available procedures and the low base rate ofthis behaviour." 10 The chance of detection is not helped when some prison doctors screening new prisoners "did not even bother to look up when talking with them."3 The answer to suicides in prisons lies in completely changing the culture of prisons. As both the chief inspector and the Home Secretary agree, the problem is not simply a medical one. It is a social problem, and it is a problem for our whole society, not just those delegated to cope with prisoners. The high rate of suicide in British prisons is rooted in the appalling conditions of the prisons -three quarters of suicides occur in local and remand prisons, which contain a quarter of the prisoners and have by far the worst conditions.3 Most of the British people have some notion that our prisons are disgusting, but only the few who have experienced the stink and squalor at first hand can really understand: you need some idea of what it is like to have to defaecate in a pot in front of others, eat your breakfast in the same cell 15 hours after your supper and two hours before your lunch, and be afraid to go to sleep for fear of assault. The problem is that the initial shock passes. There tend to be two populations when it comes to prisons -those who have never known how bad the conditions are and those in whom the disgust has worn off. But it takes time to fade: a third of suicides occur in the first four weeks in custody.3 It is one of the achievements of Stephen Tumim that he has sustained the horror he experienced when he first entered prisons. Thus, although he makes 123 specific recommendations,3 he recognises that a reduction in suicides will come only with radical changes in our prisons. It will be important to train staff and improve living conditions, food, basic hygiene, clothing, education, employment, facilities for communication with friends and family, and medical services, but these changes will not be enough. What is needed is a
change in the culture-the values, beliefs, language, and patterns of behaviour-of British prisons. The chief inspector quotes approvingly the governor of a local prison: "My own view is that the ethos of an establishment, how inmates are treated, will determine the amount of suicide and self injury. While I understand the need for form-filling and insurance policy type activity, it is not a substitute for investing in time spent with staff. Firstly, letting them know that it is part of the culture to demonstrate concern for inmates, and secondly, showing them ways of letting it show." Prison doctors might begin by letting prisoners sit down during admission consultations.3 Changing culture is never easy and usually painful, and the culture of British prisons will probably change only if there is some change in British culture at large. Societies get the prisons they deserve. But one way to change prison culture will be to get rid of the monstrous local prisons and replace them with smaller community prisons. A recent leak suggests that this is what Lord Woolf and Stephen Tumim will advocate in their forthcoming report on the Strangeways riots. RICHARD SMITH Executive editor, BMJ 1 Dooley E. Prison suicide in England and Wales, 1972-87. Br3' Psychiatry 1990;156:40-5. 2 Working Group on Suicide Prevention. Report. London: Home Office, 1986. 3 Her Majesty's Chief Inspector of Prisons for England and Wales. Suicide and self harm in prison service establishments in England and Wales. London: HMSO, 1990. 4 Cohen N. Suicides blamed on state of jails. Independent 1990 Dec 20:1. 5 Goring C. The English convict. London: Darling, 1913. 6 Topp DO. Suicide in prison. BrJ3 Psychiatry 1979;134:24-7. 7 Home Secretary. Response to the report of Her Majesty's Chief Inspector of Prison's report on Risley Remand Centre. London: Home Office, 1988. 8 Home Secretary. Response to the report of HerMajesty's Chief Inspector of Prison's report on suicide and self harm in prison service establishments in England and Wales. London: Home Office, 1990. 9 Lloyd C. Suicide and self-injury in prison: a literature review. London: HMSO, 1990. (Home Office research study 115.) 10 Pokorny A. Prediction of suicide in psychiatric patients: a report of a prospective study. Arch Gen Psychiatry 1983;40:249-57. 11 Carrel J. Woolf report to back local prisons and contracts. Guardian 1990 Dec 31:1.
