From medical qualification in early 1956 I spent six months at the Leeds General Infirmary first as Paediatric House Officer, then six months as Thoracic Surgical House Officer. Why, you may ask, did I choose these two rather unlikely first jobs? Why not middle-of-the-road training in general medicine and general surgery? I will explain. Perhaps we didn’t think too far ahead at that stage – more choose what was interesting and enjoyable!
In those days medical students were allowed to stand in for house officers when they were on leave or ill. One day only a few months after I had started clinical medicine I was walking down the corridor of the LGI, past the entrance to Ward 8, the children’s ward, when a young doctor stopped me and asked “Would you like to do a two week locum in paediatrics as the Houseman has been taken ill?” “What is paediatrics ?’ I asked him. “It’s children’s medicine – you’ll like it” he replied. “But I don’t know very much” “Not a problem – the registrar will support you all the time. We’ll fix it with your teaching firm”. So I agreed and became the paediatric house officer for two weeks.
I enjoyed the two weeks and had great support from Elizabeth Pryce-Jones (1924-2014) (photo left) the registrar at the time who had a great skill in “managing” the, at times rather difficult, Professor Craig! PJ, as she was known to all, was quite a character and great fun. Years later, after she had moved to London and become involved in community paediatrics, she asked me to give the annual lecture to the Medical Officers of Schools Association which was held at Giggleswick, my old school. Will describe this later. Suffice it to say that to give a lecture at Giggleswick School was quite an emotional and stressful experience.
To return to this paedaitric locum, my efforts over the two weeks must have been considered satisfactory for the next time the house officer went on holiday I was approached to do the locum again – which I was happy to do. So it was almost expected that when I qualified I would do the paediatric house job for 6 months.
What about Thoracic Surgery? Well my friend Dr. Ian
Adams qualified at the same time, and had done six months with the Thoracic Surgical firm. The firm was held in high regard in the hospital having risen to prominence under the leadership of Professor Philip Allison (photo L), a world leader in the thoracic surgery field, who had recently departed to take the chair of surgery at Oxford. However, Mr Geoffrey Wooler (photo R) and Mr John Alwyn were also both held in high regard. Ian had been asked to find a successor for himself who was competent, a hard worker and who liked parties! He said that I seemed to fit the bill. So I was appointed to the post of House Officer in Thoracic surgery. The six months proved to be very hard work but interesting, exciting and socially enjoyable. The skill and dynamic approach of Mr Wooler definitely inspired me to consider surgery as a career
So those are the reasons my pre-registration year in 1956/57 was spent in paediatrics and thoracic surgery rather than in general medicine and surgery which would perhaps have been more sensible.
House Officer in Paediatrics with Professor Stuart Craig and Dr Eric Allibone for six months in 1956
Now, at last, a qualified doctor I enjoyed this six months working for two very different consultants. Professor Craig was a rather irascible, dedicated “professional Scotsman”; although born in Bingley Prof. he was technically a Yorkshireman! His Scottish father was a general practitioner in the town.
A biography of Prof. Craig by Sir Gordon Wolstenholme in Royal College of Physicians Lives of Fellows is as follows –
William Stuart McRae Craig (1903-1976) was born at Bingley, Yorkshire, the son of William Craig, a Yorkshire general practitioner of Scottish origins, and his wife Catherine Jane, daughter of James Thomson Stuart, a Presbyterian minister. He was educated at Bingley Grammar School, George Watson’s College, Edinburgh, and the University of Glasgow where he graduated BSc in naval architecture in 1924. He worked for some time in the Clydeside shipyards, but on deciding to follow in his father’s footsteps he entered Edinburgh University, graduating MB ChB in 1930, proceeding to MD in 1933. He became a member of the Royal College of Physicians of Edinburgh that same year, being elected a Fellow in 1936. He was elected a Fellow of the Royal Society of Edinburgh in 1937. Following his membership of the College in 1946, he was elected a Fellow in 1956.
