603.full.pdf - Postgraduate Medical Journal

THE

POSTGRADUATEMEDICAL JOURNAL

November I962

A NEW DEAL IN CHILD HEALTHDUNCAN LEYS, D.M., F.R.C.P.

Hon. Consultant Physician, Children's Department, Farnborough Hospital, Kent

THE specialist is relatively new in medicine, andthe study of sick children as a formal discipline is amatter of only two or three decades. Many cir-cumstances have contributed both to the latenessand the intensity of the development. This centuryhas seen degradation of humanity in scale anddegree greater than any known to history, in thetoleration and sometimes the deliberate cultivationof cruelty, and in the reconciling of the humanspirit to the planned destruction of thousands,and even hundreds of thousands, at a single blowby the exploiting of atomic physics. By contrast,it has also become a century of great enlighten-mnent about the health and education of children.We have learned how the early death of children,stunted growth, bodily defects of all kinds, blind-ness and deafness, crippling respiratory and heartsiisease, can be the result of deprivations; andfqually how deprivations of a different kind cancause gross distortions of the personality, resultingin antisocial behaviour, frustrated lives, and theperpetuation of unhappiness from generation togeneration.We have turned upon sick children all the

resources which chemistry and physics have placedat our disposal. We have been able to describe interms of these sciences many of the illnesses, someof them fatal, which a previous generation ofdoctors regarded with the indifference of inevitableignorance. And we have been given and have

exploited to the full a great many potent drugswhich have transformed the practice of the doctorand the nurse confronted by children with bac-terial infections. The antibiotics have arrivedto give, as it were, the coup de grace (socially speak-ing) to the bacterial diseases: an ironical thought,if a happy one, when we remember how helplesswe were before the discovery of the sulphonamides,in the first three decades of the century, whendeaths from the common infections were the dailyexperience of all doctors in general and hospitalpractice. The ' miracle drugs ' have brought reliefto many an agonized family, but, socially speaking,the battle was won before the reinforcementsarrived, as common experience showed us (whatthe registrar's graphs had been prophesying to theinitiates), that the killing infections, like the plagueand cholera of old, were diseases of dirt andpoverty.

Ironical also is the realization of the very greatinjury we have unwittingly done to many childrenby the creation of hospitals and hospital wards forchildren, carried to their logical extreme in theperfectly hygienic cubicle with its gowned andmasked attendants and rigid exclusion of thesupposedly germ-laden mother. It is difficult forthose whose living has been earned, and witexercised, in the diagnosis and treatment of sickchildren, not to have some romantic regrets forthe children's ward, with its tiled nursery dado

London

copyright. on July 3, 2022 by guest. P

rotected byhttp://pm

j.bmj.com

/P

ostgrad Med J: first published as 10.1136/pgm

j.38.445.603 on 1 Novem

ber 1962. Dow

nloaded from



j.bmj.com

/P


j.38.445.603 on 1 Novem

ber 1962. Dow

nloaded from



j.bmj.com

/P


j.38.445.603 on 1 Novem

ber 1962. Dow

nloaded from

http://pmj.bmj.com/

http://pmj.bmj.com/

http://pmj.bmj.com/

POSTGRADUATE MEDICAL JOURNAL

and its Christmas tree. Such wards are there yet,and will remain, while children are born withdeformities of their kidneys and their hearts andaberrations of chemistry in their cells. But thecots occupied by the children with rickets andscurvy, tuberculosis, syphilis and rheumatic heartdisease; empyema, lung abscess and bronchiec-tasis; meningitis and diphtheria; the dysenteriesand enteritis and cceliac disease; all these we cannow, or very soon, pack up, and pull down, oruse for perhaps more cheerful purposes thebuildings which contained them.

In I920, 2% of all London school children hadrheumatic heart disease. There are some 50,000adults now with rheumatic heart disease, many ormost of whom will require surgery. But cripplingrheumatic heart disease in childhood has nowpractically disappeared from Southern Englandand one may expect Scotland and the North toshow more gradually a corresponding change.Some of the seemingly necessary operations onyoung children (tonsillectomy, circumcision,removal of naevi) are now seen to be oftenredundant or harmful. The need for others hasdisappeared (removal of tuberculous glands, ofbronchiectatic lungs: the protracted surgery ofchronic osteomyelitis).

