C. R. Lowe

The sex ratio of human births related to maternal age.

Data from the Annual Reports of the Registrar-General for England an d Wales (1939-1947) and for Scotland (1939-1947) were examined to determine the relationship of sex ratio to maternal age. Sex ratios of total births and live births decrease with maternal age; sex ratios of stillbirths increase. The increase in the sex ratio of stillbirths with maternal age accounts for the difference between live births and total births. The decrease in the sex ratio of total births with maternal age may be explained by changes in the sex ratios of abortions earlier than the 28th week. A trend in the sex ratio at conception would then be absent with regard to maternal age. Data from the Annual Reports of the Registrar-General for Scotland (1939-1946), which give the causes of stillbirth were used to investigate the increase of the sex ratio with maternal age. There were 4 main classes of stillbirth described and each class has a different sex ratio. Changes in the sex ratio of all stillbirths with maternal age were in part attributable to changes in the relative proportions of these classes in each age group. The class which exhibits the most definite age trend - anomalies of fetus, placenta, or cord - was examined. Results indicate that each class is influenced by individual causes within the class. Trends of stillbriths with maternal age for any single cause were absent. It is suggested that the reported trend of the sex ratio in association with birth order may also be explained by changes in the composition of stillbirths and abortions with parity.

A Note on Secular Changes in the Human Sex Ratio at Birth

Investigations of secular changes in the live-birth sex ratios of different countries have given conflicting results (Gini, 1908; Russell, 1936; Ciocco, 1938; Strand skov, 1942; Martin, 1943). In general the data are unsatisfactory, either because numbers of births are small, or because of inaccuracies and deficiencies in birth notification. Russell (1936) examined statistics for England and Wales, and drew attention to the decline of the sex ratio of live births between 1841-45 and

The Care of the Chronic Sick: I. Medical and Nursing Requirements

If we are not now aware that old age and chronic sickness are among the most urgent of contemporary medical problems, it is not the fault of the numerous writers who have tried to persuade us. Their case is supported by national statistics, and stated briefly amounts to this: the fact that preventive medicine (to use the term in its most inclusive sense) has reduced the incidence of disease in younger age groups means that a higher proportion of the general population suffers from the diseases of old age; the relative contribution of these diseases to the total Incidence of disease is already high and is increasing; we are comparatively ignorant about the diseases of late life and have the best of reasons for learning more about them (in this matter we have the double interest of the actuary and of the insured). In this paper, the first of a series based on an Investigation of the chronic sick in hospital, we deal mainly with administrative difficulties created by these diseases. It will be useful first to consider the reasons which have led to the coupling of the problem of chronic sickness with that of old age, for If we use the term chronic sickness in reference to diseases which continue or recur over a considerable period, it is quite evident that it is not limited to late life. Bronchitis, rheumatic heart disease, and disseminated sclerosis are examples, in the respira tory, circulatory, and nervous systems respectively, of chronic diseases which commonly appear for the first time in young people. The fact that we associate chronic sickness with old age reflects a natural preoccupation with the administrative problem. As scientists we should like to know the proportion of the chronic diseases which first appear in each age group, but as medical administrators we are more concerned with the proportion of individ uals in each age group who require attention.

Investigation of the Medical and Social Needs of Patients in Mental Hospitals: II. Type of Accommodation and Staff Required

A previous communication (Garratt, Lowe,and McKeown,1957) described aninvestigation ofthe medical andsocial needsofthe3,555Birmingham residents in Birmingham mentalhospitals in January, 1957. Reasons weregiven forbelieving that these patients wererepresentative ofthemental hospital population ofEngland andWales, andthe patients wereclassified according tothetypeof facilities required fortheir care.Itwasconsidered that13percent.needed thefull resources ofa hospital, 75 percent.neededlimited hospital facilities, andtheremaining 12percent. required noneoftheservices traditionally associated with hospitals. Thepurpose ofthepresent report isto examine ingreater detail thepatients assigned to eachclass, andtosuggest thetypeofaccommodation andstaff required. Themethods usedtoobtain thedataweredescribed fully inthefirst communication. Briefly, withthehelpofthepsychiatrist responsible forhis care, theneeds ofeachpatient wereexamined and used toassess thenature oftheservices which would bemostsuitable. I.PATIENTS NEEDINGFULLHOSPITAL FACILITIES Itwasestimated that459(13percent.) ofthe 3,555Birmingham patients inmentalhospitals needed tobecared forinaninstitution whichcould provide thefull rangeofservices associated witha modernhospital: x-rays, laboratories, surgery, skilled nursing, etc.Thereisofcourse, someroom fordifferences ofopinion aboutthetypeofservice whichnecessitates full hospital care.Inthecaseof patients athome, forexample, decision turnsupon theavailability ofout-patient departments, dayhospitals, laboratories, etc.Theproblem isdifferent whenpatients arealready inhospital, since itisthen somewhat unrealistic-part icularly