Craig was a pioneer in the field of community and preventive paediatrics. For him, prevention was the first consideration. By 1936 he had published several papers and was assistant paediatrician to Professor Charles McNeil at the Royal Hospital for Sick Children, Edinburgh, from whom he learned the importance of prevention and social care in paediatrics. He was a worthy pupil of a worthy master. In those days, however, there was little hope of early advancement and young paediatricians had small incomes. He joined the Ministry of Health in 1936 and was seconded to the Emergency Medical Service in 1941, where he became medical officer in charge of the South-eastern Region.
In 1946 he published Child and Adolescent Life in Health and Disease, the first book of its kind on social paediatrics, which was soon considered essential reading for budding paediatricians. In the same year he was appointed to the first full time chair of paediatrics and child health at Leeds University, a post he held until 1968. Although criticised for not building up a department dedicated to research he was unrepentant, seeing his main task as the training of students for family practice. He loved teaching and was an admirable examiner. He took a full load of clinical duties in addition to his administrative work. During his 22 years at Leeds he published more than seventy papers, of which at the very least twelve can be considered as outstanding. His second book, Care of the Newly Born Infant was published in 1955 and has already gone into at least five editions.
In 1934 he married Beatrice Anne, daughter of Thomas George Hodgson, and in his work and writing he relied heavily on her advice and encouragement, especially her experience as sister in charge of a children’s ward which was of great value to him. They had no children, but their 41 years of married life were an example of a true partnership.
On his retirement he returned to Scotland, settled at Gifford, and wrote his delightful monograph John Thomson, Pioneer and Father of Scottish Paediatrics (1968). In 1969 he gave the first Charles McNeil memorial lecture at the Royal College of Physicians of Edinburgh, and he finished writing a history of the College before his death. He was a kind and generous man, but expected a very high standard from his students. He would not tolerate dishonesty of any sort, deviousness or hypocrisy, in anyone. Off duty, he was a delightful companion, interested in ships and shipping, travelling and sketching.
This biography was a very fair summing up of Prof. Craig as we knew him.
There is a biography of Dr Allibone in the RCP Lives of Fellows. It was written by Professor Dick Smithells who had been Dr. Allibone’s registrar for a number of years earlier in his career during the Fifties.
Eric Cory Allibone (1905-1990), a Yorkshireman and proud of it, was the son of Abraham Cory Allibone, a solicitor who was a senior local government officer to the former West Riding of Yorkshire with its headquarters at Wakefield. When he left Wakefield Grammar School, Eric’s heart was already set on a medical career but his father was adamant that he should join the economic foundation of the West Riding, the textile industry. Eric joined a firm in his native Wakefield and attended a diploma course in textiles at Leeds University.
A language scholarship then took him to work for a year with a textile firm m Berlin but on his return he found the industry badly hit by recession. He was therefore able to turn to his own choice of career. His father agreed, but only on condition that Eric should never fail any examinations – a condition which was fully met. He entered the Leeds medical school and graduated with honours.
His first post at Leeds General Infirmary was as house physician to Wilfred Vining [Munk’s Roll, Vol.VI, p.445] who, at that time, was physician to adults and children but later became the first (part-time) professor of paediatrics at Leeds. After a further house post in Leeds he spent six months as house physician at the Hammersmith Hospital, London, his only clinical venture outside his native Yorkshire.
Eric returned to Leeds in 1935 as RMO, a post so arduous, especially for one as conscientious as Eric Allibone, that pulmonary tuberculosis was a well recognised complication of the appointment and one which he duly developed. This did not prevent him from obtaining his membership of the College and proceeding MD (Leeds) with distinction. He spent a further two years in Leeds as University tutor before moving to Birmingham Children’s Hospital in 1940, first as RMO and later as registrar. Here, in one of the leading British paediatric centres of the time, he first encountered academic paediatrics in the setting of a large children’s hospital, which clearly fired his enthusiasm.
Despite a heavy workload, accentuated by the absence of so many doctors on war service, he co-authored a number of publications and was awarded the degree of PhD (Birmingham). When the chair of paediatrics in Leeds fell vacant in 1946, he would dearly have loved to occupy it but this was not to be.
