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TONSILLECTOMY AND RESPIRATORY INFECTIONS
810
able and normal life than one with only two or three ? It is reasonable to think that he should ; and, although there is no statistical evidence to support this, clinical impressions suggest that he does. The radical treatment of lung cancer advocated by BROCK and WHYTEHEAD cannot yet be accepted as the best treatment.
Annotations TONSILLECTOMY AND RESPIRATORY INFECTIONS THE indications for tonsillectomy may seem to be based more on intuition than on reason. Evaluation of the results, by differing methods of assessment,1-4 has already cast serious doubt on the value of the operation. Among the lexicon-like list of reasons for undertaking it, repeated respiratory infections (and- what child does not have them ?) has been well to the fore. Now McCorkle et al.5 have made a painstaking assessment of the relation of tonsillectomy to the incidence of such infections. This study can be faulted at only one point-the small numbers concerned. But the 230 children studied were observed for up to five years, during which the mothers kept a daily health record, field workers paid a weekly visit, and physicians assessed all illnesses with the help of extensive bacteriological
investigations. The results are presented under two headings. Under the first heading " the age-specific rate of infection " of two groups of children-tonsillectomised and not, before the period of observation began-is compared. Under the second heading is shown " the age-adjusted rate of infection " in a group of 26 children who, because they had a higher than expected rate of infection, were operated on during the period of observation. McCorkle et al. state : " Comparison of these data requires the use of either age-specific or age-adjusted rates because the incidence of common respiratory illness changes with age, and post-tonsillectomy experience is heavily weighted with older children." The outcome of this study and the was that the operation had no effect at all; 26 children with a higher than expected rate of infection continued unchanged at the higher rate after the
operation. with which this study was conducted suggests that, though the numbers were small, the results would be the same whatever the total. The great
care
WEIGHT-GAIN IN INFANCY THE importance of recording reliable anthropometric data in childhood is only now being fully recognised.6 During and since the late war valuable contributions have been made by H. C. Stuart, A. H. Washburn, N. C. Wetzel..and others in the U.S.A., by workers at the Institute of Child Health, University of London, directed by A. A. Moncrien, and by J. M. Tanner and R. W. B. Ellis. Thomsonhas studied the weight-gain during the first year of life of infants at a child-welfare clinic in Edinburgh. The observations were made monthly on legitimate, singleton, first-pregnancy infants whose birthweights were within the range of over 51/2 to 91/2 lb. ; 1737 observations were made on males and 1605 on females. Thomson confirmed that throughout the first year the mean weight-gain of the male is greater than 1. Kaiser, A. D. J. Amer. med. Ass. 1930, 95, 837. 2. Spec. Rep. Ser. med. Res. Coun., Lond. 1938, no. 227. 3. Paton, J. H. P. Quart. J. Med. 1943, 12, 119. 4. Walker, J. S. Arch. Otolaryng., Chicago, 1953, 57, 664. 5. McCorkle, L. P.. Hodges, R. G., Badger, G. F., Dingle, J. H. Jordan, W. S. New Engl. J. Med. 1955, 252, 1066. 6. Tanner, J. M. Arch. Dis. Childh. 1952, 27, 10. 7. Thomson, J. Ibid, 1955, 30, 322.
