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VI.—PREVENTION OF DISEASE IN THE PRE-SCHOOL CHILD
1163
THE PREVENTIVE ASPECTS OF MEDICINE A Series
of
Lectures in progress
during
the Winter Session at
VI.—PREVENTION OF DISEASE IN THE PRE-SCHOOL CHILD Arthur Newsholme, that the curtailment of illness and the decrease of suffering come within the scope of preventive medicine, we find that preventive and clinical medicine have a common meeting ground, and are in fact inseparable. Taking this broad view of preventive medicine, there are several ways in which a doctor may practise the preventive aspect of his calling. The first and most desirable form of prevention is to advise a patient on such lines as shall forestall the appearance of disease ; we see an example of this in infancy in the administration of orange juice as a prophylactic measure against infantile scurvy, or in the use of cod-liver oil to prevent rickets. Secondly, a course of treatment may be recommended in order to create in the patient a specific immunity to certain diseases ; examples of this in childhood are vaccination against small-pox and immunisation against diphtheria. Thirdly, by diagnosing disease in its initial stages it may be possible to begin treatment early enough to thwart the natural course of the disease and alter the prognosis vastly for the better. The importance of early diagnosis in the illnesses of childhood may be illustrated by diphtheria, in which the prognosis is materially affected by the time that elapses between the first appearance of the infection and the administration of antidiphtheritic serum ; and by hypertrophic pyloric stenosis, in which the recovery-rate varies inversely as the time that elapses between the onset of symptoms and the institution of proper treatment. Fourthly, when a disease has already established itself, the avoidance of complications and sequelse is a preventive measure of much importance. Thus the thorough treatment of acute infections of the throat and ear will do much to prevent conditions such as chronic nasal catarrh and otorrhcea, while a period of good convalescence at the seaside or in the country after measles, whooping-cough, or broncho-pneumonia is invaluable as a means of preventing the chronic pulmonary catarrh which so often follows these diseases. IF
we
are
prepared
to
accept, with Sir
SORE-THROAT
to some of the common ailments of Turning mention sore-throats first, because children I young it so often happens that chronic disorders such as otorrhcea, catarrhal rhinitis, and recurrent bronchitis owe their origin to repeated infections of the pharynx. The term " sore-throat " has been used intentionally instead of tonsillitis because a sore-throat may readily occur after the tonsils have been removed, and because a day or two of fever with swelling and redness of the pharynx may be almost as fruitful a source of complications as a more frank tonsillitis. There is no means of estimating the incidence of sorethroats among children, because they are often mild enough scarcely to give rise to symptoms, and so pass unnoticed, while parents are apt to look upon them as something inevitable but on the whole harmless, and so medical advice is not sought. now
It is often surprising how slight may be the symptoms when examination shows considerable inflammation of the throat. A young child is not likely to complain of soreness, and while there may be vomiting and anorexia
these
are
King’s College Hospital
Medical School
not to be relied
The
however, invariably raised
upon. a
few
degrees,
temperature is, and it is only
a routine examination of the throat in all children who are found to be feverish that sore-throats will not be overlooked. In the milder infections the temperature may return to normal within 24 hours, and even when there is a purulent exudation on the tonsils the temperature should fall sharply to normal within 72 hours. If this does not happen, it should be a warning that some complication is brewing, such as, for example, a peritonsillar abscess, suppuration in the cervical glands, or acute otitis media, and the child should be carefully watched so that these complications may be dealt with at the earliest opportunity, and the more chronic results of neglected sorethroats (otorrhaea, chronic nasal catarrh, and so forth) may be prevented.
by making
At the present time, what happens too often to the pre-school child is that if the sore-throat is treated at all, it is dealt with by home remedies, often with the child up and about the house and mixing with other children, instead of being in bed. Delayed and imperfect recovery is a common result, complications arise more readily and are likely to be overlooked, and by the time the child begins schooling and undergoes his first medical inspection by the school medical service he is already suffering from chronic ill-health. The complications already mentioned come about from direct spread of the infection from the throat to neighbouring tissues, but not less important are the complications that arise from one to three weeks after the throat infection, and appear in distant parts of the body. The two most important are nephritis and acute rheumatism. The appearance of blood in the urine or puffiness of the face will bring the nephritic child quickly under medical care, but this is not the case with acute rheuma. tism, unless it should happen that the joints are acutely involved. Figures from the rheumatism clinic at the Hospital for Sick Children, Great Ormond-street, showed that the onset of heart disease passed unnoticed in 13 per cent. of the children with rheumatic carditis, and the state of the heart was only noticed on routine examination after the damage had already been done. One cannot doubt that some at any rate-and perhaps the majorityof these followed sore-throats, and if medical advice had been sought at the time and the illness of that throat had been properly followed up, much damage to the heart might have been avoided. It may be mentioned here that experience at the special convalescent homes for rheumatic children has shown that the degree of the inflammation of the throat is no guide as to the likelihood of rheumatic sequelae, severe carditis being often a sequel to a relatively mild faucial inflammation. It has long been recognised that the onset of rheumatic heart disease is often coupled with a history of tonsillitis or sore-throat. During the last few years the segregation of rheumatic children in special heart homes, where observation of the children can be carried out over long periods, has led to a better understanding of the close relation between these diseases, and B. Schlesinger (1930) and later myself (1931) have been able to show that there is generally an interval of roughly 7 to 21 days between the sore-throat and the development of acute rheumatism. During this interval the child seems well, and under the ordinary circumstances of the private house would probably pass from medical care before the rheumatic manifestations appeared. The bacteriology of these preliminary sore-throats has been studied, and evidence is accumulating (A. F. Coburn (1931), W. R. F. Collis (1931), W. H. Bradley (1932), and Glover and Griffith (1931)) in support of the view that when rheumatic carditis follows a sore-throat, the sorethroat is the result of haemolytic streptococcal infection.