In 1948, the year in which the NHS began, he was appointed as the first NHS consultant paediatrician in Leeds. He was responsible for half the city’s sick children, most of the domiciliary and private practice and a substantial teaching commitment, all done with minimal supporting staff. When he retired from the NHS in 1970 he was still the only NHS consultant paediatrician in Leeds and there were no NHS senior registrars (this is not true as I had been appointed in 1968!!)
Eric’s clinical work was characterized by unhurried attention to detail and a determination to keep abreast of the burgeoning paediatric literature.His teachings, as well as everyday conversations, were enlivened humour which endeared him to students and junior medical staff alike. He always had time to listen and his catch phrases were common currency among his colleagues, by whom he was always referred to as ‘Uncle Eric’: ‘the daffodil look’, or reference to a baby as ‘in vacant or in pensive mood’, carried a much better prognosis than ‘wrap me up in my tarpaulin jacket’.
He was devoted to his mother who lived with him in her closing years and this care, together with his very full clinical life, no doubt accounts for his relatively late marriage. In 1954 he married Eleanor Brook Outon, a paediatric pathologist with Irish roots, who worked at St James Hospital, Leeds. In due course she presented him with two daughters and a son.
On ‘retirement’ from his consultant post in 1970 he entered full-time general practice, continuing until he was almost 80, and was also clinical assistant to a large hospital for the mentally handicapped. Once asked if he did not think that he might have lost touch with mainstream medicine, he replied without rancour that most of his patients were elderly and just needed somebody to listen, which he was capable of doing.
Outside medicine he managed a large garden, listened to good music, took beautiful photographs and devoted the same pains to woodwork and metalwork as he did to his clinical work. When he finally gave up all clinical practice he adapted to domestic life, mastering the microwave by patient attention to the instruction manual and helping to give the same care to his elderly mother-in-law as he had given to his own mother. In clinical affairs he was a work horse rather than a race horse, more concerned with judgement than with style. As a person he was the archetypal Yorkshireman, prepared to say exactly what he thought – when others thought the same but minced their words – but with a boyish chuckle at his own candour and never a hint of malice.
Until a few days before his death, Eric Allibone enjoyed good health and was alertly interested in everything that was going on.
This account of Eric Allibone’s life and career is reproduced in full as he was a quite remarkable man and Dick Smithells knew him better than most. It is fair to say that Allibone never recovered from his failure to be appointed as professor in Leeds where he had worked so long and hard. In fact he never forgave Prof Craig for taking what he considered was rightfully his! He had little respect for Prof. as a clinician the latter having been in the Ministry of Health from 1936 until he was appointed to the Leeds Chair in 1946.
When Dr. Allibone retired Dick Smithells, who by then had succeeded Prof. Craig as Professor in Leeds, appointed Dr. Ian Forsythe, a dour established middle aged Belfast consultant paediatrican as his successor. I was very disappointed as I always considered that I would be appointed to that post having already completed 2 years as an NHS consultant in Leeds based at Seacroft and St James’s, and also recently having achieved my MD. Sadly Ian Forsythe soon proved to be a difficult colleague and it was no surprise that Forsythe and Smithells eventually had an unsatisfactory relationship as colleagues; an NHS/University rift developed as in the Craig and Allibone era.
Paediatrics in the Leeds General Infirmary in 1956
At the LGI there were two children’s medical wards – Princess Mary Ward with some 12 cots for children up to a year old and Ward 8 (photo in 1900 but the structure was very similar) where older children were nursed. There were 4 cubicles on ward 8 for children
with more serious conditions or who may be an infection risk to the other children. Prof. Craig had one half of the ward and Dr. Allibone the other; Princess Mary Ward was alsodivided between the two consultants. It was no secret that the two were totally different in character, background and experience. Prof. was very cool and respectful as far as Allibone was concerned but Allibone at times let his lack of respect for Prof. surface. “What’s Big Brother treating that patient with?” he would sometimes ask.