that of the female ;for instance, the mean weight-gain in the male at 26 weeks was not attained until 3 weeks later by the female, and the weight attained by the female at 1 year was reached by the male 8 weeks earlier. Thus there is ample justification for recording and assessing the weight pattern separately according to sex. Despite this differing pattern, Thomson found that the proportion of the total weight-gain in the first year at particular ages was the same in the two sexes ; for instance, in both sexes a quarter of the total weight-gain was attained at 10 weeks, half at 20 weeks, and threequarters at 32 weeks. This study strongly suggests that in singleton infants born at term birth-weight is unrelated to the rate of postnatal weight-gain. Accordingly in assessing progress the rate of weight-gain is much more important than the actual weight-a fact appreciated by experienced clinicians. Comparison with the careful recordings of Finlay 11 in Edinburgh thirty years ago showed that the mean weight at1 year is now 30 oz. greater. This is probably a fair reflection of the improvement in development and health in infancy throughout the country during this period of rising economic and nutritive standards. Thomson rightly emphasises that the standard graph weight-cards used in most localauthority clinics are out of date, and should be revised to provide norms which accurately reflect the improved development of infants nowadays. Parents who show an interest in the weight of their infants should be told that standard weight-for-age charts are based on the average weights of many infants ; otherwise they tend to be alarmed by weights that are not close to the average but which may be quite normal for their infant. If their infant is to be weighed at all it should be weighed methodically and accurately, as at most child-welfare clinics ; and the influence of factors such as race, heredity, and prematurity on the actual weight should always be borne in mind. Provided a baby looks healthy and seems to be making good progress it is a mistake to focus attention on weight-gain, since normal irregularities in the rate of gain are often misunderstood by parents and cause them much unnecessary worry. Routine weekly weighing is desirable in the first month or two of life ; but thereafter it should be done at lengthening intervals, provided the general progress is satisfactory, and between the ages of 6 months and 1 year 2-monthly weighing suffices. THE
LUNGS
IN
EMPHYSEMA
surface of thelungs islowerthan thatatthe mouth,
surface of the lungs is lower than that at the mouth, because of the elastic pull of the lungs. To produce inspiration/the pressure at the surface of the lungs has to be lowered still further and the fall which takes place is a measure of the force required. This force has to overcome two mechanical factors : the elastic pull of the lungs, which increases as the lung is distended, and the resistance to airflow when air moves through the respiratory passages. When expiration takes place these factors are again in operation. In order to analyse the mechanics of respiration it is necessary to separate the effects of airflow resistance from those of the elastic tension of the lungs, and, although technically difficult, this can be done graphically or, as Mead et awl. now report, by plotting the variables with a cathode-ray
oscilloscope. Mea-d et al. examined the mechanical properties of the lungs in 10 healthy people and in 10 patients with emphysema. They found that during quiet breathing pulmonary flow resistance was greater in the patients than in the healthy people throughout the respiratory cycle, but especially during expiration when it was 8. Finlay, T. Y. Edinb. med. J. 1924, 31, 317. 9. Mead, J., Lindgren, I., Gaensler, E. A. J. clin. Invest. 1955, 34, 1005.
able and normal life than one with only two or three ? It is reasonable to think that he should ; and, although there is no statistical evidence to support this, clinical impressions suggest that he does. The radical treatment of lung cancer advocated by BROCK and WHYTEHEAD cannot yet be accepted as the best treatment.
Annotations TONSILLECTOMY AND RESPIRATORY INFECTIONS THE indications for tonsillectomy may seem to be based more on intuition than on reason. Evaluation of the results, by differing methods of assessment,1-4 has already cast serious doubt on the value of the operation. Among the lexicon-like list of reasons for undertaking it, repeated respiratory infections (and- what child does not have them ?) has been well to the fore. Now McCorkle et al.5 have made a painstaking assessment of the relation of tonsillectomy to the incidence of such infections. This study can be faulted at only one point-the small numbers concerned. But the 230 children studied were observed for up to five years, during which the mothers kept a daily health record, field workers paid a weekly visit, and physicians assessed all illnesses with the help of extensive bacteriological
investigations. The results are presented under two headings. Under the first heading " the age-specific rate of infection " of two groups of children-tonsillectomised and not, before the period of observation began-is compared. Under the second heading is shown " the age-adjusted rate of infection " in a group of 26 children who, because they had a higher than expected rate of infection, were operated on during the period of observation. McCorkle et al. state : " Comparison of these data requires the use of either age-specific or age-adjusted rates because the incidence of common respiratory illness changes with age, and post-tonsillectomy experience is heavily weighted with older children." The outcome of this study and the was that the operation had no effect at all; 26 children with a higher than expected rate of infection continued unchanged at the higher rate after the
operation. with which this study was conducted suggests that, though the numbers were small, the results would be the same whatever the total. The great
care
WEIGHT-GAIN IN INFANCY THE importance of recording reliable anthropometric data in childhood is only now being fully recognised.6 During and since the late war valuable contributions have been made by H. C. Stuart, A. H. Washburn, N. C. Wetzel..and others in the U.S.A., by workers at the Institute of Child Health, University of London, directed by A. A. Moncrien, and by J. M. Tanner and R. W. B. Ellis. Thomsonhas studied the weight-gain during the first year of life of infants at a child-welfare clinic in Edinburgh. The observations were made monthly on legitimate, singleton, first-pregnancy infants whose birthweights were within the range of over 51/2 to 91/2 lb. ; 1737 observations were made on males and 1605 on females. Thomson confirmed that throughout the first year the mean weight-gain of the male is greater than 1. Kaiser, A. D. J. Amer. med. Ass. 1930, 95, 837. 2. Spec. Rep. Ser. med. Res. Coun., Lond. 1938, no. 227. 3. Paton, J. H. P. Quart. J. Med. 1943, 12, 119. 4. Walker, J. S. Arch. Otolaryng., Chicago, 1953, 57, 664. 5. McCorkle, L. P.. Hodges, R. G., Badger, G. F., Dingle, J. H. Jordan, W. S. New Engl. J. Med. 1955, 252, 1066. 6. Tanner, J. M. Arch. Dis. Childh. 1952, 27, 10. 7. Thomson, J. Ibid, 1955, 30, 322.
