- Email: [email protected]
TERMINATION OF PREGNANCY
99
experience of a deterioration after operation (which in young children is nearly as common as an improvement) reflects the fact that for a certain period in childhood the tonsils may be essential organs-a possible role being the manufacture of immune globulins. Those of us who have had to care for children after the tonsils and adenoids operation know that it is a nerve-racking and often heart-rending responsibility, and that for every fatality there are a number of near misses. The risk of death on the operating-table is known to be higher in childhood than in later life,12 and in face of panic or extreme homesickness this risk may well be increased. Blood-loss has been shown 13 to be considerable even when the operation is uneventful, and it is common knowledge that signs such as a rising pulse-rate or fall in blood-pressure are not manifest until the child’s condition is already very serious. The time has surely come when every doctor who recommends the operation of tonsils and adenoids, and every parent who signs the consent form in the hope of finding an easy way out of the nuisance and anxiety to which repeated upper respiratory infections in children give rise, should ask themselves whether the desired result is worth the risk, whether what they propose to do is a treatment or a ritual, and whether they have begged the question of whether it will do any good. My opinion would be that such a critical attitude would cut down the operating-lists by 50-60%, and would incidentally save a lot of beds and a lot of money. Neonatal Department of the Institute common
of Child Health and Nuffield Neonatal Research Unit, Hammersmith Hospital,
J.
London. W.12
A. DAVIS.
SIR,-If Sir Alan Moncrieff hesitates " to quarrel even mildly with " his " friends and previously junior colleagues ", even more do I hesitate to dispute with my friend and previous senior colleague and teacher who wrote to you last week; nevertheless I do. I have no quarrel with his opinion that children " should have been accustomed ", or even, as Sir Alan adds, conditioned, to leaving their mothers, in order that they will be able to face with equanimity a family catastrophe at the age of three years. (I do not think he is right, but neither of us could really produce evidence to support our point of view.) But as things are, some children at the age of three years will be accustomed to
not, and
good hospital
a pmnt1nno:11 nPPfle nF tha laf"TPr
their mothers, others will should be sympathetic to the
leaving c
’(uPo11
e
tha fnrmnr
Neonatal Department of the Institute of Child and Nuffield Neonatal Research Unit, Hammersmith Hospital, London, W.12.
Health,
J.
that we and the parents have a lot to work out together, and both sides have a lot to learn. We do not know what effect preparing a young child for admission to hospital has, or how much easier it is, say, for a two-year-old who seems to function satisfactorily when his mother leaves him for a time. But we do know and we are learning rapidly from our observations of children at play in hospital, that the totality of the experience-the loneliness, the strangeness of everything, the disease and the separation-is very difficult for the young child to cope with. After all Janis 11 demonstrated how even some apparently normal adults, electively admitted to hospital for surgical treatment, became
seriously emotionally disturbed. Enough is now known of the different stages of development to know when a child has the capacity of adjustment and adaptability to withstand different experiences without traumatic effect. We in paediatrics like to think ours is no longer simply a curative discipline but one deeply concerned with the promotion and maintenance of health and the prevention of disease. We are still trying to understand and learn how to help children to grow into independent adults of good personal quality. The infant’s total dependency is accepted, as is his need for support, guidance, love, and encouragement to enable him to learn to " do it yourself ". We have to be careful we do not drown the child when we are helping him to learn to swim by making him " face life " in the deep end. DAVID MORRIS.
TERMINATION OF PREGNANCY SIR,-In Dr. R. W. Smithells’ topical article last week he makes one statement which it is important to correct. This is that the recurrence risk for " severe mental deficiency of unknown aetiology " is 1 in 6. This figure is probably derived from pre-war German data which did not distinguish between high and low grade mental deficiency. New family studies are needed of severe mental deficiency of unknown aetiology using modern genetic and biochemical techniques to exclude those of known xtiology; but, in the meantime, the figure of 1 in 6 should not gain currency. Most of his colleagues in genetic counselling would regard the risk after one affected child as less than the 1 in 20 that Dr. Smithells considers acceptable. Where the couple have already had two affected children the risk is, however, considerably higher. Clinical Genetics Research Unit, 30, Guilford Street, London, W.C.1. Pædiatric Research Unit,
Guy’s Hospital, London, S.E.1.
P. M. TIZARD,
C. O. CARTER.
J. A.
FRASER ROBERTS.