There were a number of deep seated reasons for Dr. Allibone’s lack of respect for Prof. Craig as I have discussed above. Although Prof. had an impeccable paediatric training in Edinburgh during the Thirties with some of the great names in Scottish paediatrics, during the war he had worked at the Ministry of Health and was out of clinical medicine. However Prof. had written a book on child health and made many contacts in London. Also he was a good speaker and excellent writer. However, prior to his appointment he had been out of acute paediatrics for some years. In contrast, Eric Allibone was what I would call a practical, experienced, shrewd “shop floor” paediatrician – rather like myself, although more intelligent than me! He had also started in another profession, textiles, on his father’s advice but apparently changed to his first love, medicine, during the depressed state of the textile industry in the UK.
The work of the paediatric department – admissions
in 1956 all acute paediatric admissions came to LGI. Surgical problems such as fractures, obvious surgical problems were dealt with by Mr Ellis, the consultant, the three young casualty officers and the experienced nurses.
Medical paediatric problems were referred to the paediatric house officer who was called to the casualty department to see them. The children were examined and either provided with treatment and sent home, often after discussion with the paediatric registrar; the registrar would often come down to casualty to check the house officer’s findings and confirm the course of action proposed. Alternatively the child would be admitted to one of the paediatric wards at the LGI or admitted to one of the paediatric beds at Seacroft or St James’s Hospital (not St James “University” Hospital until 1970 when the Leeds medical school expanded). If suffering from an obvious infectious disease, the children were admitted directly to the Infectious Disease Department at Seacroft under the care of the consultants in infectious diseases.
The parents were not usually present at ward rounds as visiting in the Fifties and early Sixties was strictly limited to short periods once or twice a week (discussed in some detail below).
Not infrequently Dr Allibone would ring me about an ill child he had just seen on a domiciliary visit. I always enjoyed these as he would ask me to admit the child, take a history, examine the child and check the urine then ring him back with my findings. They were always very interesting and significant problems. He was an excellent clinician and by this stage vastly experienced – so important in clinical medicine.
Rounds on Ward 8 and Princess Mary wards were daily central part of the routine
For the ward round general ward activities, such as cleaning and bed-making were halted, the mobile children were confined to sit on their beds and unclothed down to their waists with a blanket round them in case the doctors wanted to examine them. Any younger children who were noisy or crying were swiftly removed to a side room or the sluice and supervised by a nurse or orderly. There were of course no relatives in evidence in 1956. (See list of rules at similar children’s department below)
The house physician would report on the medical progress and the results of any new investigations, any new X-rays would be viewed. The ward sister would report on the overall progress of the child such general behaviour and emotional state, appetite, bodily functions, whether the child was taking the prescribed treatment. After a discussion the future treatment and management was agreed. If the child was old enough what would happen was described in broad terms; as mentioned more often than not the parents would not be present as visiting was severely limited.
After the ward round the house physician would write up the notes with the decisions and the consultant’s observations in red, implement any new treatments or investigations. Some Ward Sisters provided coffee and biscuits after the ward round but I don’t remember this happening on ward 8 at the LGI!
Prof. Craig and Dr. Allibone were “on take” for acutes on alternate days. They had their own junior non-consultant staff but the resident paediatric house physician worked for both consultants. Everyone ensured that the consultants’ ward rounds did not coincide! Prof. Craig had an NHS registrar, Elizabeth Pryce-Jones (known to all as PJ) and a university Lecturer, Dr. Michael Buchanan. Dr Allibone had an NHS registrar, Dr Dick Smithells who after a spell in Liverpool at the Alder Hey Hospital would return to Leeds as Professor when Prof. Craig retired in 1968.
There were no electric pagers or mobile phones in those days. Resident doctors would be summoned when needed by a series of loud bells audible throughout the hospital, each doctor having a different number or combination of bells. When your bells sounded you rang the hospital exchange and would be told who wanted you.
In addition to daily ward rounds with the consultants and routine ward work such as admitting and discharging children, performing practical tasks such as taking blood. The paediatric house officer was first on call to see medical children in the Accident and Emergency Department. This could be very hard work – I remember one day seeing 30 children in A&E.