Treating children with spina bifida An individual programme for each child Effective surgical treatment became possible for children with spina bifida with the development of a shunt system for hydrocephalus in the late 1950s. By the end of the 1960s the main complications of ventriculoatrial shunts, including ventriculitis and low grade staphylococcal septicaemia, had been described. 1-3 The seriousness of the urinary tract problems was also being recognised and correlated with the neurological defects of the children.4 In 1971 Lorber published the results of the policy adopted in Sheffield of giving surgical treatment to all infants with meningomyelocele. His report described 524 unselected cases. I He concluded that there were four main criteria associated with a poor prognosis: severe hydrocephalus present at birth; a high level of paraplegia; congenital lumbar kyphosis; and associated congenital abnormalities or major birth injury. He showed that there was a high level of morbidity and resultant handicap in the children with more severe lesions. Lorber's next report described a trial in which active treatment, including the use of antibiotics, was withheld from 25 infants with adverse criteria, while active treatment was given to 12 infants in whom no adverse criteria were present.6 All but two of the unoperated children died within six months, and the remainder within nine months. BMJ
VOLUME 302
12 JANUARY 1991
These data had a profound effect on medical management in Britain, causing a swing of the pendulum away from advocating early treatment in all affected children towards selecting for treatment only those children who fulfilled the criteria for good prognosis. Some questioned how the survival rate of Lorber's unoperated cases could be considerably lower than had occurred 20 years previously and asked what other factors might be operative.78 The babies were being fed on demand but also being sedated.9 Nevertheless, selection became the standard policy. Later, however, the issue was reopened. The spina bifida unit in Cardiff reviewed 49 children with spina bifida cystica, survivors of a group subject to selection for early surgery born in 1973-8, compared with 39 children alive from an earlier unselected series, born in the early 1960s.'0 Sixteen children were also studied in whom the early decision not to operate had been reversed when the children survived. The authors concluded that emergency treatment was rarely necessary. The criteria being used for selection were not those related to mortality but rather to morbidity. It therefore made sense to select for early back closure those children who on established criteria were likely to be minimally handicapped. Children with more severe lesions could be treated more conservatively, allowing time for proper evaluation of the baby and discussion 65
with the parents.8 Delaying surgery to the back lesion did not necessarily increase the risk of mental handicap as long as the hydrocephalus was promptly and effectively treated. A similar policy was also reported from Liverpool, while a report from Newcastle of a group of children born in 197180 showed that the life expectation of babies with meningomyelocele not offered surgery at birth was greater in those babies whose parents participated in their early care. 13 Furthermore, when the family participated closely in the care, even of children who later died, this helped the grieving process. '1 The results of treatment of an unselected cohort of children with open spina bifida born in East Anglia between June 1963 and January 1971 have been well documented.'5'-7 Of 117 babies who had early closure of the back, 69 survived to their 16th birthday. Survival was lowest and disability greatest in the group with a sensory level above TI 1. Survival was highest and disability lowest in the group with a sensory level below L3. What conclusions should be drawn from all these studies for babies today? The ventriculoperitoneal shunt has become more successful in managing hydrocephalus in the past 10 years. The peritoneal catheter, if it remains patent, is a much safer method of diverting cerebrospinal fluid than the atrial catheter and requires fewer revisions. The advent ofcomputed tomography has made supervision of the shunt less a matter of guess work. Management of the neuropathic bladder has also improved. Clean intermittent self catheterisation, first introduced by Lapides et al in 1972,18 has indirectly been responsible for a sharp reduction in the number of urinary tract diversions performed. 18-20 More refined methods of surgical management of the urological problems are also becoming available. How well the children walk still largely depends on the level of the spinal lesion, although with good physiotherapy and polypropylene orthoses children with high lesions may be got on to their feet if they and their parents are motivated. The hip guidance orthosis developed at Oswestry reduces the high energy cost of walking. In my experience, however, younger children resort to a swing through gait to increase their walking speed. Increasing weight and spinal deformity leads to loss of realistic ambulation in adolescents who require bracing above the hips in all but the most determined. Fifteen years ago Great Britain was second only to Ireland in the prevalence of neural tube defects. Now it has one of the lowest rates in the world.2' Prenatal screening and diagnosis have been largely responsible for this, but the underlying rate has also declined by about one third in the past 20 years. Data are still unsatisfactory, however, and a national neural tube defect register is needed. Babies born with neural tube defects in the 1990s deserve an ethical, humane programme of management based on accurate background data and involving parents fully in the early decision making. Most parents want to be concerned in decisions about the care of their newborn infant.3 22 Even if surgery is not advocated parents wish to care for their babies, and much has been learnt about the care of the whole family,