MERCAPTOPURINE IN
SIR,-The points raised by Sir Alan Moncrieff last week are challenging. Do parents in fact blame the hospital entirely if their child is disturbed by his experience there ?
indeed
What difference does it make if a young child has had the experience of being without mother for a time ? The mother whose letter was quoted by Dr. MacCarthy and Dr. Mac Keith 14 at no time blamed the hospital for her child’s tragic death, and the National Association for the Welfare of Children in Hospital goes to great pains to emphasise its focus on improved visiting facilities. Its review of the visiting facilities after tonsillectomy,15 shows that at least two-thirds of 235 hospitals " allowed no visiting at all on operation day "justification enough for the N.A.W.C.H. and its endeavours. We have surely passed the stage of apportioning blame, and we are beginning to think more objectively and scientifically about the complex experience of a young child in hospital: the effect of the child’s age, personality, character and home background, the nursing and medical attitudes, the illness and its duration, and the different medical procedures. This means Report of New South Wales Committee on Anæsthetic Deaths. Med.J Aust. 1962, ii, 575. 13. Holden, H., Maher, J. Br. med. J. 1965, ii, 1349. 14. MacCarthy, D., Mac Keith, R. Lancet, 1965, ii, 1289. 15. See ibid. p. 1351.
12.
POLYRADICULONEUROPATHY
SIR,-After reading Dr. Palmer’s report 1on a patient with polyradiculoneuropathy who had been successfully treated with mercaptopurine, we decided to try this treatment on a which had failed to respond to therapy with steroids and vitamin B12. The patient is a 12-year-old girl who, after a throat infection in November, 1963, noticed weakness in her hands and legs. During the summer of 1964 her state deteriorated, and when we saw her for the first time in August, 1964, she had generalised case
muscle weakness, most pronounced in peripheral limb muscles but also involving proximal muscles quite severely. Her facial muscles were not affected. She could not rise from the lying-down position without help, she was unable to lift her arms up to her face, and she could walk only with great difficulty. Superficial sensation and vibration sense were normal. From August, 1964, to August, 1965, her cerebrospinal fluid (c.s.F.) was examined several times. It contained no cells, and the protein content varied between 125 mg. and 175 mg. per 100 ml. Conduction velocity of peripheral motornerves was roughly half the normal value. No sensory nerve 16. 17.
Janis, I. L. Psychoanalysis and the Social Sciences. Palmer, K. N. Lancet, 1965, i, 733.
New York, 1958.
experience of a deterioration after operation (which in young children is nearly as common as an improvement) reflects the fact that for a certain period in childhood the tonsils may be essential organs-a possible role being the manufacture of immune globulins. Those of us who have had to care for children after the tonsils and adenoids operation know that it is a nerve-racking and often heart-rending responsibility, and that for every fatality there are a number of near misses. The risk of death on the operating-table is known to be higher in childhood than in later life,12 and in face of panic or extreme homesickness this risk may well be increased. Blood-loss has been shown 13 to be considerable even when the operation is uneventful, and it is common knowledge that signs such as a rising pulse-rate or fall in blood-pressure are not manifest until the child’s condition is already very serious. The time has surely come when every doctor who recommends the operation of tonsils and adenoids, and every parent who signs the consent form in the hope of finding an easy way out of the nuisance and anxiety to which repeated upper respiratory infections in children give rise, should ask themselves whether the desired result is worth the risk, whether what they propose to do is a treatment or a ritual, and whether they have begged the question of whether it will do any good. My opinion would be that such a critical attitude would cut down the operating-lists by 50-60%, and would incidentally save a lot of beds and a lot of money. Neonatal Department of the Institute common
of Child Health and Nuffield Neonatal Research Unit, Hammersmith Hospital,
J.
London. W.12
A. DAVIS.
SIR,-If Sir Alan Moncrieff hesitates " to quarrel even mildly with " his " friends and previously junior colleagues ", even more do I hesitate to dispute with my friend and previous senior colleague and teacher who wrote to you last week; nevertheless I do. I have no quarrel with his opinion that children " should have been accustomed ", or even, as Sir Alan adds, conditioned, to leaving their mothers, in order that they will be able to face with equanimity a family catastrophe at the age of three years. (I do not think he is right, but neither of us could really produce evidence to support our point of view.) But as things are, some children at the age of three years will be accustomed to
not, and
good hospital
a pmnt1nno:11 nPPfle nF tha laf"TPr
their mothers, others will should be sympathetic to the
leaving c
’(uPo11
e
tha fnrmnr
Neonatal Department of the Institute of Child and Nuffield Neonatal Research Unit, Hammersmith Hospital, London, W.12.