Nurses at the Leeds General Infirmary in the Fifties
Jennifer Craig in her book “Yes Sister, No Sister: A Leeds Nurse in the 1950’s”, describes her own experiences entering nursing at the LGI in 1952 and eventually progressing to ward sister. “Naive and idealistic, girls entering nursing were immediately immersed in an atmosphere of strip discipline, stern sisters, starched uniforms and early curfews. The working training were hard, the hours long and tiring and some did drop out. For those that remained however, there were compensations: the satisfaction of providing good care and the support and camaraderie of the other student nurses”
Although my future wife, Ann Phillips, was still at school in 1956 she entered nurse training at the LGI in 1959 and we met in the outpatients in late 1960 where we met when both working in the paediatric outpatients..
Photos; Nurses at the LGI around 1960
The children in paediatric wards in the late Fifties/Sixties
One marked difference between the situation in the Fifties and today was the strictly limited visiting permitted for parents in those days in contrast to the unlimited visiting in recent years. When children were admitted their parents were advised against any visiting “until the child had settled in”. More on visiting (or more correctly the lack of visiting) later.
Ward rounds were a major feature of the daily routine either with the appropriate consultant or the registrar. The consultant may do two rounds each week and the registrar on other days. The consultant, registrar and house physician were accompanied by the ward sister and a more junior nurse. The team would proceed from bed to bed. The house physician would present the child’s details to the consultant or give an update on progress if the child was not a new patient. The results of any relevant investigations would be reported and discussed.
The key people on the ward round in the sixties were the ward sister, the house physician who provided continuing care, the registrar to provided support and expertise for the house physician, a junior nurse to help the sister with practical tasks relating to the patient – and of course the patient!
As the years progressed more people became involved in the ward round. Obviously the parents and other staff with special skills and an important contribution to make – for example the physiotherapist, the dietitian, social worker and pharmacist, in particular instances other laboratory personnel from chemical pathology and bacteriology. In later years as visiting became unrestricted, the wards became very crowded and noisy and it seemed inappropriate to discuss individual childrens’ problems in front of an audience of other children and parents. So eventually when a consultant at St James I arranged to do ward rounds in my office and see the parents and children after discussion with other members of the team.
The Platt Report 1959
In 1959 the UK’s Ministry of Health published the Platt Report requiring hospitals to implement major changes in the non-medical care of children in hospital. It made 54 recommendations, the most significant being that visiting to all children should be
unrestricted, that mothers should be able to stay with young children and that the training of medical and nursing staff should include the emotional and social needs of children and families.
Since 1952, through his contrasting documentary films, A Two Year Old Goes to Hospital and Going to Hospital With Mother, James Robertson, a psychiatric social worker from the Tavistock Institute of Human Relations, had been promoting such a pattern of care to doctors and nurses with only limited success, nor was the Ministry any more successful in gaining a more humane pattern of care for sick children.
At that time children faced long, lonely stays in hospital. Visiting hours were very short, sometimes as little as an hour twice a week and for some conditions non-existent. Parents were discouraged from visiting. It was thought they might bring infection into the ward and “their visits evidently upset the children who, if left to themselves, would quickly settle down and soon forget about home”. At that time a health correspondent could confidently state that “the vast majority of hospitals seemed oblivious to the enormous amount of suffering they put upon children and their parents by rules which break important relationships necessary for the maintenance of good mental health”.
John Bowlby, the famous British psychologist and psychiatrist (photo), who famously highlighted the bad long term effects of separation of children from their parents, wrote
of James Robertson, “He was a remarkable person who achieved great things. His sensitive observations and brilliant observations made history, and the courage with which he disseminated – often in the face of ignorant and prejudiced criticism – what were then very unpopular findings, was legendary. He will always be remembered as the man who revolutionised children’s hospitals, though he accomplished much else besides. I am personally deeply grateful for all that he did.’
In 1961 James Robertson brought the Platt recommendations to public notice with a series of articles in the Observer and a forthright programme on BBC TV based on his films. Contrary to instructions he asked viewers to write to him about what happened when their children were in hospital and urged community action to improve conditions for sick children.