Has paodiatrics then been born to flourish for afew years and then to fade like an outmodedhandicraft? In the sense that paediatrics is theapplication of the techniques of clinical medicineto the problems of the individual child, who hassurvived the first few weeks of life, posed as acuteepisodes, I think that the answer is essentiallyaffirmative, and that relatively few centres centrallyplaced in the hospital regions will meet the needfor the hospital treatment of young children withgrave disease. We shall still encounter very com-monly illnesses needing well-informed advice andtreatment in people's homes, but the homes willbe adequate, centrally heated and well ventilated,not the crowded single-roomed lodging of thecity slum; and the mother will no longer beignorant of the simple facts underlying the practiceof personal hygiene, and will be able to reinforceher care, if necessary, by the help of a well-trained nurse.Twenty years ago this prospect might have been

foreseen by someone who stood outside the dailystruggle of personal problems of health and disease,but he would have been a bold man or woman whowould have predicted the rapidity with which thevision has become an actuality. In pwdiatrics,however, the truth was first brought home by thefact that our fears of a catastrophic decline inhealth during the war were never realised. Andin the post-war years he is an insensitive personindeed who is not cheered by the daily realization

that children are stronger, more active, moreintelligent, and far, far less ill than before.A halt to this progressive healthiness, or even a

reversal of health statistics, could easily occur ifthe social trends which occasioned it should alterradically for the worse. It does not need a worldcatastrophe to bring about a reversal of the trendtowards a high standard of living. We have seenin Britain a rather ominous tendency towardssocial regression in the limitations placed upon theoriginal conception of a national health servicewhich should be comprehensive and entirely freefrom expense to the individual sick person, in thefailure to implement plans to improve schoolbuildings, to provide nursery classes, day nurseries,and community care in general. Retrograde socialtendencies of this kind are insidious. ProfessorTitmuss (I958), in an acute analysis of theeconomics of the welfare state, has shown how itis not the most needy who receive the greatestbenefit in services.Assuming, however, that a setback of this sort

is temporary, and that there is no major regressionin living standards, will ' p2ediatrics ' wither away?Are there no remaining tasks in preventing andcuring disease in childhood, and none in promotingstill further reductions in morbidity and mortalityin antenatal life and infancy, or in promoting stillhigher standards of human activity? The questionhas only to be put to be answered. Wastage offretal life (i.e. of children conceived but unborn) isstill of the order of io%. Mortality rates stilldiffer by as much as ioo% between the lowest andthe highest social classes, showing that it shouldbe possible to reduce the loss of infant life inBritain by many thousands a year. At least twochildren in a hundred are still born with a majordeformity of mind or body, some 5% sufferserious emotional disturbance; from I to 5%have convulsions; io% are subjected to someform of operation on the nose and throat. Rejec-tions for the army while conscription was main-tained made us aware of the immense gap betweenthe best and the worst, in intellectual, emotional,and physical development, and the magnitude ofthe deficiency.Advances will not be automatic, and neither will

they be implemented by types of organization andthought which were the result of circumstancesnow irreversibly changing. The traditional placeof the doctor is that of an individual adviser inpersonal problems. The grafting upon his func-tions of the immensely illuminating but also highlycomplicated techniques of applied medical sciencederived from physics and chemistry, have yieldedgreat dividends. No mother, relieved of the burdenand anxiety of a child with congenital heart diseaseby surgery, but will bear testimony to that. But

604 November I962copyright.

on July 3, 2022 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.38.445.603 on 1 N

ovember 1962. D

ownloaded from

http://pmj.bmj.com/

LEYS: A New Deal in Child Health

it is no longer the brilliant or exceptionally wiseindividual who has brought her relief, but, in theactual practice of the operation and the prepara-tion for it, a dozen or more people working withapparatus devised and made by as many others,all making use of skills which are the result oflong and more or less difficult training, and allworking in such a way that every part of theprocedure is thought out, planned and co-operative. The need for such co-operation, and theever-increasing volume of new facts and tech-niques, makes specialization more and more neces-sary and the field of the specialist more and morenarrow. There is scarcely any serious deviationfrom health for which, if the individual is toreceive efficient treatment or advice, severalspecialists are not required. The greater ourexperience, the less are we inclined to acceptvery simple explanations of disease and treatmentbased solely upon them.

Still more is efficient co-operation requiredwhen, as increasingly we must, we have to con-sider the implications of disease for society as awhole as well as for individuals, and in the morediffuse and as yet unexplored problems con-cerned with the promotion of maximum health.Therapeutics, and even the tasks of preventivemedicine as they have been undertaken in the fieldsof public health practice, have been concernedwith the individual seen to be already diseased ordeformed, or with disease as a recognizable devia-tion from what appeared to be a satisfactory levelof attainment. One has only to examine thephysical data collected from supposedly healthychildren at school in the earlier years of the centuryand to compare them with figures collected fromthe same age-groups 30 years later, to know thatstandards of ' normality' then were the standardsof a diseased community. In affairs of health, wewaited till things went wrong before we tooknotice of what they might be like when they wereright. In scarcely any other department of life hassuch an attitude prevailed. In almost all our otheractivities in industry, in farming and horticulture,in education, in the arts, our ainm is a positive one:we are striving to excel in proficiency, in newachievement, in beauty. It has been the' cranks',wrong-headed as they have been or have appearedto be in many of their ideas, who first pointed thisout and suggested that we should turn our atten-tion to the study of how to live so that all ourfaculties could be exercised.

