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FAMILY STUDIES IN CHILD HEALTH

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221 effect a synthesis of medicine and social outlook which is far harder to achieve in any culture that has a less intense sense of social purpose. These successes have been gained at the price of intellectual rigidity, and of the forfeiture of the critical approach to psychosocial medicine and to the dynamics of power on which we in Western cultures today pin much of our hope of social progress. There is no doubt, however, that such an ideology provides, to the young in particular, a source of enthusiasm com- parable to that derived from the major proselytising religions, and very similar in structure. Perhaps the rudest shocks to those unacquainted with Soviet scientific polemics (or with the theological debates of the English Puritans) come from the -appendices to Wortis’s book, containing criticism of psychological textbooks on the grounds of objectivity vis-a-vis the class struggle. Psychiatry in England can learn much, both from the refusal of Marxist psychiatry to dissociate social, political, and mental health, and from the history, successes, and blemishes of Communism in practice. It is on every count essential that we should understand modern Russia, and, that we should do so as scientific observers, despite the difficulties imposed by the suspicions and the propaganda of both sides in the present international tension. For this reason if no other, Wortis’s book is valuable to all interested either in psychiatry or in political psychodynamics. FAMILY STUDIES IN CHILD HEALTH THE increasing emphasis on child health is one manifestation of the importance now attached to pre- ventive medicine. The conception of long-term field studies of the child in his natural environment is fairly new. The most notable are those being conducted in Newcastle upon Tyne by Sir James Spence, and in Luton by Dr. R. M. Dykes, with their respective teams. These projects are already yielding a rich harvest of facts which will prove of great value in framing enlightened health policies. Dykes’ reviewed the health of the 1498 infants born in Luton in 1945 who could be observed throughout the first year (these comprised 79% of the total births) and showed that constitutional factors greatly influence child health, and also that the infant- mortality rate is a more sensitive index of social standards than the infant-morbidity rate. The carefully planned domiciliary study of the child which is being carried out in Newcastle is probably the most comprehensive of its kind ever to be undertaken. The objects and methods of this investigation were described in Boston last year by Spence,2 who discussed some of the data yielded by the first year’s work. After tracing the evolution of " preventive paediatrics" and mentioning the importance of medical statistics, hospital paediatrics, and laboratory research, he emphasised that much further progress can be made by field workers . who go outside the hospitals into the community, to study the incidence and spread of disease, the effects of social conditions on disease, and the control of disease and promotion of health by social environment. He deprecated the idea that field work is something entirely divorced from clinical and laboratory medicine, and suggested that a considerable proportion of those who work in social medicine should be clinicians and laboratory workers who follow their problems into the field when necessary. He pointed out that field inquiries are laborious, diffuse, and difficult to control with scientific standards—these are indeed the main reasons for their former neglect. He also asserted that, although research on some aspects of social medicine concerned with 1. Dykes, R. M. Comparative Study of Infant Sickness and Infant Mortality in Luton. Luton, 1950. See Lancet, 1950, i, 453. 2. Spence, J. C. New Engl. J. Med. 1950, 243, 205 family life can best be conducted by a general practi- tioner who lives in the community as the family doctor and keeps records of each individual from year to year and from one generation to another, the isolated inquiries of a general practitioner are applicable only to limited subjects ; moreover, few general practitioners have the time, training, or inclination for such work. For particular purposes such as those which the Newcastle workers are pursuing, efficient organisation and team-work are necessary. The Newcastle city health authorities have shown themselves anxious to cooperate with the university department of child health, the children’s hospitals, and the laboratory services in field research to improve child health. An initial cooperative investigation into the causes of infant mortality in Newcastle in the year 1939 was directed by Miller.3 The most notable finding was wide disparity between notified causes of death and actual causes as revealed at necropsy-a finding that indicates the inaccuracy of vital statistics relating to causes of death in infancy. A domiciliary study of morbidity in the first eight years of life was inaugurated in 1947 ; the work was greatly helped by the team spirit and technique evolved during the earlier mortality investi- gation. The main object was to observe, against the background of the home, the acute infective illnesses of young children-their incidence, clinical types, and results. Other objects were to bring those working in wards and laboratories into daily contact with field workers, thus broadening their concepts of health and disease ; to provide relevant local facts with which to freshen clinical teaching ; to guide health programmes ; and to create a method for giving a contemporary picture of disease, verified by statistics and direct clinical observation, which would reveal new problems for research. It was decided to study from the day of birth a sample of 1000 infants-one-sixth of Newcastle’s annual births. Altogether 1142 infants, born in May and June, 1947, were selected, representing a cross-section of all social groups. The team of investigators consisted of one paediatrician who devoted most of his time to the research ; two more senior paediatricians for con- sultation ; two clerks ; and five specially trained health visitors, who were entrusted with much of the intimate observation and research. Each week’s collected material was discussed at a Saturday conference attended by the medical officer of health and others concerned. As Spence aptly remarked, this study of 1000 infants inevitably became a study of 1000 families. Although this investigation has not yet reached the half-way point it has already yielded much valuable information. The records show in detail how 1000 families drawn from all social classes live, how they react to the problems of life, how they avail themselves of the health services, how the children are nurtured in body and mind, what their activities are, and the relation of these to others in the family. By the end of the first year 967 (85%) of the children remained in the investigation ; 44 had died, and 125 had removed from the city. In only 6 instances had coöperation been lacking. The study is now in its fourth year. The main object of pursuing it for eight years is to study the familial pattern of disease, particularly respiratory con- ditions. It is already apparent that the intrafamilial method of clinical investigation yields a simultaneous view of infectious disease-notably subclinical varieties -in other members of the family which could not otherwise be studied. Regular tuberculin testing is revealing exact information about the tuberculisation of the group. From this work Spence has already drawn the broad conclusion that over-emphasis on diagnostic medicine 3. Miller, F. J. W. Lancet, 1942, ii, 269.
Transcript