National Association for the Welfare of Children in Hospital
Peg Belson was one of the Battersea mothers who heeded Robertson’s call and under his guidance she set up a group, initially called Mother Care for Children in Hospital, which in 1965 changed to NAWCH – the National Association for the Welfare of Children in Hospital. Within a few years NAWCH was a UK-wide organisation with over fifty branches, a Central Office and a Government grant.
During the past 50 years going into hospital for children has changed beyond recognition. In the main children are cared for by qualified staff on children’s wards where parents are welcome at any time, sleep near their child and take part in their care, hospital play specialists help to make the experience more meaningful and endurable and wards are bright and suitably decorated.
With her colleagues Peg Belson played a significant role in helping to bring about these changes. She was a committee member and office-bearer in NAWCH (now Action for Sick Children), a member of official enquiries and represented Action for Sick Children on other national organisations. As a lecturer and writer and as a health authority member she was able to persuade others to take up the cause. She carried out many national surveys of hospital facilities for children, which gained wide press coverage and formed part of official reports. These surveys included facilities for parents, numbers of children’s trained doctors, nurses and hospital play specialists and numbers of children being nursed in adult wards as well as the availability of children’s emergency services, dedicated adolescent care and of education for sick children. In addition to helping to improve care in the UK she helped to introduce similar programmes for family involvement and play to other countries by visiting and teaching in hospitals overseas and by arranging teaching visits to UK hospitals for enthusiastic groups of overseas staff. (details from Peg Belson entry in Wikipedia).
Attitudes to children have changed radically since then.
As a young house physician and paediatric senior registrar from 1956 to the mid Sixties, I was closely involved with the everyday work of the paediatric wards at the LGI and Seacroft first as an houseman, then as senior registrar tutor, lecturer, senior lecturer and consultant. I was always very supportive of the local branch of NAWCH in Leeds and they definitely regarded me as an ally. Also from 1964 Ann and I had small children of our own and identified with the concerns of the parents whose children were admitted to hospital.
On one occasion in the mid-Sixties I nearly lost my job as lecturer in Paediatrics for criticising one of Prof. Craig’s senior Ward Sisters! The particular Sister was of the “old school” and not keen on parents visiting; she tended to be rather sharp and bad tempered with everyone. We had asked the Professor round to our house in Alwoodley for a meal and I had bought a bottle of malt whiskey which I knew he liked. After dinner we had a few whiskeys and got onto the subject of the nursing staff. Prof. would insist that the Sister on the main paediatric ward was a “wonderful person”. I disagreed having worked closely with her for some years and sadly the evening ended in strong disagreement – I wondered if I would get the sack! However, all was as usual the next day. Although I was one of the few juniors who could get on with Prof. there was just one other occasion when our relationship was put under considerable strain when I was the paediatric house physician at the LGI in 1956. I had been working virtually non-stop for 48 hours seeing acutes in casualty in addition to working on the wards. On the ward round the next morning I could hardly keep awake when we arrived at an infant’s cot. Prof. asked to see the feed chart where are the feeds were written up. They were not! He then became irate and said the house physician should always write down the feeds to be given. I’d had enough. I handed him the feed chart and walked off the ward to my room and went to sleep. However, I’m sure Liz Pryce-Jones, the registrar, told him what a bad time I’d had over the previous 2 days and I was forgiven. The rest of my six months went without serious incident.
To return to the situation regarding children in hospital, not all professionals were so accepting of the new proposals in the Platt report and in some hospitals they were implemented reluctantly. John Bowlby later explained – “There were certain groups who took to it with great enthusiasm, other groups were directly lukewarm and other hostile, each profession reacted differently. The social workers took to it with enthusiasm; the psychoanalysts treated it with caution, curiously and for me infuriatingly peadiatricians were initially hostile but subsequently many of them became very supporting; adult psychiatrists totally uninterested, totally ignorant”.
I can appreciate Bowlby’s comment above regarding the attitude of some paediatricians, and I would also add of some ward sisters and nurses, who had to change their way of working from providing all care for their child patients. Now they had to adjust to a supportive and advisory role for the parents who were present for much of the child’s stay in the ward. Some senior staff did not like the change.