66
impressively reported by Delight and Goodall in their recent monograph.23 Each child should have an individual planned programme of management with a regular review of aims. Children also need educational support to help them to be integrated into mainstream education when possible and so prevent their social isolation. Mere physical proximity to able bodied peers, however, does not necessarily promote the social skills and confidence necessary for functioning successfully in the mainstream adult world.24 Later, proper medical care will be needed for the many young adults who are likely to have problems with renal failure, skin breakdown, and shunt failure.25 26 Caring for children and adults with spina bifida and hydrocephalus is expensive and time consuming, but an impressive amount of information on all aspects of management is now available. We need to learn these lessons and use resources well for the children who survive. GILLIAN T McCARTHY Consultant Neuropaediatrician, Chailey Heritage Rehabilitation and Development Centre, North Chailey, East Sussex BN8 4EF 1 Anderson FM. Ventriculo-auriculostomy in treatment of hydrocephalus. 7 Neurosurg 1959;16: 551-7. 2 Cohen Si, Callaghan RP. A syndrome due to the bacterial colonisation of Spitz-Holter valves. A review of 5 cases. BMJ 1961;ii:677-80. 3 Black JA, Challacombe DN, Ockenden BG. Nephrotic syndrome associated with bacteraemia after shunt operations for hydrocephalus. Lancet 1965;ii:921-4. 4 Stark G. The pathophysiology of the bladder in myelomeningocele and its correlation with the neurological picture. Dev Med Child Neurol 1968;10(suppl 16):76-86. 5 Lorber J. Results of treatment of myelomeningocele: an analysis of 524 unselected cases, with special reference to possible selection for treatment. Dev Med Child Neurol 1971;13:279-303. 6 Lorber J. Early results of selective treatment of spina bifida cystica. BMJ 1973;iv:201-3. 7 Zachary RB. Severely malformed children. BM3r 1973;ii:482. 8 Guthkelch AN. Aspects of the surgical management of myelomeningocele: a review. Dev Med Child
Neurol 1986;28:525-32. 9 Black PM. Selective treatment of infants with myelomeningocele. Neurosurgery 1979;5:334-8. 10 Evans RC, Tew B, Thomas MD, Ford J. Selective surgical management of neural tube malformations. Arch Dis Child 1985;60:415-9. 11 Rosenbloom L, Cudmore RE. Spina bifida: do we have the right policies? Arch Dis Child
1985;60:403-4. 12 Robards MR, Thomas GG, Rosenbloom L. Survival of infants with unoperated myeloceles. BMJ7 1975;iv: 12-3. 13 Menzies RG, Parkin JM, Hey EN. Prognosis for babies with meningomyeloceles and high lumbar paraplegia at birth. Lancet 1985;ii:993-5. 14 Dorner S, Atwell JD. Family adjustments to the early loss of a baby born with spina bifida. Dev Med Child Neurol 1985;27:461-6. 15 Hunt GM. Spina bifida: implications for 100 children at school. Dev Med Child Neurol 1981;23: 160-72. 16 Hunt GM. A study of deaths and handicap in a consecutive series of spina bifida treated unselectively from birth. Z Kinderchir 1983;38(suppl 2):100-2. 17 Hunt GM. Open spina bifida: outcome for a complete cohort treated unselectively and followed into adulthood. Dev Med Child Neurol 1990;32:108-18. 18 Lapides J, Diokno AC, Silber SJ, Lowe BS. Clean intermittent self-catheterisation in the treatment of urinary tract disease. J Urol 1972;107:458-61. 19 Lyon RP, Scott MP, Marshall S. Intermittent catheterisation rather than urinary diversion in children with myelomeningocele. J Urol 1975;113:409-17. 20 Crooks KK, Enrile BG. Comparison of the ileal conduit and clean intermittent catheterisation for myelomeningocele. Pediatrics 1983;72:203-6. 21 Cuckle HS, Wald NJ, Cuckle PM. Prenatal screening and diagnosis of neural tube defects in England and Wales in 1985. Prenat Diagn 1989;9:393-400. 22 Charney EB. Parental attitudes toward management of newborns with myelomeningocele. Dev Med Child Neurol 1990;32: 14-9. 23 Delight E, Goodall J. Love and loss. Conversations with parents of babies with spina bifida managed without surgery. Dev Med Child Neurol 1990;32(suppl 61):8. 24 Lord J, Varzos N, Behrman B, Wicks J, Wicks D. Implications of mainstream classrooms for adolescents with spina bifida. Dev Med Child Neurol 1990;32:20-9. 25 Rickwood AMK, Hodgson J, Lonton AP, Thomas DG. Medical and surgical complications in adolescent and young adult patients with spina bifida and hydrocephalus. Health Trends
1984;16:91-3. 26 Thomas AP, Bax MCO, Smyth DPL. The health and social needs of young adults with pkvsical disabilities. Oxford: Blackwell Scientific Publications, 1990. (Clinics in Developmental Medicine No 106.)
