John Apley

Emotional and Behavioural Disorders—II

unnecessary and does not help. Almost every child can outgrow excessive shyness if he is neither thrown in at the deep end nor isolated and overprotected. When shyness becomes excessive, even pathological, probably as a result of mishandling and conditioning, -the element of fear has come to play a large part. Some fears-of pain, sudden movements, loud noises-are normal even in babies, but most fears develop later. They are learned from others, but need not be. To be afraid on appropriate occasions is a healthy, tem-

Homologous serum jaundice in infancy.

The indications for intravenous plasma therapy in paediatric practice are many. Since plasma possesses all the therapeutic properties of whole blood, except those conerred by the red cells, it is especially indicated in shock with haemoconcentration and in hypoproteinaemia. In practice it is widely employed in the treatment of such conditions as burns and severe gastro-intestinal affections. Despite its widespread use, the complications and sequelae of plasma therapy in infancy are surprisingly uncommon; homologous serum jaundice, for example, #ppears to be extremely rare. We have been able to discover only one possible case in the literature (Scheinberg et al., 1947), though another more fully substantiated case, following not plasma but blood transfusion in an infant, has recently been described (Bruyn, 1947). In later childhood, however, jaundice has followed the use of convalescent serum in several instances (Propert, 1938 ; Beeson et al., 1944), while in adults it is a common complication of plasma therapy (British Medical Journal, 1946, 2, 423), Dccurring in 7.3% of cases in one large series (Spurling et al., 1946). Various explanations may be advanced for the relatively low frequency of occurrence in infancy: a temporary passive immunity to the causative virus may be present at this period of life, hepatitis may occur but remain symptomless, or jaundice in infants may fail to be correlated with previous transfusion treatment. The history ,f the recognition of the condition in adults suggests that the last possibility is not unlikely to prove correct. For this reason two cases of fatal homologous serum jaundice occurring in infants are recorded, together with an inquiry to determine the incidence of this sequel after transfusion with reconstituted dried plasma.

Cockles of the heart

SIR,-I was interested to read of the high incidence of deep vein thrombosis (DVT) following total hip replacement described by Mr J D Stamatakis and his colleagues (23 July, p 223). This alarming incidence, coupled with the known serious embolic complications, gives much food for thought and obviously should influence us in the management of patients undergoing the operation. However, I would like to ask two questions. Firstly, what were the diagnoses of the patients, and, secondly, what were the prior drug therapies ? Presumably some of the patients suffered from rheumatoid arthritis and some may well have been taking aspirin. It is my clinical impression that DVT is rare in rheumatoid disease and aspirin is well known to influence the clotting mechanism. Although drug action may be difficult to assess by the methods used in the study, the influence of the underlying disease process could easily be judged and I think it is important that that information should be made available.

Widening Horizons of Child Health

We may not be able to make you love reading, but widening horizons of child health will lead you to love reading starting from now. Book is the window to open the new world. The world that you want is in the better stage and level. World will always guide you to even the prestige stage of the life. You know, this is some of how reading will give you the kindness. In this case, more books you read more knowledge you know, but it can mean also the bore is full.