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effect a synthesis of medicine and social outlook which isfar harder to achieve in any culture that has a less intensesense of social purpose. These successes have been gainedat the price of intellectual rigidity, and of the forfeitureof the critical approach to psychosocial medicine andto the dynamics of power on which we in Western culturestoday pin much of our hope of social progress. There isno doubt, however, that such an ideology provides, tothe young in particular, a source of enthusiasm com-parable to that derived from the major proselytisingreligions, and very similar in structure. Perhaps therudest shocks to those unacquainted with Soviet scientificpolemics (or with the theological debates of the EnglishPuritans) come from the -appendices to Wortis’sbook, containing criticism of psychological textbookson the grounds of objectivity vis-a-vis the class

struggle.Psychiatry in England can learn much, both from the

refusal of Marxist psychiatry to dissociate social, political,and mental health, and from the history, successes, andblemishes of Communism in practice. It is on everycount essential that we should understand modernRussia, and, that we should do so as scientific observers,despite the difficulties imposed by the suspicions and thepropaganda of both sides in the present internationaltension. For this reason if no other, Wortis’s book isvaluable to all interested either in psychiatry or in

political psychodynamics.

FAMILY STUDIES IN CHILD HEALTH

THE increasing emphasis on child health is one

manifestation of the importance now attached to pre-ventive medicine. The conception of long-term fieldstudies of the child in his natural environment is fairlynew. The most notable are those being conducted inNewcastle upon Tyne by Sir James Spence, and in Lutonby Dr. R. M. Dykes, with their respective teams. Theseprojects are already yielding a rich harvest of factswhich will prove of great value in framing enlightenedhealth policies. Dykes’ reviewed the health of the1498 infants born in Luton in 1945 who could be observedthroughout the first year (these comprised 79% of thetotal births) and showed that constitutional factors

greatly influence child health, and also that the infant-mortality rate is a more sensitive index of social standardsthan the infant-morbidity rate.The carefully planned domiciliary study of the child

which is being carried out in Newcastle is probably themost comprehensive of its kind ever to be undertaken.The objects and methods of this investigation weredescribed in Boston last year by Spence,2 who discussedsome of the data yielded by the first year’s work. After

tracing the evolution of " preventive paediatrics" andmentioning the importance of medical statistics, hospitalpaediatrics, and laboratory research, he emphasised thatmuch further progress can be made by field workers

. who go outside the hospitals into the community, tostudy the incidence and spread of disease, the effects ofsocial conditions on disease, and the control of diseaseand promotion of health by social environment. He

deprecated the idea that field work is something entirelydivorced from clinical and laboratory medicine, and

suggested that a considerable proportion of those whowork in social medicine should be clinicians and laboratoryworkers who follow their problems into the field whennecessary. He pointed out that field inquiries are

laborious, diffuse, and difficult to control with scientificstandards—these are indeed the main reasons for theirformer neglect. He also asserted that, although researchon some aspects of social medicine concerned with