Although I was a strong supporter of open visiting, when there were numerous parents and noisy siblings between every bed on the ward one sometimes thought wistfully of the “bad old days” when the ward was quiet with the children sitting quietly in their cots or on their beds and one could hear a pin drop!
Some of the medical conditions affecting hospitalised children in the Fifties
Some of the conditions affecting the children in hospital medical wards are rarely seen these days. Problems affecting hospitalised children today are not so frequently related to episodic illnesses apart from acute respiratory conditions, many of which are dealt with in general practice. In hospitals children in recent years more often have chronic disorders, such as asthma, cystic fibrosis, leukaemia, metabolic disorders, diabetes, congenital malformations, various other handicaps, accidents and illnesses related to social and family stress. One condition that was not recognised was non-accidental injury although “neglect” was diagnosed when nutrition and care of children fell below acceptable. It difficult to accept that parents would deliberately physically injure there own children. It was 20 years, when I was a consultant, before Dr Chris Hobbs and the late Dr. Jayne Wynn in Leeds brought the whole spectrum of child abuse to our notice.
This serious condition is now only rarely encountered in children in the UK although in the Fifties it was not unusual to have one or more affected children in the ward for many weeks. The condition remains a major problem in many developing countries.
Affected children may have a combination of severe joint pain, fever, chest pain or palpitations, jerky uncontrollable movements, (chorea) and a very characterisitc rash, erythema marginatum. Cardiac involvement leads to cardiac signs even failure and long term damage. The children were treated with penicillin, salycilates in high doses, some had corticosteroids. But bed rest was prescribed for weeks or months until signs of inflammation had settled – often six weeks to six months; half those affected are left with chronic rheumatic heart disease. 500,000 new cases worldwide occur annually and at least 15 million people have chronic rheumatic heart disease”.
This was another condition that would bring children into the ward for a prolonged period. It was an acute inflammation of the glomeruli and other parts of the kidney causing reduction in urine output associated with blood stained urine, swelling of the face and tissues, and high blood pressure. Although the symptoms are alarming the prognosis for children is usually good, symptoms and signs settling within weeks. Most children made a good recovery.
Bed rest and fluid restriction was usual during the first weeks and Professor Craig ordered a “renal binder” said to help recovery. These were days before the introduction of paediatric renal biopsy, the procedure having been first reported in 1951 by Iversen and Brun in Copenhagen: a development that formed the basis for the development of nephrology as speciality around 1960. To put matters in perspective the International Study of Kidney Disease was not convened until 1966.
The story is similar to that of rheumatic fever in that there is a declining incidence of acute nephritis worldwide, particularly in industrialised nations but it remains a significant problem in the less developed world,
Tuberculosis and tuberculous meningitis.
These were all relatively common conditions in the Fifties and
treated in a medical paediatric unit. TB meningitisrequired a prolonged stay and distressing intensive treatment with both systemic streptomycin, isoniazid and intrathecal streptomycin daily, the latter for 3 weeks. In fact primary tuberculosis was relatively common and a Mantoux skin test was carried out on most children admitted as a routine on admission.
Meningococcal meningitis was the most common type of treated on the paediatric wards but we also saw pneumococcal and H. influenzae meningitis.
Infectious diseases were still a major problem.
Measles, mumps, chickenpox and whooping cough were relatively common. Severe streptococcal tonsillitis amounting to scarlet fever was taken seriously. The infectious diseases were taken as an almost inevitable occurrence for children. When the diagnosis was obvious and admission considered necessary either from the severity of the illness or the social conditions, the child was transferred to the Infectious Disease Unit at Seacroft Hospital.
Dr. Robert Marion, a paediatrician and geneticist in the USA summed up the situation regarding changes in occurrence of infectious diseases as follows –“Until the last few years, the campaigns to immunise children against measles, mumps, rubella, diphtheria, pertussis, tetanus, polio, hepatitis B, Haemophilus influenzae, and others, have been so successful that most young peadiatricians have never seen a single case. But these conditions were the bread and butter of pediatric practice prior to 1960. The measles-mumps-rubella (MMR) vaccine was developed in the early 1970s, but each of the components was developed in the 1960s.