1164
THE PREVENTIVE ASPECTS OF MEDICINE
This should occasion no surprise when it is remembered that rheumatic carditis has been recognised for years as one of the sequelsa of scarlet fever-a disease now known to be due to infection of the throat by haemolytic
streptococci. The prevention of
a disease which leads to so much invalidism as does rheumatic carditis requires no advocate, and it may well be that during the sinister period-silent of symptoms-that elapses between the sore-throat and the appearance of rheumatic manifestations, we have an opportunity to attempt preventive measures. A sore-throat in a child should be looked upon as a warning that acute rheumatism may follow, especially if the sore-throat is attributable to h2emolytic streptococcal infection. At the present day, when a throat swab is sent to the laboratory, the bacteriologist is usually asked simply to say whether diphtheria bacilli are present or not. The question should be amended to : Are diphtheria bacilli or haemolytic streptococci present° If the report shows the presence of haemolytic streptococci, two results should follow. Firstly, the child should be isolated (if that has not already been done) until the inflammation of the throat has disappeared and the temperature has fallen to normal; secondly, the child should be kept under medical observation for a month, in order that any cardiac involvement might be promptly realised and treated. Older children need not be kept away from school all this time, but during their month of supervision the heart should be examined at least every week, either by a private doctor or perhaps in some cases by arrangement with the school medical service. Of course rheumatism does not follow all haemolytic streptococcal sore-throats ; it only follows in about 5 per cent. of cases of scarlet fever, and so far as we know there is no reason to suppose that its incidence after non-scarlatinal haemolyticstreptococcal throats would be greater. To diagnose rheumatic carditis at its inception may fairly be looked upon as a preventive measure, for it is likely that the outlook will be benefited by prompt treatment. Whether anything more definitely prophylactic can be done during the " silent period " is at present uncertain, but in children who have already had one attack of rheumatism and then get a sore-throat, experience at West Wickham Heart Home and at Cheyne Hospital has suggested that aspirin (grs. 15-30 per diem according to age) given during the silent period immediately after the sore-throat may have a modifying effect upon the ensuing rheumatic exacerbation.
TUBERCULOSIS
I mention tuberculosis next because it is one of the most frequent causes of death in childhood. In 397 consecutive autopsies made by me at the Hospital for Sick Children, death was due to this disease in 17 per cent. Moreover, the young child has practically no immunity against tuberculosis, so that if exposed to infection, he will almost inevitably develop the disease. The question of preventing this grave disease is bound up with its paths of infection. To all intents and purposes, a child is likely to be infected by one of two routes ; either by the inhalation of particles of infected sputum from a phthisical person, or else by the ingestion of infected food, particularly milk. The inhalatory route is the more common ; in the series of autopsies referred to above, infection was by the intrathoracic route in 67 per cent. of the deaths from tuberculosis-a figure which compares closely with that obtained by G. F. Still, who found that
in a series of 269 children dying from tuberculosis, infection was by the intrathoracic route in 63.8 per cent. The prevention of intrathoracic tuberculosis in young children depends on shielding them from contact with phthisical adults. It may be safely assumed that any young child who is brought up in a household which harbours one member with a positive sputum will inevitably become infected, and for infection to take place it is only necessary for the adult to stay in the house for a week or two. The chance of infection of young children in this way cannot be entirely prevented, for a child may already be infected before the disease in the adult is discovered, but clearly there are certain rules which should always be observed. Thus, no adult known to have phthisis should be allowed to stay in a house where there are children; and the appearance of tuberculosis in an adult who is living in a house where there are children should mean that either the adult or else the children should be taken to live elsewhere. Perhaps it would be possible to send the children away to be brought up by relatives, but it is better for the adult to be sent away to an institution or sanatorium for treatment. The children should also undergo a thorough medical examination, and to begin with, a holiday at the seaside or at a convalescent home would be a sound
precautionary measure. As to infection by milk, this can be prevented by sterilising the milk either by boiling or pasteurisation. Unless the milk happens to be obtained from a herd of certified tuberculosis-free cattle (for which the has to pay a high price), milk given to children should aM’es be sterilised by one of these two methods. Much of the milk-supply in our large cities is now pasteurised before delivery, and a considerable advance in the prevention of tuberculosis would result if this were made compulsory. Pasteurisation in the home is best done with special apparatus, and in any case needs care and intelligence, so that it is generally wiser to recommend sterilisation of milk in the home by the more simple method of bringing the milk to the boil. consumer
Mothers who have carried out this precaution for their infants often ask how long they should continue with the boiling of the milk, and the answer should be-throughout childhood. There is surely no point in exposing older children to risks from which they have been shielded in infancy. The argument that small doses of tubercle bacilli in the milk may assist the child to build up an immunity is a treacherous one, for there is no means of regulating the dose of bacilli which might reach the child in this way, and further, the majority of children will almost certainly encounter enough bacilli by the inhalatory route to arouse their immunity mechanism.
Before leaving this subject, mention must be made of the important part which measles and whoopingcough play in promoting tuberculous infection in the chest. These diseases reach their maximum incidence during the pre-school years, and at this age it is not uncommon to see a child whose convalescence from them has been protracted and unsatisfactory, who has remained feverish and gradually lost weight, while signs have remained in the chest and have eventually culminated in a tuberculous catastrophe. It may be that the swelling and congestion of the mediastinal glands that occurs in these diseases lights up a dormant tuberculous focus in them, while the catarrhal state of the lungs which often persists after these illnesses offers a suitable nidus for the development of a tuberculous lesion. It follows that too much attention cannot be paid to thorough convalescence after measles and whooping-cough. Merely
1165
THE PREVENTIVE ASPECTS OF MEDICINE or the increasingly common family going by car to the seaside each week-end, gives a false sense of security and is quite a
week at the seaside,
practice
of the
The child should be away at the sea or in the country for a minimum of six weeks, and during that time fresh air and daily exercise should be balanced by an hour or two of rest in the middle of the day. Cod-liver oil and Parrish’s Food are useful adjuncts, but they do not take the place of a change of air.
insufficient.