A Scheme for the Care of the Aged and Chronic Sick

Formerly it was laid down as a cardinal principle that operation should be considered only after a full course of medical treatment had been tried and failed. Such a standpoint can no longer be maintained. On the one hand, few patients can now afford the time and cost of a full course of medical treatment, involving as it does a lengthy period of rest in bed with a prolonged convalescence, on a diet which, to be adequate, must prove quite expensive. On the other hand, operative treatment is far less of a hazard than formerly. Owing largely to improvements in anaesthesia and in medical care before and after operation, the risk to life is now very small, while with a proper selection of cases there is a strong prospect of speedy convalescence and quick return to full health and strength. In considering the advisability of operation, attention must be given to the duration and severity of the symptoms, to the economic disablement they cause, and to the presence or probability of complications such as haemorrhage and pyloric stenosis. In gastric ulcer the question of malignancy also arises. Ulcers in the prepyloric region are especially dangerous. In this area the diagnosis between benign and malignant ulcers is by no means easy, whether based on clinical or radiological criteria or on gastroscopic examination, and, even though benign at the time of examination, such an ulcer is liable to malignant change. Though it is now agreed that the frequency of this development is not high, nevertheless it is sufficient to demand consideration. In suspicious cases operation should be advised at once, while even in cases of undoubted benignity operation should be advised if complete healing has not been achieved within a few months. The treatment of the bleeding peptic ulcer is too big a problem to consider here, but it will be agreed that a history of previous haemorrhages must always weigh the scales in favour of operation. Pyloric stenosis also, though sometimes capable of a good deal of relief by medical measures, is usually to be regarded as a clear indication for operation. In uncomplicated cases the decision to operate should be based on the severity of the symptoms, and it must be borne in mind that the best results are generally to be expected in patients with a long history and much pain. Among other criteria nocturnal pain and deep boring pain penetrating to the back are regarded as indications for surgical treatment.

Sex Ratio of Stillbirths related to Birth Weight

(1) There are more male foetuses at risk, for, as indicated by the sex ratio of stillbirths and live births combined (51-5 for England and Wales, 1939-47), there are more males than females in the uterus at 28 weeks, the time from which still births are notified. The male excess at 28 weeks must result from one or both of two causes: (a) a high sex ratio at conception (b) a greater loss of females than of males as abortions in the period between conception and notification.

The Care of the Chronic Sick. II. Social and Demographic Data.

The transfer of responsibility for the care of the chronic sick in hospital from Local Authorities to Regional Hospital Boards has raised two important questions. First, Regional Hospital Boards have to decide on the location and number of beds to be provided for this class of patient. Their waiting lists indicate that more accommodation is needed, but more accommodation of the existing type would aggravate staffing difficulties which are already serious. The alternative possibility of catering for these patients in general hospitals has much to recommend it, but raises the objection that the apparent number of patients would prohibit the general application of such a policy. Second, Local Authorities have to agree on the interpretation of those sections of Part III of the National Health Services Act* (1946) and of Part III of the National Assistance Actf (1948), which refer to their responsibility for complementary facilities. The intention of the acts is evidently to leave to Local Authorities domiciliary and institutional care of persons who need not be admitted to hospitals, but the wording of the acts reflects the lack of informa tion about the numbers and types of patients for whom Local Authorities will be expected to cater. The fact that social as well as medical needs have in the past determined the admission and retention of patients in hospitals for the chronic sick suggested that the number of patients now in hospital is unreliable as a guide to future develop ments. Consideration of the medical, nursing, and social requirements of 1,005 patients in one hospital indicated that about three-fifths were not in need of hospital services and could have been cared for in their own homes or in institutions other than hospitals (Lowe and McKeown, 1949). One-fifth of the patients required institutional supervision because of their abnormal mental state, and only the remaining one-fifth were in need of services which could properly be considered the concern of general hospital authorities. Reduced to these dimensions, the problem of the chronic sick in hospital can be reconsidered in relation to the general hospitals. In this paper we examine other data which have a bearing on the commitments

Investigation of the Need for Physical Treatment during Prolonged Absence from Work

For this purpose the circular suggested that hospital rehabilitation services should be expanded, and should include physiotherapy departments, remedial gymnasia, and occupational therapy rooms. Responsibility for these services falls mainly upon Regional Hospital Boards. The Boards are, however, finding it difficult to finance expansion of the traditional services, and require to know whether the cost of extending the rehabilitation services will be justified. According to the Ministry circular, experience has shown that: