Maternity and Child Welfare Group

I)IJBIJC HEAI,TH, August, 1951

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doctor to his patients. The conmmn use of this designation may have influenced the negotiators in their failure to assess the real importance of the posts and the Award had suffered accordingly. After further discussion in which Drs. Tilley, Walton, Hebblethwaite and Ardley took part, it was agreed that the following resolutions be forwarded for consideration by the Council of the Society:-(1) T h a t this Branch is dissatisfied with the Industrial Court Award. (2) That in view of the failure of many Local Authorities to implement the Award, consideration of the salaries of Public Health Medical Officers be reopened, with a view to it being declared a Dispute for decision by the National Arbitration Tribunal. (3) T h a t the present designation of " A s s i s t a n t " as applied to officers employed in the School and Maternity and Child Welfare Services be replaced by some other whic[~ would indicate that the Officers had some definite personal responsibility in much of their work.

rates. In his view the remuneration of a dentist treating the priority classes should not be less than that of those engaged in the General Dental Service. In the discussion which followed, great interest was expressed in Mr. Stocker's views. Mr. Bingay assured Mr. Stocker that in Middlesex the maximum clinical freedom was granted to each officer within the limits imposed by the exigencies of the service, With regard to statistics, these were not unreasonably required by the Ministry of Education who paid a considerable share of the cost of the School Dental Service. Mr. Smyth pointed out that with the present shortage of staff some limitation of the scope of treatment had become inevitable. Mr. Sykes pointed out the advantages of the service being provided by the Local Education Authority, and Mr. Webster said that in Hendon careful records had been kept of the number of children who had received complete treatment from general practitioners. This showed that the increase since July 5th, 1948, the date on which the National Health Service Act had been implemented, was only 0"6%. tn his reply to the points raised in the discussion Mr. Stoeker said that from his personal experience he considered the civil service set-up more flexible than that of a local authority. A vote of thanks to Mr. Stocker for his stimulating paper was proposed by the President and carried by acclamation. It is hoped that a fuller report of Mr. Stocker's paper will appear in a later issue of PtmLIC HEALTH.

DENTAL OFFICERS' GROUP President: P. G. Oliver, L.n.s. (Chief D.O., Croydon C.B.). Hon. Secretary: J. V. Bingay, M.B.~:., L.O.S. (Chief D.O., Middlesex). A meeting of the Group was held at the London School of Hygiene and Tropical Medicine on Saturday, May 5th, 1951, at 2.30 p.m. The President, Mr. P. G. Oliver, was m the chair, and was supported by 14 other members. In introducing* ihe speaker the President said that Mr. Stocker had only recently qualified as a Dental Surgeon and was a part-time member of the staff of the Middlesex County Council. Before the war he had been a chartered accountant, and his views on the Public Dental Service would, in consequence, be of particular interest. Mr. Stocker then read his paper entitled " A Newly Qualified Entrant Looks at the Service." He spoke of his subject from three main viewpoints, the subjective, the objective, and the municipal. He found tile work interesting and rewarding apart from minor frustrations. The position of the Service had radically changed since the introduction of the National Health Service Act, and he considered that it was wrong in principle that the treatment of the priority classes should remain a charge on the local

M A T E R N I T Y A N D CHILD W E L F A R E G R O U P President: Dr. Miriam Florentin (S.M.O., M. & C.W., West t l a m C.B.). Hon. Secretary: Dr. Kathleen Hart (A.Div.M.O., Middlesex). Hon. Asst. Secretaries: Drs. Mabel Dodds and Doris Craigmile (A.Div.M.O.s, Middlesex). Post-graduate Week-end, Sheffield, May 4th to 6th, 1951 Nearly 50 members attended this post-graduate course held in Sheffield. On Friday night a Civic Reception was held at the Town Hall. The Deputy Lord Mayor received guests. Members of the local B.M.A., the Medical Women's Federation and the Sheffield Public Health Staff were present to meet memhers of the Group. (Continued on page 218)