INDIGESTION
Chronic
indigestion
is
a common
disorder in the
pre-school child, and the symptoms show a wide range. They may point directly to a disturbed digestive function, and then include loss of appetite, failure to thrive, and the passage of undigested, slimy, offensive stools. Other common symptoms include perversions of appetite, such as " drinking all day," or eating raw vegetables, paper, or coal; persistent threadworm infection ; daily pyrexia of a degree or so ; or disturbances of sleep, such as bed-wetting and night terrors.
There are three principal factors that lead to chronic indigestion, and by giving attention to them, many of the symptoms which I have outlined can be
.prevented.
swallowing of infected Early morning cough,
mucopus from the
pharynx. vomiting of mucus before breakfast, are likely complaints. The prevention of these symptoms will depend upon a thorough treatment of acute infections of the throat in the first place, and perhaps later on the removal of persistently infected tonsils. BILIOUS ATTACKS
or
the
(CYCLICAL VOMITING)
Under this heading I include attacks which are ushered in by a day or two of loss of appetite, lassitude or irritability, with furred tongue and offensive breath, followed by vomiting which is usually severe and lasts two or three days, accompanied by high fever and acetonuria. Occasionally a periodic fatty diarrhoea takes the place of the
vomiting. The prevention
of these attacks is largely a matter of diet, which should be low in fat content and high in sugar. The fat of cow’s milk is particularly troublesome, and the milk should always be skimmed before it is given to children with this sort of complaint. Cream should be entirely omitted, and the number of eggs should not be more than two a week. The various courses should be sweetened whenever possible, and honey, jam, and treacle should be regular items of the diet. Additional glucose after the meal is a useful adjunct, but is of little value in the absence of the other dietetic modifications. Any attempt to feed up these children, particularly with extras like cod-liver oil, should be strongly discouraged. Sodium bicarb. in grs. 20 doses twice a day has been found useful in the prevention of these attacks.
Unsuitable diet.-The diet often errs in that the child is given too much starchy food such as potato, bread, and the root vegetables, which leads to excessive bacterial fermentation, and the passage of loose, offensive motions. Often these foods are composed of much indigestible cellulose, which remains in the bowel as "roughage." This class of food has sometimes been recommended in the treatment of chronic constipation, but though it may be a useful line of DENTAL CARIES therapy for adults, in children it does more harm To anyone working much with children, the frethan good. The residue from this diet is bulky and quency of caries of the teeth must be most striking. to the reacts which intestine, irritating large by The work Mellanby, and C. Lee Pattison (1928) secreting large amounts of mucus. Peristaltic move- and othersofinM.the last few years has established the ments then become less effective, and the stools when fact that much dental decay is undoubtedly preventhard and and contain much are passed lumpy, and the application of this new knowledge should undigested material and often masses of whitish able, lead to a considerable lessening of dental troubles in mucus. Foods that when given to excess offend in this way are the root vegetables, such as carrots and the children of the future. It is often surprising decay of the teeth of the first dentition turnips, dried peas and beans, especially haricot and how much may exist without complaint of toothache, and this butter beans, nuts, coarse oatmeal, wholemeal bread, may perhaps account for the frequency with which and raw fruits containing skins and pips. The parents are ignorant of, or disregard, the fact that mucous catarrh of the bowel which this type of diet their children’s teeth are decayed. Yet there can to be to the particularly conducive engenders seems of almost threadworm infection ; always be no doubt that disease of the milk teeth gives rise persistence to much disorder of health, including anorexia, one finds that children with a resistant threadworm chronic indigestion, and sometimes habit spasms. infection are passing undigested and slimy motions, Infection of the tooth socket by streptococci and is difficult to until these and the infection overcome other organisms is not uncommon, and may lead to in been reduced elements the diet have or irritating apical abscesses or sometimes cause such distant removed. Mismanagement.-This includes such obvious faults effects as rheumatism. The prevention of dental caries should properly begin as allowing the child to eat as much as he likes of at a time when the teeth are still forming within the whatever he likes whenever he likes. Every child is jaw and are undergoing calcification, because the better entitled to have certain likes and dislikes ; for instance the tooth at the time of eruption the more able is it to some children will not touch an egg, others cannot resist caries. It has been shown that diets that contain bear even the sight of green vegetables on their plate, adequate supplies of vitamin D greatly stimulate the and the fat of meat is often refused. It is better to calcification of teeth, while cereal diets, particularlv recognise these peculiarities, and to replace the oatmeal, lead to the formation of hypoplastic poorly unwanted food by other foods having a similar calcified teeth. nutritional value, rather than to attempt to force the The teeth of the first dentition begin to calcify as early child to take what he obviously dislikes. Other as the fifth month of intra-uterine life, and from then on children will be content to eat heartily of one particular calcification progresses rapidly. It follows that in order foodstuff-often rather harmful to them-to the to ensure the eruption of a well-calcified set of milk teeth, exclusion of others, and to allow an indulgence of this attention should be directed to the maternal diet, seeing that the mother during her pregnancy does not undergo sort constitutes mismanagement. a shortage of such foods as milk, eggs, and butter, which Chronic infection of the nasopharynx.- This is not contain vitamin D. But the prevention of caries in the uncommonly associated with chronic indigestion, first dentition does not stop there, for the workers referred the latter being probably due to the constant to above have shown that the initiation and spread of
1166
THE SERVICES
caries in children can be limited by incorporating vitamin D in their diet, while on the other hand a cereal diet with a low vitamin content tended to have the opposite effect. They were also able to show that when caries had begun, a diet rich in vitamin D tended to arrest the process by " producing a hardening " of the teeth.