BMJ
VOLUME
302
12
JANUARY
1991
change in the culture-the values, beliefs, language, and patterns of behaviour-of British prisons. The chief inspector quotes approvingly the governor of a local prison: "My own view is that the ethos of an establishment, how inmates are treated, will determine the amount of suicide and self injury. While I understand the need for form-filling and insurance policy type activity, it is not a substitute for investing in time spent with staff. Firstly, letting them know that it is part of the culture to demonstrate concern for inmates, and secondly, showing them ways of letting it show." Prison doctors might begin by letting prisoners sit down during admission consultations.3 Changing culture is never easy and usually painful, and the culture of British prisons will probably change only if there is some change in British culture at large. Societies get the prisons they deserve. But one way to change prison culture will be to get rid of the monstrous local prisons and replace them with smaller community prisons. A recent leak suggests that this is what Lord Woolf and Stephen Tumim will advocate in their forthcoming report on the Strangeways riots. RICHARD SMITH Executive editor, BMJ 1 Dooley E. Prison suicide in England and Wales, 1972-87. Br3' Psychiatry 1990;156:40-5. 2 Working Group on Suicide Prevention. Report. London: Home Office, 1986. 3 Her Majesty's Chief Inspector of Prisons for England and Wales. Suicide and self harm in prison service establishments in England and Wales. London: HMSO, 1990. 4 Cohen N. Suicides blamed on state of jails. Independent 1990 Dec 20:1. 5 Goring C. The English convict. London: Darling, 1913. 6 Topp DO. Suicide in prison. BrJ3 Psychiatry 1979;134:24-7. 7 Home Secretary. Response to the report of Her Majesty's Chief Inspector of Prison's report on Risley Remand Centre. London: Home Office, 1988. 8 Home Secretary. Response to the report of HerMajesty's Chief Inspector of Prison's report on suicide and self harm in prison service establishments in England and Wales. London: Home Office, 1990. 9 Lloyd C. Suicide and self-injury in prison: a literature review. London: HMSO, 1990. (Home Office research study 115.) 10 Pokorny A. Prediction of suicide in psychiatric patients: a report of a prospective study. Arch Gen Psychiatry 1983;40:249-57. 11 Carrel J. Woolf report to back local prisons and contracts. Guardian 1990 Dec 31:1.