that of the female ;for instance, the mean weight-gain in the male at 26 weeks was not attained until 3 weeks later by the female, and the weight attained by the female at 1 year was reached by the male 8 weeks earlier. Thus there is ample justification for recording and assessing the weight pattern separately according to sex. Despite this differing pattern, Thomson found that the proportion of the total weight-gain in the first year at particular ages was the same in the two sexes ; for instance, in both sexes a quarter of the total weight-gain was attained at 10 weeks, half at 20 weeks, and threequarters at 32 weeks. This study strongly suggests that in singleton infants born at term birth-weight is unrelated to the rate of postnatal weight-gain. Accordingly in assessing progress the rate of weight-gain is much more important than the actual weight-a fact appreciated by experienced clinicians. Comparison with the careful recordings of Finlay 11 in Edinburgh thirty years ago showed that the mean weight at1 year is now 30 oz. greater. This is probably a fair reflection of the improvement in development and health in infancy throughout the country during this period of rising economic and nutritive standards. Thomson rightly emphasises that the standard graph weight-cards used in most localauthority clinics are out of date, and should be revised to provide norms which accurately reflect the improved development of infants nowadays. Parents who show an interest in the weight of their infants should be told that standard weight-for-age charts are based on the average weights of many infants ; otherwise they tend to be alarmed by weights that are not close to the average but which may be quite normal for their infant. If their infant is to be weighed at all it should be weighed methodically and accurately, as at most child-welfare clinics ; and the influence of factors such as race, heredity, and prematurity on the actual weight should always be borne in mind. Provided a baby looks healthy and seems to be making good progress it is a mistake to focus attention on weight-gain, since normal irregularities in the rate of gain are often misunderstood by parents and cause them much unnecessary worry. Routine weekly weighing is desirable in the first month or two of life ; but thereafter it should be done at lengthening intervals, provided the general progress is satisfactory, and between the ages of 6 months and 1 year 2-monthly weighing suffices. THE
LUNGS
IN
EMPHYSEMA
surface of thelungs islowerthan thatatthe mouth,
surface of the lungs is lower than that at the mouth, because of the elastic pull of the lungs. To produce inspiration/the pressure at the surface of the lungs has to be lowered still further and the fall which takes place is a measure of the force required. This force has to overcome two mechanical factors : the elastic pull of the lungs, which increases as the lung is distended, and the resistance to airflow when air moves through the respiratory passages. When expiration takes place these factors are again in operation. In order to analyse the mechanics of respiration it is necessary to separate the effects of airflow resistance from those of the elastic tension of the lungs, and, although technically difficult, this can be done graphically or, as Mead et awl. now report, by plotting the variables with a cathode-ray
oscilloscope. Mea-d et al. examined the mechanical properties of the lungs in 10 healthy people and in 10 patients with emphysema. They found that during quiet breathing pulmonary flow resistance was greater in the patients than in the healthy people throughout the respiratory cycle, but especially during expiration when it was 8. Finlay, T. Y. Edinb. med. J. 1924, 31, 317. 9. Mead, J., Lindgren, I., Gaensler, E. A. J. clin. Invest. 1955, 34, 1005.