If we consider for the moment only the milk teeth, it is clear that the care of the teeth means among other things the supervision of the diet, not merely in infancy, when already much attention is paid to vitamins, but during the whole of the pre-school period as well, to see that as far as possible the diet shall not be composed mainly of cereals (which on account of their cheapness and bulkiness are apt to be the main constituent of the diet in the poorer homes), but that the amount of cereal shall be adequately balanced by foods containing vitamin D. During these years a child should have a pint of milk a day, three eggs a week, and at least 2 oz. of butter a day, and preferably double that amount. If the home circumstances are such that a deficient diet is likely, a teaspoonful of a cod-liver oil emulsion should be given twice a day during the winter months. It must not be supposed that by giving attention to the diet to prevent caries, the customary hygiene of the teeth-such as cleaning them twice a daymay be neglected. But it is not uncommon to see children whose teeth, in spite of scrupulous cleaning, are badly decayed, while others who have not taken the same care have a good set of strong teeth. No amount of cleaning can undo the harm wrought by a bad diet. The remarks made concerning the prevention of caries in the first dentition apply with even greater emphasis to the permanent dentition. The first tooth of the second dentition begins to calcify a short time before birth, and except for the wisdom teeth, all the others of the second dentition begin to calcify during the first two years, and calcification goes on throughout the pre-school period ; so that if during this time the diet is supervised along the lines indicated above, not only will the prevention of caries in the milk teeth be attempted, but the best foundation will be laid for ensuring a healthy set of permanent teeth.
of the infection should be borne in mind.
possibility
Preparalytic stage.-According to J. M. Smellie (1933) stage only lasts a day or two, during which time the temperature is raised and there is headache, with perhaps pains in the back or limbs, and there may be vomiting or drowsiness. The most suggestive sign is stiffness of the neck muscles, not amounting to retraction of the head, but enough to prevent any movement which requires full this
spine. These symptoms are unfor. but examination of the cerebro-spinal fluid may settle the matter, and therefore when there are grounds for a healthy clinical suspicion a lumbar puncture should be carried out. The cerebro-spinal fluid is under increased pressure, and the cells are increased to between 50 and 200 per c.mm., the type of cell being mainly polymorphonuclear at first, and later lymphocytic. The protein is raised, the chloride value remains unaltered, the sugar is unaffected, and culture is sterile. The differential diagnosis from tuberculous meningitis may offer considerable difficulty, but the short clinical history in poliomyelitis and the usually reduced chloride value of the cerebro-spinal fluid in tuberculous meningitis are important distinguishing features. flexion of the neck
eminently desirable. Several years ago S. Flexner and A. J. Lewis serum of patients who were convalescent from poliomyelitis contained protective substances which could prevent the development of paralysis in animals after they had received inoculations of the virus, and recently this work has been applied to the disease in the human subject with encouraging results. There are two difficulties in the preventive use of poliomyelitis serum. In the first place there have been no large stores of serum on which a doctor could draw, and secondly the serum, to be effective, needs to be given during the acute febrile stage of the disease before the appearance of paralysis, and until recently the possibility of diagnosing the disease in its preparalytic stage has scarcely been realised. During an epidemic of the disease, early diagnosis would be less difficult, but the majority of cases in this country occur sporadically. The disease has its greatest incidence in the third quarter of the year, and during this period the
(1910) showed that the
or
tunately very vague,
As soon as the diagnosis is made no time should be lost in giving convalescent serum. It should be given intrathecally in an amount slightly less than the amount of cerebro-spinal fluid that has been withdrawn, and a second injection should be given intravenously, the total varying between 25 and 50 c.cm. Information concerning the available supply of serum has been given in THE LANCET of Oct. 14th, 1933, p. 874. Outfits containing enough serum for the treatment of one case can be obtained from the medical superintendent of the Western Hos-
pital, Seagrave-road, Fulham, London, S.W.6, dition that
account of the
on con-
and the result of treatment are subsequently furnished. A prophylactic antiserum prepared from the horse by the Lister Institute of Preventive Medicine is also available, and may be given to those who have been
exposed
to
an
case
infection, particularly during
an
epidemic,
and for this purpose an intramuscular injection of 5 c.cm. is recommended. WILFRID SHELDON, M.D., F.R.C.P. Physician
in
charge of the Children’s Department, King’s College Hospital.
THE
POLIOMYELITIS
Although the deformities of poliomyelitis may be met with at all ages, the onset of the disease attains its maximum incidence between the ages of 2 and 5 years; the amount of crippling and invalidism caused by poliomyelitis makes its prevention
particularly
SERVICES
ROYAL ARMY MEDICAL CORPS Lt.
(on prob.) R. V. Wright retires
on
account of
ill-health. TERRITORIAL ARMY
Capt. T.
E. A. Carr to be Maj. Lts. H. A. Raeburn and W. P. Kennedy to be Capts. supern. for serv. with Med. Unit, Edinburgh Univ. Contgt., Sen. Div., O.T.C. Lt. P. J. May to be Capt. J. B. Fulton (late Cadet, Glasgow Univ. Contgt., Sen. Div., O.T.C.) to be Lt. TERRITORIAL ARMY RESERVE OF OFFICERS
Capt.
W. W. Brown, from Active List, to be
Capt.
INDIAN MEDICAL SERVICE Col. Sir R. McCarrison to be Maj.-Gen. Capt. F. E. B. Manning to be Maj. Capt. M. S. Katre relinquishes his temp. commn. ROYAL AIR FORCE The undermentioned Flying Officers are promoted to the rank of Flight Lt. : E. Donovan and J. F. Sandow. COLONIAL MEDICAL SERVICE Dr. H. B. Lee (Medical Officer) has been promoted to Specialist, Nigeria; and Dr. P. D. Oakley (DeputyDirector, Medical Service, Gold Coast) becomes Directqr of Medical and Sanitary Services, Sierra Leone.