National Health ServiceThe National Health Service was brought into

being as a public acknowledgment of social need,but in the face of a good deal of opposition from amajority of men and women on the active medical

list. Faced with the accomplished fact, doctorshave learned in a remarkably short period ofyears to work together in the spirit of a publicservice. They have seen hospital service improveout of all recognition, in spite of severe economiesin staffing and supply. Far from the practice ofmedicine having suffered, there have been notableimprovements stemming directly from the partialabandonment of the direct profit-making incentive,and the acceptance of co-operation rather thancompetition as the fundamental principle. Butdefects remain both in concept and execution.Administrative partitioning of the service ofdoctors into its three separate groups of generalpractitioner, hospital and public health, has pro-duced less, rather than more, integration thanexisted before 1948, when the National HealthService was inaugurated. Within hospitals therigid determination to apply the ' parallel ' systemof organization throughout the service, has led tothe rejection, outside some research departments,of any institution with a corporate structure, withthe result that it is only by prodigious efforts ofunofficial co-operation, that anything approachingan agreed or connected plan of attack on diseasecan be achieved.New thinking, new attitudes, new methods, are

needed to meet an entirely new situation. Childhealth is no longer a field of ignorance and neglect,and it is no longer the exclusive province of themedical profession. The doctor must descendfrom the pedestal on which an anxious anddependent society has placed him during the last50 to ioo years, to learn from and collaborate withother disciplines. The doctor must cease to thinkof himself as in contract with private individuals,undertaking for a consideration a purely personalservice, and eager to defend the illusory ' freedom '

which must leave him outside the mainstream ofsocial progress. His work, like the teacher's, will,in future, be part of a service which is personalprecisely at the point where interests and needs ofthe individual coincide with those of society as awhole.

In pwdiatrics, more than in any other field, wecan see not only the need for, but the inevitabletendency to work out in the field, plans for co-operative medicine. So long as administrativedivisions divide health workers into separategroups, each reluctant to abandon traditional andexclusive roles, unofficial efforts can only be par-tially successful. It is clear that in pwdiatrics weshould have the opportunity to do fundamentalwork in preventing disease by establishing at thebeginning of life right principles of living and goodrelationships with individuals and with society.But the very problems themselves can only beidentified by free discussion between all kinds of

605November I962copyright.


http://pmj.bm

j.com/

Postgrad M


ovember 1962. D

ownloaded from

http://pmj.bmj.com/


people who bear responsibility for the health andeducation of children, and there is at present noway of bringing these people together eithernationally or locally under official auspices.

The Practice of Pediatrics

i. Hospital P&eediatricsI believe that Robert Hutchison wrote his

'Lectures on Diseases of Children' during thefew days of enforced idleness of the general strikeof I926. The writing is intimate and elegant, andthis, together with the obvious pleasure of theauthor in his subject and his experience as abedside teacher, made this the most convincingand acceptable book for the children's doctorknown to me. Such a book might still be writtenperhaps, as a condensation of personal experience,but it could not possibly be, as Hutchison's bookwas in his day, a reasonably complete account ofclinical padiatrics. The relative simplicity of hisfield alone made this possible, and for that veryreason there were, in I926, practically no Britishpxdiatricians; or rather, any clinician couldclaim equality of competence in the diagnosis andtreatment of the sick child. The slate was almostclean. All that we now understand as the basis ofclinical poediatrics was still hidden, including thephysiology of the ftetus and the newborn, micro-chemistry of the blood, identification of metabolicdisease, the use of insulin, of the ECG, of theEEG, air studies of the brain, the technique ofblood transfusion, the whole of cardiac, plasticand neuro-surgery, genetic prediction and thediscovery of chromosome aberrations, and, perhapsmost important of all, objective study of childbehaviour and the construction of a rationalhypothesis of psycho-sexual development.

In Britain, piediatrics means hospital paediatrics,i.e. it is defined as a specialist function and indeedthe British Paediatric Association is unlikely toconsider for membership anyone who does nothold an appointment as paediatrician to a medicalschool or to a regional hospital board, or a com-parable position in a research centre. For suchappointments membership of the College ofPhysicians and four or more years of postgraduatework in poediatrics are required.

- There is a technology of poediatrics which is asimportant as that of any other field of medicalpractice. No amount of human sympathy andinsight can compensate, in a general pediatrician,for lack of understanding of haemolytic disease ofthe newborn, its mechanism, the critical featuresin anticipation of the birth of an affected infant, orfor poor judgment in diagnosis and practicalability in treatment. But the 'know-how' hascertainly been too narrowly conceived in training

and in consideration of candidates for hospitalappointments. There is a' know-how' also of thesymptoms and signs of delayed or pervertedintellectual and emotional growth, and of the'handicapped child'. It is possible to 'make adiagnosis' and yet to be ignorant of the circum-stances which led to an illness, and which may stillobtain.To be ' fond of children' is not a reasonable