Health,
J.
that we and the parents have a lot to work out together, and both sides have a lot to learn. We do not know what effect preparing a young child for admission to hospital has, or how much easier it is, say, for a two-year-old who seems to function satisfactorily when his mother leaves him for a time. But we do know and we are learning rapidly from our observations of children at play in hospital, that the totality of the experience-the loneliness, the strangeness of everything, the disease and the separation-is very difficult for the young child to cope with. After all Janis 11 demonstrated how even some apparently normal adults, electively admitted to hospital for surgical treatment, became
seriously emotionally disturbed. Enough is now known of the different stages of development to know when a child has the capacity of adjustment and adaptability to withstand different experiences without traumatic effect. We in paediatrics like to think ours is no longer simply a curative discipline but one deeply concerned with the promotion and maintenance of health and the prevention of disease. We are still trying to understand and learn how to help children to grow into independent adults of good personal quality. The infant’s total dependency is accepted, as is his need for support, guidance, love, and encouragement to enable him to learn to " do it yourself ". We have to be careful we do not drown the child when we are helping him to learn to swim by making him " face life " in the deep end. DAVID MORRIS.
TERMINATION OF PREGNANCY SIR,-In Dr. R. W. Smithells’ topical article last week he makes one statement which it is important to correct. This is that the recurrence risk for " severe mental deficiency of unknown aetiology " is 1 in 6. This figure is probably derived from pre-war German data which did not distinguish between high and low grade mental deficiency. New family studies are needed of severe mental deficiency of unknown aetiology using modern genetic and biochemical techniques to exclude those of known xtiology; but, in the meantime, the figure of 1 in 6 should not gain currency. Most of his colleagues in genetic counselling would regard the risk after one affected child as less than the 1 in 20 that Dr. Smithells considers acceptable. Where the couple have already had two affected children the risk is, however, considerably higher. Clinical Genetics Research Unit, 30, Guilford Street, London, W.C.1. Pædiatric Research Unit,
Guy’s Hospital, London, S.E.1.
P. M. TIZARD,
C. O. CARTER.
J. A.
FRASER ROBERTS.
MERCAPTOPURINE IN
SIR,-The points raised by Sir Alan Moncrieff last week are challenging. Do parents in fact blame the hospital entirely if their child is disturbed by his experience there ?
indeed
What difference does it make if a young child has had the experience of being without mother for a time ? The mother whose letter was quoted by Dr. MacCarthy and Dr. Mac Keith 14 at no time blamed the hospital for her child’s tragic death, and the National Association for the Welfare of Children in Hospital goes to great pains to emphasise its focus on improved visiting facilities. Its review of the visiting facilities after tonsillectomy,15 shows that at least two-thirds of 235 hospitals " allowed no visiting at all on operation day "justification enough for the N.A.W.C.H. and its endeavours. We have surely passed the stage of apportioning blame, and we are beginning to think more objectively and scientifically about the complex experience of a young child in hospital: the effect of the child’s age, personality, character and home background, the nursing and medical attitudes, the illness and its duration, and the different medical procedures. This means Report of New South Wales Committee on Anæsthetic Deaths. Med.J Aust. 1962, ii, 575. 13. Holden, H., Maher, J. Br. med. J. 1965, ii, 1349. 14. MacCarthy, D., Mac Keith, R. Lancet, 1965, ii, 1289. 15. See ibid. p. 1351.
12.
POLYRADICULONEUROPATHY
SIR,-After reading Dr. Palmer’s report 1on a patient with polyradiculoneuropathy who had been successfully treated with mercaptopurine, we decided to try this treatment on a which had failed to respond to therapy with steroids and vitamin B12. The patient is a 12-year-old girl who, after a throat infection in November, 1963, noticed weakness in her hands and legs. During the summer of 1964 her state deteriorated, and when we saw her for the first time in August, 1964, she had generalised case
muscle weakness, most pronounced in peripheral limb muscles but also involving proximal muscles quite severely. Her facial muscles were not affected. She could not rise from the lying-down position without help, she was unable to lift her arms up to her face, and she could walk only with great difficulty. Superficial sensation and vibration sense were normal. From August, 1964, to August, 1965, her cerebrospinal fluid (c.s.F.) was examined several times. It contained no cells, and the protein content varied between 125 mg. and 175 mg. per 100 ml. Conduction velocity of peripheral motornerves was roughly half the normal value. No sensory nerve 16. 17.
Janis, I. L. Psychoanalysis and the Social Sciences. Palmer, K. N. Lancet, 1965, i, 733.
New York, 1958.