THE PREVENTIVE ASPECTS OF MEDICINE A Series
of
Lectures in progress
during
the Winter Session at
VI.—PREVENTION OF DISEASE IN THE PRE-SCHOOL CHILD Arthur Newsholme, that the curtailment of illness and the decrease of suffering come within the scope of preventive medicine, we find that preventive and clinical medicine have a common meeting ground, and are in fact inseparable. Taking this broad view of preventive medicine, there are several ways in which a doctor may practise the preventive aspect of his calling. The first and most desirable form of prevention is to advise a patient on such lines as shall forestall the appearance of disease ; we see an example of this in infancy in the administration of orange juice as a prophylactic measure against infantile scurvy, or in the use of cod-liver oil to prevent rickets. Secondly, a course of treatment may be recommended in order to create in the patient a specific immunity to certain diseases ; examples of this in childhood are vaccination against small-pox and immunisation against diphtheria. Thirdly, by diagnosing disease in its initial stages it may be possible to begin treatment early enough to thwart the natural course of the disease and alter the prognosis vastly for the better. The importance of early diagnosis in the illnesses of childhood may be illustrated by diphtheria, in which the prognosis is materially affected by the time that elapses between the first appearance of the infection and the administration of antidiphtheritic serum ; and by hypertrophic pyloric stenosis, in which the recovery-rate varies inversely as the time that elapses between the onset of symptoms and the institution of proper treatment. Fourthly, when a disease has already established itself, the avoidance of complications and sequelse is a preventive measure of much importance. Thus the thorough treatment of acute infections of the throat and ear will do much to prevent conditions such as chronic nasal catarrh and otorrhcea, while a period of good convalescence at the seaside or in the country after measles, whooping-cough, or broncho-pneumonia is invaluable as a means of preventing the chronic pulmonary catarrh which so often follows these diseases. IF
we
are
prepared
to
accept, with Sir
SORE-THROAT
to some of the common ailments of Turning mention sore-throats first, because children I young it so often happens that chronic disorders such as otorrhcea, catarrhal rhinitis, and recurrent bronchitis owe their origin to repeated infections of the pharynx. The term " sore-throat " has been used intentionally instead of tonsillitis because a sore-throat may readily occur after the tonsils have been removed, and because a day or two of fever with swelling and redness of the pharynx may be almost as fruitful a source of complications as a more frank tonsillitis. There is no means of estimating the incidence of sorethroats among children, because they are often mild enough scarcely to give rise to symptoms, and so pass unnoticed, while parents are apt to look upon them as something inevitable but on the whole harmless, and so medical advice is not sought. now
It is often surprising how slight may be the symptoms when examination shows considerable inflammation of the throat. A young child is not likely to complain of soreness, and while there may be vomiting and anorexia
these
are
King’s College Hospital
Medical School
not to be relied
The
however, invariably raised
upon. a
few
degrees,
temperature is, and it is only
a routine examination of the throat in all children who are found to be feverish that sore-throats will not be overlooked. In the milder infections the temperature may return to normal within 24 hours, and even when there is a purulent exudation on the tonsils the temperature should fall sharply to normal within 72 hours. If this does not happen, it should be a warning that some complication is brewing, such as, for example, a peritonsillar abscess, suppuration in the cervical glands, or acute otitis media, and the child should be carefully watched so that these complications may be dealt with at the earliest opportunity, and the more chronic results of neglected sorethroats (otorrhaea, chronic nasal catarrh, and so forth) may be prevented.
by making
At the present time, what happens too often to the pre-school child is that if the sore-throat is treated at all, it is dealt with by home remedies, often with the child up and about the house and mixing with other children, instead of being in bed. Delayed and imperfect recovery is a common result, complications arise more readily and are likely to be overlooked, and by the time the child begins schooling and undergoes his first medical inspection by the school medical service he is already suffering from chronic ill-health. The complications already mentioned come about from direct spread of the infection from the throat to neighbouring tissues, but not less important are the complications that arise from one to three weeks after the throat infection, and appear in distant parts of the body. The two most important are nephritis and acute rheumatism. The appearance of blood in the urine or puffiness of the face will bring the nephritic child quickly under medical care, but this is not the case with acute rheuma. tism, unless it should happen that the joints are acutely involved. Figures from the rheumatism clinic at the Hospital for Sick Children, Great Ormond-street, showed that the onset of heart disease passed unnoticed in 13 per cent. of the children with rheumatic carditis, and the state of the heart was only noticed on routine examination after the damage had already been done. One cannot doubt that some at any rate-and perhaps the majorityof these followed sore-throats, and if medical advice had been sought at the time and the illness of that throat had been properly followed up, much damage to the heart might have been avoided. It may be mentioned here that experience at the special convalescent homes for rheumatic children has shown that the degree of the inflammation of the throat is no guide as to the likelihood of rheumatic sequelae, severe carditis being often a sequel to a relatively mild faucial inflammation. It has long been recognised that the onset of rheumatic heart disease is often coupled with a history of tonsillitis or sore-throat. During the last few years the segregation of rheumatic children in special heart homes, where observation of the children can be carried out over long periods, has led to a better understanding of the close relation between these diseases, and B. Schlesinger (1930) and later myself (1931) have been able to show that there is generally an interval of roughly 7 to 21 days between the sore-throat and the development of acute rheumatism. During this interval the child seems well, and under the ordinary circumstances of the private house would probably pass from medical care before the rheumatic manifestations appeared. The bacteriology of these preliminary sore-throats has been studied, and evidence is accumulating (A. F. Coburn (1931), W. R. F. Collis (1931), W. H. Bradley (1932), and Glover and Griffith (1931)) in support of the view that when rheumatic carditis follows a sore-throat, the sorethroat is the result of haemolytic streptococcal infection.