basis for the practice of any discipline involving thecare of children, and one would be a little scepticalof its adequacy when offered as a motive by anaspirant to paediatrics. Yet to be interested in, orrather to be fascinated by the efflorescence ofchildhood: genuinely to like to be with very youngchildren and especially the newborn: to feelsympathetically towards adolescents, these doseem to be prerequisites. Women, therefore,should, and do, make good padiatricians. Therules of medical training are still very muchman-made, and women are not given as goodopportunities as men. The late Sir James Spence,whom I knew well, a man of strong personalityand original and liberal thought, could yet be soblinded by sex antagonisms as to say to me thatin his experience women made good poediatricregistrars, but bad consultants, and he rationalizedthis prejudice by the supposed difficulty of re-conciling maternal feeling with professional de-tachment. None of us males, I think, is entirelyfree from resentment at the idea that womencan be as or more intelligent and competent inmedicine than ourselves. The process of dis-embarrassment from the obsession of malesuperiority is slow, and in padiatrics very im-portant, for women play a large part in childhealth services, and the necessary integration ofhospital pediatrics with public health work hasscarcely begun.There has so far been little specialization in

hospital pediatrics. I was about to say littleopportunity for specialization, but this is rather aquestion of a few people seeing the need andmaking or taking the opportunity and filling theroles. There are,phild psychiatrists, but no childneurologists or endocrinologists. Cardiology isslowly emerging as a pa2diatric specialty, and thereis a place for clinical specialization in psychoso-matics, and in preventive and neonatal piediatrics,and, I think, in dermatology, otorhinology,ophthalmology and orthopadics. The fault, if itis one, lies partly in the way in which pediatrichospital appointments are made, and this, in turn,reflects the failure of any national organization toemerge which undertakes to consider the needs ofchildren as a whole, and to plan for them.*The organization of undergraduate, and even of

postgraduate teaching is still an uneasy compromise

606 November i962copyright.


http://pmj.bm

j.com/

Postgrad M


ovember 1962. D

ownloaded from

http://pmj.bmj.com/


between traditional ' apprentice' methods de-pendent upon individual clinical practice, and alogically planned sequence of teaching. ' Vestedinterests' are strong in opposition to change.Developmental neuro-psychiatry is vital to padia-trics, but there is not a single professorial depart-ment of child psychiatry or developmentalneurology in Britain.The regional paediatrician is a maid-of-all-work

for children, yet must think of himself as aspecialist. He must not just try to be, but must,in fact, be informed on a great variety of difficulttechnical subjects such as fluid and electrolytebalance, the differential diagnosis of develop-mental heart disease and the possibilities of radicaland of emergency treatment; he must have a goodworking knowledge of the ECG, not in itself amarginal or trivial matter; increasingly he mustlearn the clinical application of genetics and ofchromosome diagnosis, a subject which is likely tobecome increasingly important and increasinglycomplex.The suggestion has often been made that

paediatrics needs to be organized in relativelylarge departments served by several senior paediat-ricians who can have the opportunity, by theirassociation, of mutual consultation, both onindividual cases and upon policy, and also of somedegree of specialization. The South-East Metro-politan Regional Hospital Board accepts thispolicy, recommended by their pediatric advisorycommittee, in principle, but has, in fact, only onesuch centre. The advantages are great. All themajor activities of a padiatrician are facilitated, andhe is in a much stronger position, vis-a'-vis othercompeting interests, in advocating necessary de-velopments. He can, wvith his colleagues, present astrong case for senior resident staff, without whomit is next to impossible to build an effectivepxdiatric service in maternity departments. Heis able to organize conferences, and postgraduatecourses for family doctors and child health staff;he is more free, because of the ' cover' provided,to attend conferences himself, and he is in a muchbetter position to take part in research.

I think two factors have militated against this

*But there has been established, in I962, with thehelp of the National Council of Social Service, a' National Bureau for Co-operation in Child Care'.' Child Care ' is now the customary term for services fordeprived children. This may seem a limited object andnot very relevant. But I think that if the pioneers of thisidea interpret their work in an imaginative way, as theirconstitution suggests that they do, then the concept ofan integrated service for all children might well receivea kind of pilot study, and become a model. For deprivedchildren are in a very direct way the immediate andtotal responsibility of us all, of the community, for alltheir needs.

obvious development. Firstly, there was, at theinauguration of the National Health Service, whichprovided a splendid opportunity for re-organiza-tion, a terrible fear, almost wholly irrational, of' regimentation ', of dictatorial methods in ad-ministration and particularly of clinical control.There had certainly been some very bad examplesof professional hierachy in the municipal hospitals,and some of the Government's advisers had ex-perience of the harm done by dictatorial rule insome continental, and especially in German,hospitals. A rigid rule of parity in all hospitalappointments was therefore established, and thishas made it impossible, or at least very difficult, toorganize the kind of department of which I havebeen speaking, which must have a director ortitular head. Secondly, there was the relativelymeagre but superficially attractive prospect of theindependence and profit of private practice,distracting and competitive. Unfortunately, theinstitution of ' domiciliary consultation ', or-ganized on a strictly individual, and again oftencompetitive, basis, increased this tendency for theindividual pediatrician to be distracted from hispublic, preventive and co-operative function to-wards a relatively barren personal success. Homevisits by padiatricians are important: not to visitis to be largely ignorant of how people live.Reluctance to visit is an important cause ofpopular feeling of dissatisfaction with doctors,which has assumed quite grave proportions in theUnited States. But visiting should not be made amatter of individual reward: this concept relatesto an obsolete conception of medical practice:home visiting should be part of normal padiatricpractice, organized on a co-operative, not acompetitive basis.There are really splendid opportunities now for