1. Dykes, R. M. Comparative Study of Infant Sickness andInfant Mortality in Luton. Luton, 1950. See Lancet, 1950,i, 453.

2. Spence, J. C. New Engl. J. Med. 1950, 243, 205

family life can best be conducted by a general practi-tioner who lives in the community as the family doctorand keeps records of each individual from year to yearand from one generation to another, the isolated inquiriesof a general practitioner are applicable only to limitedsubjects ; moreover, few general practitioners have thetime, training, or inclination for such work. For particularpurposes such as those which the Newcastle workersare pursuing, efficient organisation and team-work arenecessary.The Newcastle city health authorities have shown

themselves anxious to cooperate with the universitydepartment of child health, the children’s hospitals, andthe laboratory services in field research to improve childhealth. An initial cooperative investigation into the causesof infant mortality in Newcastle in the year 1939 wasdirected by Miller.3 The most notable finding was widedisparity between notified causes of death and actualcauses as revealed at necropsy-a finding that indicatesthe inaccuracy of vital statistics relating to causes ofdeath in infancy. A domiciliary study of morbidity inthe first eight years of life was inaugurated in 1947 ;the work was greatly helped by the team spirit andtechnique evolved during the earlier mortality investi-gation. The main object was to observe, against thebackground of the home, the acute infective illnesses ofyoung children-their incidence, clinical types, andresults. Other objects were to bring those working inwards and laboratories into daily contact with fieldworkers, thus broadening their concepts of health anddisease ; to provide relevant local facts with which tofreshen clinical teaching ; to guide health programmes ;and to create a method for giving a contemporarypicture of disease, verified by statistics and direct clinicalobservation, which would reveal new problems forresearch. It was decided to study from the day of birtha sample of 1000 infants-one-sixth of Newcastle’sannual births. Altogether 1142 infants, born in Mayand June, 1947, were selected, representing a cross-sectionof all social groups. The team of investigators consistedof one paediatrician who devoted most of his time tothe research ; two more senior paediatricians for con-sultation ; two clerks ; and five specially trained healthvisitors, who were entrusted with much of the intimateobservation and research. Each week’s collected materialwas discussed at a Saturday conference attended by themedical officer of health and others concerned. AsSpence aptly remarked, this study of 1000 infantsinevitably became a study of 1000 families.Although this investigation has not yet reached the

half-way point it has already yielded much valuableinformation. The records show in detail how 1000families drawn from all social classes live, how theyreact to the problems of life, how they avail themselvesof the health services, how the children are nurturedin body and mind, what their activities are, and therelation of these to others in the family. By the endof the first year 967 (85%) of the children remained inthe investigation ; 44 had died, and 125 had removedfrom the city. In only 6 instances had coöperation beenlacking. The study is now in its fourth year. The main

object of pursuing it for eight years is to study thefamilial pattern of disease, particularly respiratory con-ditions. It is already apparent that the intrafamilialmethod of clinical investigation yields a simultaneousview of infectious disease-notably subclinical varieties-in other members of the family which could nototherwise be studied. Regular tuberculin testing is

revealing exact information about the tuberculisationof the group.From this work Spence has already drawn the broad

conclusion that over-emphasis on diagnostic medicine

3. Miller, F. J. W. Lancet, 1942, ii, 269.

222

diverts attention from the detailed study of the sequenceof clinical events that make an illness ; and that ascientific study of this sequence of events, minutelyobserved and carefully recorded, is the method of thenatural scientist which becomes a powerful instrumentin the training of the young clinician. Such a broadapproach to the study of life-particularly child life-is like a breath of fresh air in these days of ultrascientificmedicine when many students, and their teachers, cannotsee the wood for the trees.

BEDPAN EXERCISE

As a labour-saving device the bedpan is a total loss.Patients have known this all along, and the news isnow reaching the doctors, and even a few of the hospitals.Dr. J. G. Benton, Dr. Henry Brown and Dr. H. A. Rusk 1have lately been measuring the energy expended bypatients on the bedpan and comparing it with that

expended on the bedside commode. They studied theoxygen consumption of patients in these two situationsby means of a closed-circuit metabolism apparatus.Since there were psychological and other obstacles tothe study of patients during actual defsecation, the sub-jects were asked to

" bear down " 10 times when seatedfirst on the bedpan and later, after a rest, on the commode.The tests were conducted in a small quiet room and thepatient was screened off from the doctor, who couldnevertheless observe him through a crack. Of the 28

patients studied 15 had cardiac conditions, and theremainder were either normal or had other disorders.The tests showed that in all patients there was a con-sistently greater oxygen consumption for performanceon the bedpan than on the commode, and that there wasno improvement with practice. The rise above restinglevels was, in the cardiac patients, 50-7% higher on thebedpan than the commode, and in the other subjects48-4%. This finding confers the blessing of science onthe universal opinion of those who have used a bedpan.If we wish to spare patients, and especially cardiac

patients, we will give them a bedside commode ; if wewish them to use half as much energy again we will insiston the bedpan.