1164
THE PREVENTIVE ASPECTS OF MEDICINE
This should occasion no surprise when it is remembered that rheumatic carditis has been recognised for years as one of the sequelsa of scarlet fever-a disease now known to be due to infection of the throat by haemolytic
streptococci. The prevention of
a disease which leads to so much invalidism as does rheumatic carditis requires no advocate, and it may well be that during the sinister period-silent of symptoms-that elapses between the sore-throat and the appearance of rheumatic manifestations, we have an opportunity to attempt preventive measures. A sore-throat in a child should be looked upon as a warning that acute rheumatism may follow, especially if the sore-throat is attributable to h2emolytic streptococcal infection. At the present day, when a throat swab is sent to the laboratory, the bacteriologist is usually asked simply to say whether diphtheria bacilli are present or not. The question should be amended to : Are diphtheria bacilli or haemolytic streptococci present° If the report shows the presence of haemolytic streptococci, two results should follow. Firstly, the child should be isolated (if that has not already been done) until the inflammation of the throat has disappeared and the temperature has fallen to normal; secondly, the child should be kept under medical observation for a month, in order that any cardiac involvement might be promptly realised and treated. Older children need not be kept away from school all this time, but during their month of supervision the heart should be examined at least every week, either by a private doctor or perhaps in some cases by arrangement with the school medical service. Of course rheumatism does not follow all haemolytic streptococcal sore-throats ; it only follows in about 5 per cent. of cases of scarlet fever, and so far as we know there is no reason to suppose that its incidence after non-scarlatinal haemolyticstreptococcal throats would be greater. To diagnose rheumatic carditis at its inception may fairly be looked upon as a preventive measure, for it is likely that the outlook will be benefited by prompt treatment. Whether anything more definitely prophylactic can be done during the " silent period " is at present uncertain, but in children who have already had one attack of rheumatism and then get a sore-throat, experience at West Wickham Heart Home and at Cheyne Hospital has suggested that aspirin (grs. 15-30 per diem according to age) given during the silent period immediately after the sore-throat may have a modifying effect upon the ensuing rheumatic exacerbation.
TUBERCULOSIS
I mention tuberculosis next because it is one of the most frequent causes of death in childhood. In 397 consecutive autopsies made by me at the Hospital for Sick Children, death was due to this disease in 17 per cent. Moreover, the young child has practically no immunity against tuberculosis, so that if exposed to infection, he will almost inevitably develop the disease. The question of preventing this grave disease is bound up with its paths of infection. To all intents and purposes, a child is likely to be infected by one of two routes ; either by the inhalation of particles of infected sputum from a phthisical person, or else by the ingestion of infected food, particularly milk. The inhalatory route is the more common ; in the series of autopsies referred to above, infection was by the intrathoracic route in 67 per cent. of the deaths from tuberculosis-a figure which compares closely with that obtained by G. F. Still, who found that
in a series of 269 children dying from tuberculosis, infection was by the intrathoracic route in 63.8 per cent. The prevention of intrathoracic tuberculosis in young children depends on shielding them from contact with phthisical adults. It may be safely assumed that any young child who is brought up in a household which harbours one member with a positive sputum will inevitably become infected, and for infection to take place it is only necessary for the adult to stay in the house for a week or two. The chance of infection of young children in this way cannot be entirely prevented, for a child may already be infected before the disease in the adult is discovered, but clearly there are certain rules which should always be observed. Thus, no adult known to have phthisis should be allowed to stay in a house where there are children; and the appearance of tuberculosis in an adult who is living in a house where there are children should mean that either the adult or else the children should be taken to live elsewhere. Perhaps it would be possible to send the children away to be brought up by relatives, but it is better for the adult to be sent away to an institution or sanatorium for treatment. The children should also undergo a thorough medical examination, and to begin with, a holiday at the seaside or at a convalescent home would be a sound
precautionary measure. As to infection by milk, this can be prevented by sterilising the milk either by boiling or pasteurisation. Unless the milk happens to be obtained from a herd of certified tuberculosis-free cattle (for which the has to pay a high price), milk given to children should aM’es be sterilised by one of these two methods. Much of the milk-supply in our large cities is now pasteurised before delivery, and a considerable advance in the prevention of tuberculosis would result if this were made compulsory. Pasteurisation in the home is best done with special apparatus, and in any case needs care and intelligence, so that it is generally wiser to recommend sterilisation of milk in the home by the more simple method of bringing the milk to the boil. consumer
Mothers who have carried out this precaution for their infants often ask how long they should continue with the boiling of the milk, and the answer should be-throughout childhood. There is surely no point in exposing older children to risks from which they have been shielded in infancy. The argument that small doses of tubercle bacilli in the milk may assist the child to build up an immunity is a treacherous one, for there is no means of regulating the dose of bacilli which might reach the child in this way, and further, the majority of children will almost certainly encounter enough bacilli by the inhalatory route to arouse their immunity mechanism.
Before leaving this subject, mention must be made of the important part which measles and whoopingcough play in promoting tuberculous infection in the chest. These diseases reach their maximum incidence during the pre-school years, and at this age it is not uncommon to see a child whose convalescence from them has been protracted and unsatisfactory, who has remained feverish and gradually lost weight, while signs have remained in the chest and have eventually culminated in a tuberculous catastrophe. It may be that the swelling and congestion of the mediastinal glands that occurs in these diseases lights up a dormant tuberculous focus in them, while the catarrhal state of the lungs which often persists after these illnesses offers a suitable nidus for the development of a tuberculous lesion. It follows that too much attention cannot be paid to thorough convalescence after measles and whooping-cough. Merely
1165
THE PREVENTIVE ASPECTS OF MEDICINE or the increasingly common family going by car to the seaside each week-end, gives a false sense of security and is quite a
week at the seaside,
practice
of the
The child should be away at the sea or in the country for a minimum of six weeks, and during that time fresh air and daily exercise should be balanced by an hour or two of rest in the middle of the day. Cod-liver oil and Parrish’s Food are useful adjuncts, but they do not take the place of a change of air.
insufficient.