Rubella (German measles) vaccine in particular was developed because of the devastation of congenital rubella. Throughout the mid 20th century, epidemics of rubella raged every couple of years. Although the disease itself was mild, pregnant women contracting the virus were at risk to have children with deafness, blindness, congenital heart disease, failure to thrive, intellectual disabilities (then called “mental retardation”), and….yes, you guessed it…..autism. How ironic is it that the vaccine developed to prevent the leading cause of autism became the focus of this pseudoscientific crusade to prevent all humans from using vaccines? Pretty amazing, huh? (Marion is referring to the Dr. Andrew Wakefield’s research which caused such problems regarding the relationship of MMR to autism after the 1998 publication of his fraudulent research paper in The Lancet linking the combined measles, mumps, and rubella (MMR) vaccine to colitis and autism. The paper was partially retracted in 2004 and fully retracted in 2010 and Wakefield struck of the medical register)
Dr Marion continues “We see a fair amount of pertussis because it causes its real harm in very young children, before their full course of immunisations is complete. This is a life-threatening illness in infants, who cough so much that they can’t take in air. They’re at risk to develop hypoxic-ischemic encephalopathy, permanent brain damage, as a result, and every year, there are deaths from pertussis in the very young”.
In the Leeds LGI casualty department we were constantly on the look out for an infectious disease being responsible for a child’s acute symptoms and signs such as slight soreness of the eyes and Koplik’s spots (photo) inside the cheeks for measles.
It was very important we were always on the look out for infectious disease appearing before the classical signs developed for the child could be admitted into the open paediatric ward and spread the condition to other children. This was particularly the case in the late Fifties before children were immunised against the common infectious diseases. In fact throughout my career I always considered the worst possible explanation for a child’s symptoms and worked from there. Also with any conditions mistakes could occur when a child presented very early in the course of an illness or when there were two conditions occurring at the same time. Tonsillitis seems to be associated with other conditions emphasising the importance of a general examination of every ill child.
Many years ago when I was a paediatric house officer I saw an acutely ill child in the LGI casualty department with what appeared to be severe acute tonsillitis – livid red tonsils with fresh yellow exudate and tender tonsillar glands. He was sent home with a bottle of sulphadimidine (M&B), which was the usual treatment for streptococcal tonsillitis at the time. He returned the next morning to the casualty for follow-up and his mother reported he was generally very much better in himself but he seemed to have slight pain on moving his head; she had also noted a few small purple spots on his feet . On examination, although definitely a little better than on the previous day, he had quite obvious neck stiffness highly suggestive of meningitis. I admitted him and a lumbar puncture revealed infected cerebrospinal fluid due to meningococcal meningitis which was treated with panicillin! Fortunately the infection had obviously been partly controlled by the sulphonamide prescribed the previous day for his tonsillitis and he made a good recovery. I was even told in the Edinburgh Membership, by a very unpleasant examiner, that sulphonamides alone were a quite adequate treatment for meningococcal meningitis when I suggested penicillin!
There were few children with cystic fibrosis (CF) as, in the Fifties, most with the condition died in early childhood. However, infants and children were frequently admitted for investigation of “failure to thrive” some of whom had coeliac disease and others cystic fibrosis, I will discuss CF and coeliac disease in more detail in subsequent sections (also in http://www.cfmedicine.com/history) but mention here that the sweat electrolyte salt abnormality in CF was not described by Paul di Sant’Agnese until 1953 and the sweat test was by no means a routine to diagnose the condition in 1956. Also dietary gluten as the cause of coeliac disease was not identified by Willem Dicke until 1953; the characteristic subtotal villous atrophy of the small bowel mucosa was not described until 1954 by Paulley in adults and until 1957 by Margot Shiner in children. But there is more on this in later sections.
These were some of the conditions that were relatively common for the paediatric house officer to encounter at the Leeds General Infirmary in 1956. There were other conditions which are rarely seen these days, for example infants with hypothermia, pink disease thought to be due to mercury toxicity, laburnum ingestion and lead poisoning to mention a few.
I will discuss the six months with the Thoracic Surgery Firm in a subsequent section.