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Ante-Natal Care Two lectures were given at the Children's Hospital on Saturday morning. T h e first, given by Prof. Scott Russell, who was introduced by the President, was on Ante-natal Care. Prof. Russell summarised the history of the care of the expectant m o t h e r from the time, in 1916, when the first external antenatal clinic was started. He said that Dr. Valentine, w h o p u b lished a paper on Ante-natal Care, pointed out how difficult it then was to get an ante-natal patient into hospital and made plans for a maternity hospital with provision for ante-natal beds. At a time when the maternal mortality was 4 per 1,000 heart disease played a large part in the high maternal mortality, causing as m u c h as 30% of all associated deaths. Rickets, too, was an important contributory cause of death. T u r n i ~ g to present-day care, Prof. Russell said that, while he did not consider a multiplicity of routine tests were advisable. m a n y patients were found to be suffering from some degree of anaemia. He felt that often insufficient care was taken of the expectant mother, between the thirty-second and the thirtysixth week of pregnancy, especially in regard to malpresentation of the foetus. Another error was to fail to recognise the oversized baby, and hydrocephalus was a snare not often recognised ante-natally: indeed it m i g h t be very difficult to detect. He commented on the value of regular weighing of the patient and said that we m u s t control the weight gain, in order t,~ save impairment of the health of the mother. Ohstetrics was a matter of team work and ante-natal care laid a foundation on which to build. In answer to questions, Prof. Russell said that he felt that the value of relaxation exercises was chiefly to give the patient a sense of well-being and lack of fear; it was possible for a patient to over-relax and to go to sleep when she should be active in the second stage of labour. It was generally agreed that the Ministry circular on antenatal care by general practitioners intended the two ante-natal examinations to be a m i n i m u m and not the desired extent of ante-natal care. A vote of thanks was given by Dr. B. Hatherley (Birmingham).

Elasticity in Infant Management Prof. Illingworth, who followed Prof. Scott Russell, spoke on " Elasticity in I n f a n t Management." He spoke of the use of the Self-demand Feeding Schedule in use in the Jessop Hospital. While m a n y new-born babies liked a comparatively rigid routine and settled to it, there was considerable variation in the personality of babies, in the stomach emptying times, etc., which varied with activity and temperature. If a b a b y was allowed to cry when hungry; both mother a n d b a b y became tired out, and if a night feed was withheld the father suffered also. Many infants required two feeds at night, at first, but discontinued this of their own free will by the tenth week. In Sheffield the baby was placed beside the mother's bed and he considered that the fact that, from the fifth to ninth days, babies demanded frequent (nine to 12) feeds, was physiologically satisfactory and gave the mother's breasts the stimulus they required for efficient lactation. A more rigid schedule appeared detrimental and produced more cracked nipples. Of the few disadvantages of this m e t h o d he said t h a t some babies took longer t h a n others to settle to their own r h y t h m . A very few required only three feeds a day and did not stimulate lactation sufficiently, but this could be overcome by m a n u a l expression. It was possible for a stupid mother to misinterpret every cry as a request to be fed. It was found that if a b a b y only wanted to be cuddled it would quieten when picked up. There was some evidence that children treated thus grew up happier and it was as wrong to leave a child crying as it was silly to waken h i m for a feed. T h e duration of the breast feed was proportional to the rate of flow of milk and varied considerably. Only in the newborn period did the baby require more t h a n ten minutes; after six weeks three to four minutes was often sufficient. The young b a b y went to sleep after it had taken sufficient, the older b a b y began to play and take an interest in its surroundings. As regards the q u a n t i t y of milk taken, Prof, Illingworth said that a baby rarely takes too much. Many of the toddlers' diet sheets giving details of quantities to be served were nonsense. He referred to the Chicago experiments, where toddlers were allowed free choice of diet. There was no food refusal or digestive upsets and the total calorie and constituent intake was optimum. Anorexia was a frequent result of food forcing. Similarly constipation was, in 99% of cases, due to maternal anxiety and mismanagement. It was impossible to " train " a child to control his sphincters, but a m o t h e r could " help " her child to become clean,

Prof. IPingworth said that o n l y fondling a child when he did not want attention would spoil a child; he would then grow unable to play and amuse himself on his own. There was no evidence that rigid methods helped a child to be happier, tn closing, Prof. Illingworth recommended to his listeners the book " Baby and Child Care," by Benjamin Spock. A lively discussion followed and a vote of thanks was pro posed by Dr. T. P. Evans (Amersham). T h e afternoon was spent in a coach tour round places of interest in the district, including a visit to Haddon Hall.