INDIGESTION
Chronic
indigestion
is
a common
disorder in the
pre-school child, and the symptoms show a wide range. They may point directly to a disturbed digestive function, and then include loss of appetite, failure to thrive, and the passage of undigested, slimy, offensive stools. Other common symptoms include perversions of appetite, such as " drinking all day," or eating raw vegetables, paper, or coal; persistent threadworm infection ; daily pyrexia of a degree or so ; or disturbances of sleep, such as bed-wetting and night terrors.
There are three principal factors that lead to chronic indigestion, and by giving attention to them, many of the symptoms which I have outlined can be
.prevented.
swallowing of infected Early morning cough,
mucopus from the
pharynx. vomiting of mucus before breakfast, are likely complaints. The prevention of these symptoms will depend upon a thorough treatment of acute infections of the throat in the first place, and perhaps later on the removal of persistently infected tonsils. BILIOUS ATTACKS
or
the
(CYCLICAL VOMITING)
Under this heading I include attacks which are ushered in by a day or two of loss of appetite, lassitude or irritability, with furred tongue and offensive breath, followed by vomiting which is usually severe and lasts two or three days, accompanied by high fever and acetonuria. Occasionally a periodic fatty diarrhoea takes the place of the
vomiting. The prevention
of these attacks is largely a matter of diet, which should be low in fat content and high in sugar. The fat of cow’s milk is particularly troublesome, and the milk should always be skimmed before it is given to children with this sort of complaint. Cream should be entirely omitted, and the number of eggs should not be more than two a week. The various courses should be sweetened whenever possible, and honey, jam, and treacle should be regular items of the diet. Additional glucose after the meal is a useful adjunct, but is of little value in the absence of the other dietetic modifications. Any attempt to feed up these children, particularly with extras like cod-liver oil, should be strongly discouraged. Sodium bicarb. in grs. 20 doses twice a day has been found useful in the prevention of these attacks.
Unsuitable diet.-The diet often errs in that the child is given too much starchy food such as potato, bread, and the root vegetables, which leads to excessive bacterial fermentation, and the passage of loose, offensive motions. Often these foods are composed of much indigestible cellulose, which remains in the bowel as "roughage." This class of food has sometimes been recommended in the treatment of chronic constipation, but though it may be a useful line of DENTAL CARIES therapy for adults, in children it does more harm To anyone working much with children, the frethan good. The residue from this diet is bulky and quency of caries of the teeth must be most striking. to the reacts which intestine, irritating large by The work Mellanby, and C. Lee Pattison (1928) secreting large amounts of mucus. Peristaltic move- and othersofinM.the last few years has established the ments then become less effective, and the stools when fact that much dental decay is undoubtedly preventhard and and contain much are passed lumpy, and the application of this new knowledge should undigested material and often masses of whitish able, lead to a considerable lessening of dental troubles in mucus. Foods that when given to excess offend in this way are the root vegetables, such as carrots and the children of the future. It is often surprising decay of the teeth of the first dentition turnips, dried peas and beans, especially haricot and how much may exist without complaint of toothache, and this butter beans, nuts, coarse oatmeal, wholemeal bread, may perhaps account for the frequency with which and raw fruits containing skins and pips. The parents are ignorant of, or disregard, the fact that mucous catarrh of the bowel which this type of diet their children’s teeth are decayed. Yet there can to be to the particularly conducive engenders seems of almost threadworm infection ; always be no doubt that disease of the milk teeth gives rise persistence to much disorder of health, including anorexia, one finds that children with a resistant threadworm chronic indigestion, and sometimes habit spasms. infection are passing undigested and slimy motions, Infection of the tooth socket by streptococci and is difficult to until these and the infection overcome other organisms is not uncommon, and may lead to in been reduced elements the diet have or irritating apical abscesses or sometimes cause such distant removed. Mismanagement.-This includes such obvious faults effects as rheumatism. The prevention of dental caries should properly begin as allowing the child to eat as much as he likes of at a time when the teeth are still forming within the whatever he likes whenever he likes. Every child is jaw and are undergoing calcification, because the better entitled to have certain likes and dislikes ; for instance the tooth at the time of eruption the more able is it to some children will not touch an egg, others cannot resist caries. It has been shown that diets that contain bear even the sight of green vegetables on their plate, adequate supplies of vitamin D greatly stimulate the and the fat of meat is often refused. It is better to calcification of teeth, while cereal diets, particularlv recognise these peculiarities, and to replace the oatmeal, lead to the formation of hypoplastic poorly unwanted food by other foods having a similar calcified teeth. nutritional value, rather than to attempt to force the The teeth of the first dentition begin to calcify as early child to take what he obviously dislikes. Other as the fifth month of intra-uterine life, and from then on children will be content to eat heartily of one particular calcification progresses rapidly. It follows that in order foodstuff-often rather harmful to them-to the to ensure the eruption of a well-calcified set of milk teeth, exclusion of others, and to allow an indulgence of this attention should be directed to the maternal diet, seeing that the mother during her pregnancy does not undergo sort constitutes mismanagement. a shortage of such foods as milk, eggs, and butter, which Chronic infection of the nasopharynx.- This is not contain vitamin D. But the prevention of caries in the uncommonly associated with chronic indigestion, first dentition does not stop there, for the workers referred the latter being probably due to the constant to above have shown that the initiation and spread of
1166
THE SERVICES
caries in children can be limited by incorporating vitamin D in their diet, while on the other hand a cereal diet with a low vitamin content tended to have the opposite effect. They were also able to show that when caries had begun, a diet rich in vitamin D tended to arrest the process by " producing a hardening " of the teeth.