Treating children with spina bifida An individual programme for each child Effective surgical treatment became possible for children with spina bifida with the development of a shunt system for hydrocephalus in the late 1950s. By the end of the 1960s the main complications of ventriculoatrial shunts, including ventriculitis and low grade staphylococcal septicaemia, had been described. 1-3 The seriousness of the urinary tract problems was also being recognised and correlated with the neurological defects of the children.4 In 1971 Lorber published the results of the policy adopted in Sheffield of giving surgical treatment to all infants with meningomyelocele. His report described 524 unselected cases. I He concluded that there were four main criteria associated with a poor prognosis: severe hydrocephalus present at birth; a high level of paraplegia; congenital lumbar kyphosis; and associated congenital abnormalities or major birth injury. He showed that there was a high level of morbidity and resultant handicap in the children with more severe lesions. Lorber's next report described a trial in which active treatment, including the use of antibiotics, was withheld from 25 infants with adverse criteria, while active treatment was given to 12 infants in whom no adverse criteria were present.6 All but two of the unoperated children died within six months, and the remainder within nine months. BMJ
VOLUME 302
12 JANUARY 1991
These data had a profound effect on medical management in Britain, causing a swing of the pendulum away from advocating early treatment in all affected children towards selecting for treatment only those children who fulfilled the criteria for good prognosis. Some questioned how the survival rate of Lorber's unoperated cases could be considerably lower than had occurred 20 years previously and asked what other factors might be operative.78 The babies were being fed on demand but also being sedated.9 Nevertheless, selection became the standard policy. Later, however, the issue was reopened. The spina bifida unit in Cardiff reviewed 49 children with spina bifida cystica, survivors of a group subject to selection for early surgery born in 1973-8, compared with 39 children alive from an earlier unselected series, born in the early 1960s.'0 Sixteen children were also studied in whom the early decision not to operate had been reversed when the children survived. The authors concluded that emergency treatment was rarely necessary. The criteria being used for selection were not those related to mortality but rather to morbidity. It therefore made sense to select for early back closure those children who on established criteria were likely to be minimally handicapped. Children with more severe lesions could be treated more conservatively, allowing time for proper evaluation of the baby and discussion 65
with the parents.8 Delaying surgery to the back lesion did not necessarily increase the risk of mental handicap as long as the hydrocephalus was promptly and effectively treated. A similar policy was also reported from Liverpool, while a report from Newcastle of a group of children born in 197180 showed that the life expectation of babies with meningomyelocele not offered surgery at birth was greater in those babies whose parents participated in their early care. 13 Furthermore, when the family participated closely in the care, even of children who later died, this helped the grieving process. '1 The results of treatment of an unselected cohort of children with open spina bifida born in East Anglia between June 1963 and January 1971 have been well documented.'5'-7 Of 117 babies who had early closure of the back, 69 survived to their 16th birthday. Survival was lowest and disability greatest in the group with a sensory level above TI 1. Survival was highest and disability lowest in the group with a sensory level below L3. What conclusions should be drawn from all these studies for babies today? The ventriculoperitoneal shunt has become more successful in managing hydrocephalus in the past 10 years. The peritoneal catheter, if it remains patent, is a much safer method of diverting cerebrospinal fluid than the atrial catheter and requires fewer revisions. The advent ofcomputed tomography has made supervision of the shunt less a matter of guess work. Management of the neuropathic bladder has also improved. Clean intermittent self catheterisation, first introduced by Lapides et al in 1972,18 has indirectly been responsible for a sharp reduction in the number of urinary tract diversions performed. 18-20 More refined methods of surgical management of the urological problems are also becoming available. How well the children walk still largely depends on the level of the spinal lesion, although with good physiotherapy and polypropylene orthoses children with high lesions may be got on to their feet if they and their parents are motivated. The hip guidance orthosis developed at Oswestry reduces the high energy cost of walking. In my experience, however, younger children resort to a swing through gait to increase their walking speed. Increasing weight and spinal deformity leads to loss of realistic ambulation in adolescents who require bracing above the hips in all but the most determined. Fifteen years ago Great Britain was second only to Ireland in the prevalence of neural tube defects. Now it has one of the lowest rates in the world.2' Prenatal screening and diagnosis have been largely responsible for this, but the underlying rate has also declined by about one third in the past 20 years. Data are still unsatisfactory, however, and a national neural tube defect register is needed. Babies born with neural tube defects in the 1990s deserve an ethical, humane programme of management based on accurate background data and involving parents fully in the early decision making. Most parents want to be concerned in decisions about the care of their newborn infant.3 22 Even if surgery is not advocated parents wish to care for their babies, and much has been learnt about the care of the whole family,