Course Dinner {)n Sazurday evening a dinner was held at the Grand ttatel, Sheffield, with the President of the Group, Dr. Miriam Florentin. in the chair. T h e guests at the dinner were Dr. IAywelyn Roberts, M.O.H., Sheffield, the Deputy Lord Mayor and Mrs. Barton, A l d e r m a n Yorke, C h a i r m a n of the H e a l t h Committee. Prof. Hobson, Professor of Social and Industrial Medicine. Sheffield University, and Prof. Scott Russell, Professor ol ()bstetrics. Dr. Dorothy Egan proposed the toast of the City, to which the Deputy Lord Mayor replied. Dr. Hilda Davis proposed the toast of the Guests, to which Prof. Hobson replied. Dr. Llywelyn Roberts proposed the toast of the G r o u p tc which the President, Dr. Florentin, replied.

The Aetlology of Congenital Malformations On Sunday m o r n i n g the Group met at the City General Hospital. Prof. Hobson, Professor of Social and Industrial Medicine, chose as his subject " The Aetiology of Congenital Malformations." He said that while very little was known about the causes of congenital malformations, as the infant deathrate fell they were b e c o m i n g a relatively more important cause of death. There was as well as an apparent rise in the proportional death-rate a very slight absolute rise in the n u m b e r of deaths due to these causes. T h e aetiology could be divided into genetic causes and environmental causes. Of the genetic causes, Prof. Hobson said t h a t the inheritance m i g h t be either recessive or dominant and he showed in illustration a case where synphalangy had been transmitted t h r o u g h 14 generations. Sexlinked inheritance for example in haemophilia m i g h t resuh in affected m a l e s b u t the female offspring who inherited the disease probably died i n u t e r o . Where the genetic factors were important in foetal deaths, McKeown e t a l . have shown that a recurrence in the same family is 24 times as likely as in a normal family and that defects tend to be reduplicated in the sibship. Pyloric stenosis and anencephaty were two examples of a sexlinked inheritance. True genetic factors operated independently of environments. T u r n i n g to the consideration of environmenta~ factors, Prof. t t o b s o n said that although considerable knowledge had been gained from experimental work with anima's, this could not as yet be applied to h u m a n genetics. The association of mongolism with a h i g h maternal age and of maternal diabetes wilh increased abortion and congenital malforamtion rates suggested that the maternal endocrine state might play a part in the development of abnormalities in the baby. T h a t the virus of rubella affects the adrenal cortex has been suggested by Brown. T h e same defect could be the result of various influences. Prof. Hobson dealt in more detail with the infections during pregnancy. Gregg (Australia), who investigated the relationship of rubella in pregnancy to foetal abnormalities, suggested that these were most frequent if the mother became infected in the fourth to eighth week of pregnancy. Heart disease, cataract and deafness were the most frequently found lesions. Subsequent work both in Britain and other countries has not shown such a deformity rate in other epidemics. He, himself, when he wa~ investigating congenital heart disease in Bristol found no history of rubella. In Manchester, where German meas'es is notifiab'.e, the evidence is negative. It was suggested that the Australian epidemic which produced such a large crop of abnormalities was perhaps unusually severe. The combination of rubella and early pregnancy was so rare in Britain that no drastic preventive measures were required. In Holland exposed mothers were inoculated with i m m u n e globulins. After discussion, a vote of thanks was proposed by Dr. Nelson (Dewsbury). Members were then taken to the wards to see obstetric cases of interest shown by Dr. Clancy, and pediatric cases illustrating congenital abnormalities of the gastrointestinal tract and cases of illness which had been detected at the routine welfare examination by Dr, Gordon,