If we consider for the moment only the milk teeth, it is clear that the care of the teeth means among other things the supervision of the diet, not merely in infancy, when already much attention is paid to vitamins, but during the whole of the pre-school period as well, to see that as far as possible the diet shall not be composed mainly of cereals (which on account of their cheapness and bulkiness are apt to be the main constituent of the diet in the poorer homes), but that the amount of cereal shall be adequately balanced by foods containing vitamin D. During these years a child should have a pint of milk a day, three eggs a week, and at least 2 oz. of butter a day, and preferably double that amount. If the home circumstances are such that a deficient diet is likely, a teaspoonful of a cod-liver oil emulsion should be given twice a day during the winter months. It must not be supposed that by giving attention to the diet to prevent caries, the customary hygiene of the teeth-such as cleaning them twice a daymay be neglected. But it is not uncommon to see children whose teeth, in spite of scrupulous cleaning, are badly decayed, while others who have not taken the same care have a good set of strong teeth. No amount of cleaning can undo the harm wrought by a bad diet. The remarks made concerning the prevention of caries in the first dentition apply with even greater emphasis to the permanent dentition. The first tooth of the second dentition begins to calcify a short time before birth, and except for the wisdom teeth, all the others of the second dentition begin to calcify during the first two years, and calcification goes on throughout the pre-school period ; so that if during this time the diet is supervised along the lines indicated above, not only will the prevention of caries in the milk teeth be attempted, but the best foundation will be laid for ensuring a healthy set of permanent teeth.
of the infection should be borne in mind.
possibility
Preparalytic stage.-According to J. M. Smellie (1933) stage only lasts a day or two, during which time the temperature is raised and there is headache, with perhaps pains in the back or limbs, and there may be vomiting or drowsiness. The most suggestive sign is stiffness of the neck muscles, not amounting to retraction of the head, but enough to prevent any movement which requires full this
spine. These symptoms are unfor. but examination of the cerebro-spinal fluid may settle the matter, and therefore when there are grounds for a healthy clinical suspicion a lumbar puncture should be carried out. The cerebro-spinal fluid is under increased pressure, and the cells are increased to between 50 and 200 per c.mm., the type of cell being mainly polymorphonuclear at first, and later lymphocytic. The protein is raised, the chloride value remains unaltered, the sugar is unaffected, and culture is sterile. The differential diagnosis from tuberculous meningitis may offer considerable difficulty, but the short clinical history in poliomyelitis and the usually reduced chloride value of the cerebro-spinal fluid in tuberculous meningitis are important distinguishing features. flexion of the neck
eminently desirable. Several years ago S. Flexner and A. J. Lewis serum of patients who were convalescent from poliomyelitis contained protective substances which could prevent the development of paralysis in animals after they had received inoculations of the virus, and recently this work has been applied to the disease in the human subject with encouraging results. There are two difficulties in the preventive use of poliomyelitis serum. In the first place there have been no large stores of serum on which a doctor could draw, and secondly the serum, to be effective, needs to be given during the acute febrile stage of the disease before the appearance of paralysis, and until recently the possibility of diagnosing the disease in its preparalytic stage has scarcely been realised. During an epidemic of the disease, early diagnosis would be less difficult, but the majority of cases in this country occur sporadically. The disease has its greatest incidence in the third quarter of the year, and during this period the
(1910) showed that the
or
tunately very vague,
As soon as the diagnosis is made no time should be lost in giving convalescent serum. It should be given intrathecally in an amount slightly less than the amount of cerebro-spinal fluid that has been withdrawn, and a second injection should be given intravenously, the total varying between 25 and 50 c.cm. Information concerning the available supply of serum has been given in THE LANCET of Oct. 14th, 1933, p. 874. Outfits containing enough serum for the treatment of one case can be obtained from the medical superintendent of the Western Hos-
pital, Seagrave-road, Fulham, London, S.W.6, dition that
account of the
on con-
and the result of treatment are subsequently furnished. A prophylactic antiserum prepared from the horse by the Lister Institute of Preventive Medicine is also available, and may be given to those who have been
exposed
to
an
case
infection, particularly during
an
epidemic,
and for this purpose an intramuscular injection of 5 c.cm. is recommended. WILFRID SHELDON, M.D., F.R.C.P. Physician
in
charge of the Children’s Department, King’s College Hospital.
THE
POLIOMYELITIS
Although the deformities of poliomyelitis may be met with at all ages, the onset of the disease attains its maximum incidence between the ages of 2 and 5 years; the amount of crippling and invalidism caused by poliomyelitis makes its prevention
particularly
SERVICES
ROYAL ARMY MEDICAL CORPS Lt.
(on prob.) R. V. Wright retires
on
account of
ill-health. TERRITORIAL ARMY
Capt. T.
E. A. Carr to be Maj. Lts. H. A. Raeburn and W. P. Kennedy to be Capts. supern. for serv. with Med. Unit, Edinburgh Univ. Contgt., Sen. Div., O.T.C. Lt. P. J. May to be Capt. J. B. Fulton (late Cadet, Glasgow Univ. Contgt., Sen. Div., O.T.C.) to be Lt. TERRITORIAL ARMY RESERVE OF OFFICERS
Capt.
W. W. Brown, from Active List, to be
Capt.
INDIAN MEDICAL SERVICE Col. Sir R. McCarrison to be Maj.-Gen. Capt. F. E. B. Manning to be Maj. Capt. M. S. Katre relinquishes his temp. commn. ROYAL AIR FORCE The undermentioned Flying Officers are promoted to the rank of Flight Lt. : E. Donovan and J. F. Sandow. COLONIAL MEDICAL SERVICE Dr. H. B. Lee (Medical Officer) has been promoted to Specialist, Nigeria; and Dr. P. D. Oakley (DeputyDirector, Medical Service, Gold Coast) becomes Directqr of Medical and Sanitary Services, Sierra Leone.