosts for the microorganisms which are, at present, unavoidably brought into the theatre— for example, by the operating staff—and which cannot be removed with absolute certainty by ventilation. stated in the letter by Mr. Sutherland and cost of filters of very high efficiency is low compared with the cost of infection of even one patient, the case for using filters of the highest possible efficiency
Since,
as
Mr. Firman,7 the
seems
irrefutable.
Salisbury, Wilts.
C. G. TROTMAN.
HYPONATRÆMIA IN INFANTILE MALNUTRITION SIR,-Since Dr. Smith’s excellent work while he was in this unit, we have been aware of the danger of pulmonary oedema in malnourished infants, referred to in his letter of April 6. The unit’s views are expressed in a recent review of treatment and prognosis in malnutri-
tion : " The most dangerous pitfall is fluid into a wasted child."1
to
infuse
too
much
Of the last 13 children who died, only 1 had severe puloedema, while 5 more had minimal fluid in the lower lobes at postmortem. 9 of these children were admitted with signs of failure of hepatic function (i.e., bilirubin above 1 mg. per 100 ml. or serum glutamic-pyruvic transaminase over 250 V.. per 0.1 ml.), and of these, 5 had serum-sodium levels of 125 mEq. per litre or less. The question now is not " Do the babies die of hyponatræmia or of hyperbilirubinæmia ? " but " What cell functions 6. Coulsting, H. Brit. J. Psychiat. 1961, 107, R.M.P.A. supplement monary
7. 8.
(April), p. 25. Lancet, 1962, ii, 1169. Garrow, J. S., Picou, D., Waterlow, J. C. 11, 217.
W. Indian
med. J. 1962,