the young pediatrician attached to such a regionaldepartment as I have outlined to become a keyfigure in the community. His main interest can bedirected in one or more of several directions.Some tasks will be thrust upon him (prematurityand care of the newborn, behaviour disorders andpsychosomatic disease): for others he must, byhis interest, attract support and so create hisopportunity. Examples are: assessment and careof handicapped children; family counselling.Whether we like it or not, the public is becoming

much better informed about disease and abouthealth, through the Press and through televisionand sound broadcasts; we must become willing toexplain and willing to take our places, togetherwith other disciplines and in co-operation withthem, in a combined effort to improve life andhealth. Increasingly pxediatricians are magistratesin juvenile courts, advisers to societies concernedin child welfare, co-opted members of health,

November i962 607copyright.


http://pmj.bm

j.com/

Postgrad M


ovember 1962. D

ownloaded from

http://pmj.bmj.com/


education and children's committees of localauthorities. In all fields of children's welfare theyhave a specific contribution to make, but also muchto learn from teachers, psychologists, socialworkers and probation officers. The ' profile' ofthe pontificating pa!diatrician, making ' foot-of-the-bed' diagnoses and holding himself aloof, isnot just out-dated-it has become an absurdity.

Nothing stands still, but it would seem that welive in a period of more than usually rapid andrevolutionary change, as the result of a century ofmajor intellectual excitement and discovery whichmay or may not have passed its zenith. The timesrequire the exercise of a faculty not much en-couraged by orthodox methods of education, andperhaps more than usually ignored in the teachingof doctors, namely, the ability to keep one's head.There is a large and often incoherent mass of factand theory to be acquired as the working basis ofprofessional life: and there is fashion, never moreobvious than now, when journalists have decidedthat medicine is good copy and that the public hasa right to know. There are hundreds of remediesand combinations of remedies, some specific, someonly seemingly so, and many with no function atall, but generously advertised. All are potentiallydangerous, and pressure to prescribe is only lessintense in padiatrics than in adult medicine. Thereis constant temptation to grasp at the latest thingas an over-all explanation, at the EEG as an' explanation' of epileptic phenomena rather thanas a contingency; or, with more substance butstill with too great naivety, of chromosome aber-ration as the 'explanation' of mongolism. Thehistory of medical fashion is melancholy commenton professional credulity: there has never been atime when it has been more necessary to becritical.

2. Peediatrics in General PracticeIt is rather the fashion to say that the family

doctor is the foundation of medical practice andthat the tendency to remove from him the totalresponsibility for individual patients must bereversed. One cannot say that the general prac-titioner has, during the last half century, occupieda position of greater or less value to people thanthe hospital specialist or public health doctor, but,with explosive advances in all branches of medicine,his professional position in society is becomingsomething of an anachronism. He can no longerclaim that he, unaided, is capable of offering tofamilies all the help they need in prevention andcure of disease.What do children now need the family doctor

for? What knowledge do doctors possess, or whatpowers do they exercise, when presented with theproblems of childhood, which other disciplines do

not possess? We are emerging from the periodwhen infection and malnutrition were the mostimportant causes of ill health, and the childhoodproblems now presenting to the general prac-titioner are increasingly of two kinds, often inter-related, namely, of physical and mental handicapdue to errors of development, and secondly, ofsocial maladjustment.

It must be confessed that a large part of thetraining given to the intending general practitionerhas little relation to the tasks he is likely to becalled on to perform. To begin at the beginning,he might be expected, since there is nobody elsein a position to act as guide, to be able to offerpeople about to marry information about theirfitness for marriage and parenthood, on the needsand difficulties of married love, on the psychologyof love, pregnancy, childbirth and motherhood;on preparation for lactation and on the techniquesof successful breast feeding; on the way to estab-lish the best possible relationship between parentsand children; on the difficulties likely to beencountered in the nurture of the first and sub-sequent children. He should be trained in birthcontrol, and the reasons for, and treatment of,sterility, and he should be at least in a position toobtain advice on genetic prediction when eitherparent has some defect believed to be inherited,or when a child has already been born with aninherited defect. He needs to know at least inoutline the interplay of environmental and geneticcauses in disease, as, for example, in mongolism,and to be able therefore to offer truthful informa-tion to parents or intending parents, rather thanthe sort of vague warnings or reassurances whichhave been considered by many doctors to be allthat can be expected.