Ulster: Understanding Human Behaviour

In Belfast a group of student volunteers would organize a childrens outing to the seaside on Saturdays, with games and a picnic; but when 6 oclock came their charges asked anxiously: Please, will we be back in time for the rioting? No, it is not easy to introduce new interests and to penetrate the o>bsession with violence of mere children . . . expenadable instruments of terror. Suchacrid extracts f,rom neowspapers and the poignant ca-se histories enhance the limpid language with which Dr. Fraser, a child psychiatrist, persuades the reader to share the emotions and reactions of children in Northern Ireland. It is a scene from which many of us turn away in despair, sick at heart. Not least of the authors achievements is to make the actors on this small, blood-spattered stage teach us about the larger stage of the world in which we live. I read the book first as a citizen, agonizing with fellow citizens in Ulster. Then, oomposing myself, I read again, this time as a childrens doctor, trying to comprehend the passion and the compassion. Do we believe in the power of reason to resolve all confl.icts? For politicians Frasers lesson is one which in similar situations has forever to be re-learned: There can be no political solution. In Ireland the basic prejudice, he says, is racial and cultural, rather than religious, and prejudice is beyond the reach of laws and orders. Fraser hopefully holds that aggression is a learned habit. Konrad Lorenz and Rdbert Ardrey would not agree; but, even if aggression is, as they consider, largely instinctive, habit and training unquestionably make a significant contribution. The training sequence is described in three stages. The first is to define the childs bogeyman (this is too weak a word: I suggest devil-figure instead). To the Protestant child this is the Catholic; to the Catholic child, the British soldier. When they play at rioters and soldiers the unpopular boys are the soldiers. The second stage is to fan the childs fears until he is obsessed with fantasies of riddance-and the blurred boundaries between childhood fantasy and reality can offer ,ittle resistance. Thirdly, fantasies are precipitated into violent action. Children come to act willingly not only as alibis or cover-ups for adults, but as decoys, attackers, even killers. The authors psychological studies show how children react in an environment of fear and violence, bombs and fires. The common reaction is the childhod equivalent of adult anxiety: sleep disturbances, separation fears, school refusal, head and tummy pa ns, disordered gut or bladder function. Such complaints are commonplace among children living in a riot area; but Fraser finds they clear quickly when the district settles down again. On the other hand, the less common, incapacitating psychiatric illnesses occur in areas adjacent to the riot areas; and these illnesses may persist after the violence has abated. Severe disturbances are commonest among children about ten years of age, when the dangers can be comprehended but the child is still dependent on adult reaction cues. Particularly at risk are dhildren from unstalble homes. Again and again we see that violence and irrationality run in the family, yet the childs abiding fear is in essence the loss of the security that goes with family life. In troubled Ulster the father of the family is often absent and there are few relatives to share in the childs upbrin;ging; the child, looking for a new group, finds it in a gangand the aggregation into gangs is known to pro<mote the growth of violence. I have myself seen in Vietnam a population grown up from childhood to aduit life with no experience of peace, only of war. In Ulster the children now approaching puberty have no recollection of peace, only of sporadic and close violence, of vigilance, tension, fear. Fraser believes, and gives some evidence, that the future for young children in Ulster is not entirely without hope. Children are growing, learning organisms and their learned behaviour can be modified. He would light up the dark torture chambers of prejudice during the early years when attitudes are moulded in the template of family and oommunity. He suggests that children should be given equal status contact at school, and enjoy integration instead of segregation. The latter suggestion was made half a century ago and nothing came of it. Is the urgency to succeed against entrenched opposition now sufficiently overriding? I wish it could be so. To the understanding of aggression and violence this compelling book is a notable contribution. We must, I believe, turn more and more to childhood to uncover and explore the clear springs of human behaviour.

Erudition and Amphorisms

A 5-year-old girl had been in complete haematological remission on the Medical Research Council UKALL I protocol, without C.N.S. prophylaxis, since the diagnosis ofacute lymphoblastic leukaemia in October 1970. She had three episodes of meningeal leukaemia, each successfully treated with intrathecal methotrexate, the last, in March 1972, being followed by craniospinal radiotherapy. A further meningeal relapse in January 1973 was treated with intrathecal methotrexate. One week later she developed pancytopenia associated with epistaxes and pneumonia. She recovered with antibiotics and withdrawal of chemotherapy, and bone marrow remission was confirmed. Pancytopenia recurred after restarting chemotherapy and again the drugs were stopped. Two days later she had a febrile cold and two further days later vomiting started and continued for 12 hours; her respiration became laboured and she became unconscious and flaccid with unreactive pupils, but she did not have fits. Until her death 12 hours later she had varying limb tone, tendon reflexes, and pupil responses, but no localizing neurological signs. She had mild hepatomegaly and was hypothermic. Terminally she had a large haematemesis. Investigations showed haemoglobin 9-7 g/100 ml, platelets 10,000/F1l, neutrophils 12% (280/il), lymphocytes 83% (2000/41), myelocytes 5% (120*1>). The blood film showed a picture of microangiopathic haemolytic anaemia. Prothrombin and partial thromboplastin times were prolonged and plasma factor V was reduced, but the thrombin time was normal. Plasma electrolytes: Na 143 mEq/l., K 3-8 mEq/l., total bicarbonate 6 mmol/l.; urea blood 19 mg/100 ml; serum bilirubin 2-5 mg!100 ml; S.G.O.T. 744 I.U./ l.; S.G.P.T. 558 I.U./l. Cerebrospinal fluid: sugar 25 mg/l10 ml; no white cells present. Full bacterial and viral cultures were negative. Necropsy showed cerebral oedema, haemorrhagic gastric ulceration, a nutmeg liver, and dilatation of the right heart, but on microscopy fatty degeneration of the liver, renal tubules, and myocardium was confirmed without inflammatory or leukaemic infiltration in any organ.

Thumb-sucking and the Teeth

SIR,-In his letter of 14 August, p. 422, Mr. C. A. Pitt-Steele makes out a convincing case against thumb-sucking, but before those of us who have hitherto concurred with Dr. Apley will be prepared to sacrifice the infants pleasure to the adolescents pride it would be helpful if he would provide chapter and verse for his assertions. No doubt the truth is available in the orthodontic literature, but paediatricians cannot all be polymaths, and those with responsibility for teaching must be able to judge the evidence for themselves. At first sight it would seem a difficult case to prove, in that there are so many degrees of thumb-sucking and such a wide variation in the shape of the human face.-I am, etc., Institute of Child Health, J. A. DAVIS. Hammersmith Hospital, London W.2.