66
impressively reported by Delight and Goodall in their recent monograph.23 Each child should have an individual planned programme of management with a regular review of aims. Children also need educational support to help them to be integrated into mainstream education when possible and so prevent their social isolation. Mere physical proximity to able bodied peers, however, does not necessarily promote the social skills and confidence necessary for functioning successfully in the mainstream adult world.24 Later, proper medical care will be needed for the many young adults who are likely to have problems with renal failure, skin breakdown, and shunt failure.25 26 Caring for children and adults with spina bifida and hydrocephalus is expensive and time consuming, but an impressive amount of information on all aspects of management is now available. We need to learn these lessons and use resources well for the children who survive. GILLIAN T McCARTHY Consultant Neuropaediatrician, Chailey Heritage Rehabilitation and Development Centre, North Chailey, East Sussex BN8 4EF 1 Anderson FM. Ventriculo-auriculostomy in treatment of hydrocephalus. 7 Neurosurg 1959;16: 551-7. 2 Cohen Si, Callaghan RP. A syndrome due to the bacterial colonisation of Spitz-Holter valves. A review of 5 cases. BMJ 1961;ii:677-80. 3 Black JA, Challacombe DN, Ockenden BG. Nephrotic syndrome associated with bacteraemia after shunt operations for hydrocephalus. Lancet 1965;ii:921-4. 4 Stark G. The pathophysiology of the bladder in myelomeningocele and its correlation with the neurological picture. Dev Med Child Neurol 1968;10(suppl 16):76-86. 5 Lorber J. Results of treatment of myelomeningocele: an analysis of 524 unselected cases, with special reference to possible selection for treatment. Dev Med Child Neurol 1971;13:279-303. 6 Lorber J. Early results of selective treatment of spina bifida cystica. BMJ 1973;iv:201-3. 7 Zachary RB. Severely malformed children. BM3r 1973;ii:482. 8 Guthkelch AN. Aspects of the surgical management of myelomeningocele: a review. Dev Med Child
Neurol 1986;28:525-32. 9 Black PM. Selective treatment of infants with myelomeningocele. Neurosurgery 1979;5:334-8. 10 Evans RC, Tew B, Thomas MD, Ford J. Selective surgical management of neural tube malformations. Arch Dis Child 1985;60:415-9. 11 Rosenbloom L, Cudmore RE. Spina bifida: do we have the right policies? Arch Dis Child
1985;60:403-4. 12 Robards MR, Thomas GG, Rosenbloom L. Survival of infants with unoperated myeloceles. BMJ7 1975;iv: 12-3. 13 Menzies RG, Parkin JM, Hey EN. Prognosis for babies with meningomyeloceles and high lumbar paraplegia at birth. Lancet 1985;ii:993-5. 14 Dorner S, Atwell JD. Family adjustments to the early loss of a baby born with spina bifida. Dev Med Child Neurol 1985;27:461-6. 15 Hunt GM. Spina bifida: implications for 100 children at school. Dev Med Child Neurol 1981;23: 160-72. 16 Hunt GM. A study of deaths and handicap in a consecutive series of spina bifida treated unselectively from birth. Z Kinderchir 1983;38(suppl 2):100-2. 17 Hunt GM. Open spina bifida: outcome for a complete cohort treated unselectively and followed into adulthood. Dev Med Child Neurol 1990;32:108-18. 18 Lapides J, Diokno AC, Silber SJ, Lowe BS. Clean intermittent self-catheterisation in the treatment of urinary tract disease. J Urol 1972;107:458-61. 19 Lyon RP, Scott MP, Marshall S. Intermittent catheterisation rather than urinary diversion in children with myelomeningocele. J Urol 1975;113:409-17. 20 Crooks KK, Enrile BG. Comparison of the ileal conduit and clean intermittent catheterisation for myelomeningocele. Pediatrics 1983;72:203-6. 21 Cuckle HS, Wald NJ, Cuckle PM. Prenatal screening and diagnosis of neural tube defects in England and Wales in 1985. Prenat Diagn 1989;9:393-400. 22 Charney EB. Parental attitudes toward management of newborns with myelomeningocele. Dev Med Child Neurol 1990;32: 14-9. 23 Delight E, Goodall J. Love and loss. Conversations with parents of babies with spina bifida managed without surgery. Dev Med Child Neurol 1990;32(suppl 61):8. 24 Lord J, Varzos N, Behrman B, Wicks J, Wicks D. Implications of mainstream classrooms for adolescents with spina bifida. Dev Med Child Neurol 1990;32:20-9. 25 Rickwood AMK, Hodgson J, Lonton AP, Thomas DG. Medical and surgical complications in adolescent and young adult patients with spina bifida and hydrocephalus. Health Trends
1984;16:91-3. 26 Thomas AP, Bax MCO, Smyth DPL. The health and social needs of young adults with pkvsical disabilities. Oxford: Blackwell Scientific Publications, 1990. (Clinics in Developmental Medicine No 106.)
BMJ
VOLUME
302
12
JANUARY
1991