' Preventive Pediatrics ' touches on half a dozenspecialist fields: it is not a subject in which anysingle person can hope to be adequate, but forchildren, as for their parents, it is the familydoctor who must act as guide, and for this heneeds training. Developmental medicine embracesnow a genuine body of knowledge. From Gesellonwards a succession of people have been provid-ing us with an increasingly reliable picture ofbehaviour progress in children, which allowsestimates to be made about individual children,increasingly accurate as the months go by.Although we may still be very ignorant as towhat can be done to increase the experience andrange of activity of a handicapped child, littleprogress can be made in this field unless disabilityis detected early. This is true for the whole field ofperception and behaviour. A child who is slow tosit independently may be mentally handicapped, orhave cerebral palsy, or both. An inattentive childmay also be mentally handicapped, but he may be

6o8 November I962copyright.


http://pmj.bm

j.com/

Postgrad M


ovember 1962. D

ownloaded from

http://pmj.bmj.com/


deaf or blind. How does one test hearing andvision in a three- or four-month-old baby? A childwho is slow to speak may have tone deafness, ordysarthria, or emotional inhibition or merely lackof stimulus. A parent or grandparent may suspecta defect: the family doctor should be able toconfirm or to reassure with confidence. Suchconfidence is not gained by a few lectures; itrequires practice, and so does the recognition ofcerebral injury in the newborn; and so do theproblems of adolescents-their half-realized needs,and half-understood behaviour, and their clasheswith parents and teachers. Such problems cannotbe discovered, analysed and solved in a fewminutes, nor in isolation; they are problems re-quiring the self-education and interest of parents,nurses and doctors, and later of teachers andwelfare workers, working together.

I regret that early plans for group practice, work-ing from health centres, which many people con-sidered the corner-stone of the National HealthService, were abandoned. Pwediatrics in generalpractice should be a first-class profession, but itcan only flourish if the doctor is given a chance tospecialize as one of a group: when he does so, heshould also be given the opportunity, which hisexperience should fully entitle him, of being incharge of infant welfare or ' well-baby ' clinics.

3. Child HealthOf the three main groups of doctors who serve

children, hospital p.Tdiatricians, general prac-titioners and public health officers, I speak withgreatest diffidence about the last. As it is thefashion to exalt the position of the general prac-titioner, so it is the fashion to speak slightingly ofthe work of school doctors and infant welfareclinics, and to regard them as superfluous. I amnot ignorant of their work, having myself workedas a young man for over a year as school medicalofficer and infant welfare doctor, having had goodcontact with child health service over the greaterpart of my professional life and the highly valuedfriendship of many school medical officers. Theyhave less contact with hospital paediatricians andgeneral practitioners than the other two groupshave among themselves. They have less oppor-tunity for mastering the very great advances whichhave been made in the last two or three decadesin our understanding of disease, but better oppor-tunities than the other groups of realizing the needfor changing disciplines in paediatrics. There areamong them greater extremes of accomplishmentthan in hospital padiatrics. Relative to the muchsmaller demand made upon them for a specialistdiscipline, some clinic work is poor-old fashionedin outlook and ill-informed; but some child healthdoctors have, especially in the kind of work which

demands a good understanding of social medicine,of personal relationships, the emotional needs ofparents and children, and knowledge of normaldevelopment, higher standards than many hospitalpadiatricians.

Increasingly, in ' western' civilization, a childspends, after the first three years of life, quite asignificant part of his waking life apart from hisparents, in day nurseries, nursery schools, schools,holiday camps, clubs; not a few children spend amajor part of their life living wholly apart fromtheir families. In all of this doctors have, orshould have, a significant role. At his, or moreusually perhaps, her best, the school doctor is moreintimately concerned with a family, and a morereadily available source of reliable advice in familyproblems than anyone else. Many are faute demieux practical psychiatrists. They have manydifficulties; for example, no access to specialistadvice except by permission of the family doctor,who may or may not be a willing ally; they haveminimal secretarial help and good record keepingis a labour often performed in nominally leisurehours.To see that these three groups of practitioners in

paediatrics should have a common administration,a common meeting place and parity of esteem,requires no great profundity of thought. But itseems unlikely, in the face of very powerfullyrooted prejudices, vested interests, and economicdifficulties, that any integration will take placeunder official auspices. The opportunity existedwhen the National Health Service was inaugurated,and when professional and public opinion wasmuch more fluid and ready for change: such asituation does not arise more than once or twice ina life-span.Terms which we use so freely, as if they had

precise meaning in terms of a child's needs-' education ', ' nurture', ' health', are only con-veniences; as someone has said of the departmentsof a university, they are the names which decideto whom salaries go. Nobody can say where' education' or ' health' begin and end, nor howearly either is to be thought of as socially necessaryfeatures in a child's life. In his parents? Before heis conceived?The discovery and channelling of measures to

improve the health and vigour of children, to givethem the conditions in which they can exploit theirendowment, to develop the sort of personality onwhich a hopeful future for all of us can be built, isnot going to be the business of one professionalgroup. There are, of course, tentative ventureshere and there, unofficial groups and societies,who make it their business to think about socialpxediatrics. Their activities are mostly unrecordedand unblessed by any agency of government.