NEUROLOGICAL COMPLICATIONS OF DISSECTINGANEURYSM

WITH dissecting aneurysms of the aorta neurologicalinvolvement is not uncommon, and its presence mayhelp in diagnosis. In 1944 Weisman and Adams 2

described 11 confirmed cases of dissecting aneurysm withprominent neurological dysfunction. This was associatedwith ischæmic necrosis of the peripheral nerves, the spinalcord, or the brain. With necrosis of the peripheralnerves the circulation through the main artery of thelimb was impeded, with a pulseless cold extremity,weakness, anaesthesia, and loss of tendon reflexes. Whenthe blood-supply of the spinal cord was affected a trans-verse lesion of the cord developed rapidly, with flaccidparalysis, sensory impairment up to a spinal level, andloss of sphincter control. Impairment of the cerebralblood-supply resulted in hemiplegia often accompaniedby confusion, stupor, or coma, and at times a

" carotidhemiplegia " with blindness on the side opposite to thehemiplegia. Weisman and Adams showed that the causeof the neurological disturbance was either extension ofthe dissection into one of the major branches of the aorta(such as the common carotid artery) with occlusion ofthe lumen, or severance of the smaller branches of theaorta by the dissection ; this was the commoner cause ofinterference with the blood-supply of the spinal cord.Moersch and Sayre 3 have analysed the Mayo Clinic

1. J. Amer. med. Ass. 1950, 144, 1443.2. Weisman, A. D., Adams, R. D. Brain, 1944, 67, 69.3. Moersch, F. P., Sayre, G. P. J. Amer. med. Ass. 1950, 144, 1141.

records of 26 verified cases of dissecting aneurysm.Clinical neurological signs were present in 12, butprobably this does not truly reflect the incidence of

neurological complications, since 9 other patients died sosuddenly that neurological examination was impossible.They found ischaemic lesions of the spinal cord andbrain but no convincing evidence of peripheral-nervelesions.

These studies indicate that dissecting aneurysm of theaorta is a possible diagnosis when a sudden cerebral orspinal disturbance is associated with other symptomssuch as severe pain in the chest or abdomen, perhapsradiating to the back. It is of historical interest that

probably the first recorded patient with a dissectinganeurysm and cerebral involvement was King George IIwho " was found fallen on the ground, speechless andmotionless," 4 and in whom post-mortem examinationshowed a dissecting aneurysm of the ascendingaorta.

ANIMAL OR VEGETABLE?

FOR some of us the true tragedy of Kongwa lies notin the sad loss of E36 million but in the harm that the ’failure may do to other projects which demand somethingmore than a parochial outlook on food problems. Weare told there is nothing so shy as a million dollars, anda million dollars once bitten can be expected to be twiceshy. There are others who feel the most recent reductionof the meat ration as another tragedy. It is useless topoint out to such people that they have available, oftenquite cheaply, abundant supplies of animal protein insuch forms as milk, cheese, fish, and the rabbit or hare.For them " protein " means a pre-1914 steak.

Things being as they are, the Nutrition Society couldnot have chosen a more topical theme for its symposiumin London on Jan. 20 than the, comparative merits ofanimal and vegetable foods. Problems relating to thesupply of food have a fascinating complexity. AsD. A. Boyd showed, cost in money, man-power, and

acreage must be balanced against the value of the foodsas sources of energy, protein, vitamins, and " wasteproducts " which can be utilised to provide more foods.By setting the balance more correctly, we are now

producing for human consumption nearly twice as muchvegetable food as before the late war. Animal productshave also been increased in total amount, despite largereductions in imported feeding materials. The dairy cow, which needs little protein in its diet because it cansynthesise amino-acids in its rumen, is largely responsiblefor this increase. K. L. Blaxter has calculated that thecow can take, from cereal, residues of which a highproportion are inedible by man, and manufacture fromthem, and yield in its milk, enough lysine to make upfor the shortage of this amino-acid in the original cereal.The cow needs much attention, but repays the extracost of labour by the high value of its produce. Othercreatures such as the hen need even more attention, and,as K. J. Carpenter pointed out, must be provided withrations rich in well-balanced protein. Such a diet is

usually costly, but the cost can be reduced by the skilfulmixing of proteins from different sources. This is whatwe do for ourselves when we insist on a " good mixeddiet." G. R. Tristram showed that many plants, if theywere eaten entire, would provide at least a good mixtureof amino-acids. It is the specialised organs such as theseed which have the incomplete mixtures.

If the protein in the diets of newly weaned childrenis inadequate the syndrome of kwashiorkor, or malignantmalnutrition, may appear. Dr. Lucy Wills has obtainedexcellent results by treating this disease with largeamounts of the protein of dried skim-milk. Cow’s milkand other agents reported to cure the disease may act

4. Nicholls, F. Phil. Trans. roy. Soc. London, 1761, 52, 265.


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