6ogNovember i962copyright.


http://pmj.bm

j.com/

Postgrad M


ovember 1962. D

ownloaded from

http://pmj.bmj.com/


There is nothing new about the idea of a childhealth centre. I do not use thi-s term in the sense ofuniversity departments of child health, whichhave their place, and presumably an increasinglyuseful one, in research of a highly technical kind.I mean by this term an extra-mural child healthcentre, which serves as the local clearing house forideas and the place towards which everyone canlook whose work provokes (or should provoke)self-questioning, for the opportunity to exchangeinformation, to report developments or observa-tions which he thinks are of importance; to gainsupport for what he considers to be necessarychanges or reforms; to take part in a continuingstudy of the welfare of the child population of hisneighbourhood, and to undertake, with colleaguesin all branches of child nurture, planned studieswhich can make useful contributions to knowledgein that district, or for children as a whole.Examples of such studies would be the specialhealth risks of a local community; changes infood consumption; in living habits; industrialhazards; housing; and the infinite variety ofconditions which can affect individual children,the family and a community. I see the opportunityto establish such a centre being taken most easily ina city of some 500,000 people, its own master in allthe main functions of government, with its uni-versity centre, a health department capable ofentertaining new concepts in the activities of itsdoctors and health workers, a co-operativeRegional Hospital Board and a progressive citycouncil encouraging initiative and ready to takeadvantage of every possible Act of Parliament tofinance new ventures.

4. Pe-diatrics in Underdeveloped CountriesIn Cape Town, African children with tuberculous

meningitis are commonly treated as outpatients.Recently a candidate for an English appointment,who was resident in Africa, said he wanted ' topractice padiatrics ', not to spend all his timetreating children with malnutrition and infections.Perhaps he wished to do research work, but I guessthat he hankered after the relative elegance andleisure of pxdiatric practice in a country with ahigh living standard. There are opportunities forpxdiatric practice in underdeveloped countries,with communities living on a subsistence economy,and on the edge of starvation. I have not myselfworked in Africa or Asia, but I imagine conditionsnot wholly unlike my own experiences in Londonin the 1920'S, when infant mortality was three timesits present level, when hospital outpatient depart-ments were thronged with infants with broncho-pneumonia, whooping cough, congenital syphilis,skin infections, osteomyelitis, mastoiditis, nutri-tional anamia, rickets and scurvy. One was often

oppressed then by the meagreness of the help to beoffered, but there was great satisfaction neverthe-less in being able to offer something. Very muchmore can be offered now.

But I think it is true to say that there is notmuch place now for the missionary idea, which isessentially patronizing. The colonial empire hasgone, but there is still a genuine demand for'Europeans', and especially for Britons, in manyparts of Africa and in India, where the need fordoctors is only secondary to the need for technicalexperts in agriculture and industry, and in educa-tion. The African and Indian peoples do not verymuch want people with missionary spirit: theyare ready to give conditions and salaries which arecompetitive ', and indeed prefer to do so, to

people who possess the 'know-how' and whowant to exercise their skill.They need public buildings, schools and

hospitals and doctors to staff them, as visibleevidence of the fact that they are masters of theirown destinies. They are not ignorant of the factthat such things are (relatively speaking) luxuries.They do not appreciate being patronized; theydo not need advice from us on how to organizethemselves or how to spend their limited budgets,but their statesmen realize only too well how fewof their own nationals are trained in the techniquesand arts of modern civilization.

Research in PediatricsMedicine is a branch of biology. I don't know

when the term ' research' came into currentusage, but the Oxford dictionary says it wasderived from ' rechercher'; and of the ninemeanings attaching to the prefix, the RE of re-search implies intensification or concentration. Allof us have the impulse to enquire and we are allintentional or unintentional experimenters-wetry things out and we accumulate observations,and our behaviour is, whether explicitly or not,derived from them. But unless such observationsand experiments are well ordered or designed,irrelevancies and ' observer error' reduced to aminimum and 'chance' taken into account, theyare unlikely to be valuable. Research in this senseis modern; it is in the biological field complicatedand expensive and dependent on work by a teamof people trained in relatively narrow fields withhighly technical expertise. We owe all the majoradvances in pediatrics to highly organized workof this kind, in which single men and women mayprovide the ideas, but in which execution demandsorganization. Nationally we are still very parsi-monious in medical research, spending on it lessthan I% of the total cost of medical services. Themajor source of funds has been from taxation(Medical Research Council), but a very remarkable

6I0 November i962copyright.


http://pmj.bm

j.com/

Postgrad M


ovember 1962. D

ownloaded from

http://pmj.bmj.com/

November I962 LEYS: A New Deal in Child Health 6ii

development has occurred with the endowment bythe National Spastics Society of an Institute ofPrediatric Research at Guy's Hospital. Otherassociations, e.g. the Eugenics Society and theNational Society for Mentally HandicappedChildren, have made grants to individuals orgroups for particular projects. There is a reallyunlimited field of investigation in padiatrics,biological, therapeutic, sociological, psychological,educational, and nobody can work for long in thisfield without having ideas. But there is a ratherlarge gap between the idea and the actual study,which can only be bridged by quite hard work,and many or most lines of study do require a greatdeal of technical knowledge and facilities. Yet itwould be wrong to suppose that research itself isa ' specialism', and I have myself been associatedwith several studies which were carried throughby a number of ' amateurs ' in paediatrics or childhealth, as co-operative projects. Statistical adviceis not difficult to obtain and the trustees of re-search funds are willing to consider any seriouslyplanned investigation. The main 'growing-points'of pwdiatrics at present are in genetics, in the' epidemiology' of developmental abnormality, inthe analysis of the disability of handicapped chil-dren, and in psycho-sexual development anddisorder. While work in each of these fields isspecialized, and often, as in chromosome studiesor the biochemistry of genetic distortion, veryhighly specialized, there is still quite a considerablecontribution to be made by organized non-specialist study.One of the co-operative studies which I mention

above was an ambitious attempt to gain someinsight into the conditions in which the 'healthiest'children of a community were conceived andnurtured (' Epidemiology of Health '). There havebeen many attempts to describe in general terms

what we are striving for in child nurture; none ofthese can perhaps obtain general support, even in asociety with a settled and generally accepted' philosophy' of life. There will be fairly sharpdifferences of opinion as to the degree to which achild should be made to conform to an acceptedpattern of behaviour, what sanctions it is justifiableto employ, whether our aim in education is know-ledge or the power to think, the inculcation of anethic or the ability of each individual to form hisown. The same regime will to some appear rigid,to others so lax as to leave children confused. Yetthe differences of opinion will be chiefly as tomeans and all will desire that children shouldfulfil themselves as a well-nurtured plant willgrow to full stature, bloom with full fragrance andcolour, and procreate. Tentatively one mightexpress the aim of child nurture as the achieve-ment of adulthood in full physical vigour, with anattitude to life based upon reason rather thanprejudice; sensitive to the needs of others and withoccupations which are constructive rather thanpassive.

I would urge padiatricians to seek a place insociety which is not only one of direct professionalwork, but in which they could have an opportunityto share with teachers, sociologists, psychologistsand social workers, their thoughts on the needs ofchildren. Such an opportunity can come throughchild health societies, through membership of thebench of a juvenile court or of a children's com-mittee. Increased understanding of childhood is soclearly the key to the understanding of adult be-haviour. And I do not think it an extravagance tosuppose that we can, by the deliberate fostering ofwhat I call social p ediatrics, explore ways ofdelivering humanity from some, at least, of itsmaterial as well as its moral dilemmas.

REFERENCETITMUSS, R. M. (1958): 'Essays on the Welfare State'. London: Allen and Unwin.



j.bmj.com

/P


j.38.445.603 on 1 Novem

ber 1962. Dow

nloaded from

http://pmj.bmj.com/

4 POSTGRADUATE MEDICAL JOURNAL January I963

partly due to its geographic isolation and partlyto the traditions of its two staple industries.

Comparison with other Medical InstitutesMost other medical institutes in this country

are in cities with undergraduate medical schoolsand they therefore serve a rather different functionfrom that envisaged for the North StaffordshireMedical Institute. The recently opened medicalcentre at Kingston-on-Thames is again notstrictly comparable for its primary purpose is toserve as a common meeting place for generalpractitioners and hospital staffs. The Stoke-on-Trent scheme is perhaps most akin to the newPostgraduate Institute at Exeter. There isperhaps a major difference in the underlyingconcepts of the two Institutes. The primarypurpose behind the planning of the North

Staffordshire Medical Institute was to provide thefacilities for achieving and maintaining thehighest possible standard of medical practice, atall levels, in the district. This must remain thefirst objective though clearly the future develop-ment of the Institute may expand along moreambitious paths.

In conclusion it should be emphasized that theconcept of the North Staffordshire MedicalInstitute had long been in the minds of the seniormembers of the medical profession of the district.Its realization is due to the combined efforts ofnumerous individuals, including consultaints,general practitioners and laymen who haveselflessly devoted much of their spare time to theachievement of a goal which all believed wouldbenefit the community.

It is with great regret that we announce the death of Professor R. F. Woolmer, V.R.D.,B.M., F.F.A.R.C.S. Professor Woolmer was appointed director of the new research departmentof anaesthetics at the Royal College of Surgeons in I957 and became the first holder of theChair of Anoesthetics established there by the British Oxygen Co. in 1959. He joined theExecutive Committee of the Fellowship of Postgraduate Medicine in June 1959. He leaves awife and two daughters, to whom we extend our sincere sympathy.

CORRECTIONProfessor Findlay Ford, Professor of Child Health,

University of Cape Town, and Dr. Edmund Cooper,M.O.H., City of Cape Town, have written to say thatDr. Duncan Leys has been misinformed about the treat-ment of African children with tuberculous meningitisin that city. They wish ' to state most emphatically that

neither they nor any of our numerous ethnic groupshere are treated on lines other than those which wouldbe entirely acceptable to experts elsewhere '.The Postgraduate Medical Journal sincerely apologizes

for this error in the issue of November I962 (Pediatrics2).

Documents

603.full.pdf - Postgraduate Medical Journal