196 somewhat higher than at other times and in control areas. The sharp reduction in fertility among these cohorts, however, combined with weak famine effects when conception occurred, indicates that starvation before conception more likely leads to infecundity than to conception with subsequent injury to off-

MATERNAL NUTRITION AND LOW BIRTH-WEIGHT

SIR,-Dr Pasamanick’s insistence (Dec. 6, p. 1145) on a "fatal flaw" in our study of the effects of prenatal exposure to the Dutch famine obliges us to reply. The major hypothesis tested was that nutritional deprivation late in gestation would retard brain growth and depress mental performance. A second hypothesis was that deprivation early in gestation would result in congenital defects and death or handicap. We built our retrospective cohort design chiefly around military induction records. About 120 000 19-year-old male survivors of complete cohorts born in sixteen cities from 1944 to 1946 were assigned to famine exposed and unexposed groups according to place and date of birth, thus controlling simultaneously for place and time. Dr Pasamanick’s first point is that food in the famine area was not randomly distributed. Hence women able to "conceive, maintain pregnancies, and obtain live births", and classed by us as exposed, he asserts were upper class, or Nazi collaborators, or others who obtained more food. This comprises the "fatal flaw". Because the famine lasted only six months, however, such selective food distribution could affect either cohorts born during the famine and conceived previous to it (Bl, B2 in figure) or cohorts conceived during the famine and born subsequent to it (D1, D2).

spring. Pasamanick’s second point is that starvation in "control" cities invalidates them as controls. However, contemporary reports, and the weekly food rations, make clear the more favoured situation of control cities. In sum, cohorts bom in famine cities before and after the famine, and cohorts born in control cities throughout the study period, did not show the fall in births, the retarded fetal growth, nor the rise in infant deaths found in famine-exposed cohorts. None of the birth cohorts, whether in famine or control areas, showed changes over time with respect to mental competence. In our book on this study,’ the data are set out in full in an appendix, and those interested can test the issues for themselves. Division of Epidemiology, Columbia University School of Public Health, 600 West 168th Street, New York, N.Y. 10032, U.S.A. Columbia University and New York State Psychiatric Institute.

MERVYN SUSSER

ZENA A. STEIN

THE ALCOHOLIC DOCTOR

Design of study. Cohorts by month of conception and month of birth, in the Netherlands, 1943-46, related to famine exposure. Solid vertical lines bracket the period of famine, and broken vertical lines bracket the period of births conceived during famine.

Pasamanick’s criticism is

not

germane

to our

main

hypoth-

esis, tested in cohorts exposed to famine in late pregnancy (B1,

B2). As anticipated among cohorts conceived before the famine, neither in number nor in social class distribution is there evidence of changes in fertility. The mothers of these birth cohorts were reduced in weight. Their offspring were reduced in birth-weight, length, placental weight, and head size, and they suffered heavy excess mortality in the first 3 months of life. Despite these effects, adult survivors among the poorest as among the best-off social classes showed no decline in mental competence, nor in physique and health state. Pasamanick’s criticism could be germane to our second hypothesis, tested in cohorts exposed to famine in early pregnancy (Dl, D2). Indeed we considered the point in detail. Fertility among these cohorts, we showed, was socially selective, and births over-represented the upper classes. This, we concluded, resulted from better maternal nutrition at the time of conception. Mean birth-weights were not reduced among these cohorts. Survivors had the mental competence expected from the changed social-class composition of the cohort, but with social class controlled no famine effects were found in time and place comparisons. Rates for stillbirths and c.N.s. defects were ’

SiR,—The subtitle, a Case of Neglect, of Dr Griffith Edwards’ timely article (Dec. 27, p. 1297) applies not only to the treatment of the unfortunate sufferer but also to the coverage of alcohol misuse in the medical curriculum. Partly due to this neglect there is a high prevalence of heavy drinking among doctors and the stigma attached to the diagnosis of alcoholism by the general population is perpetuated. The problem is urgent because alcoholism is clearly on the increase in the U.K., especially among the young. Twenty years ago only 5% of patients admitted to the alcoholic unit at Warlingham Park Hospital were under thirty;2 today, in my unit, some 18% of alcoholic admissions are in this age-group. Alcoholism is not only a treatable illness, but it is also one that is, or should be, preventable. In the future doctors will have an important role to play in prevention as well as in treatment. But the average general practitioner probably knows of no more than 2 out of 20 alcoholics on his list, and the high prevalence of alcoholism among doctors is further evidence of the lack of medical undergraduate education. Liver cirrhosis mortality among doctors, according to the Registrar General’s figures for 1961, was 3ytimes higher than that among the general population, and in line with such estimates is the finding that over the past 25 years the proportion of doctors among our alcoholic patients admitted to the units at Warling. ham Park and St Bernard’s has been 2-%. Doctors are clearly a high-risk group. Various factors may be involved. Social acceptance of heavy drinking among undergraduates may pave the way, and after qualification the doctor may fall back on his familiar "comforter" at times of strain for relaxation, especially since drink is so often freely offered by friends and colleagues. Preventive programmes of must include attempts to reduce consumption, by education the public, beginning in schools. There is an urgent need for education to be directed at high-risk groups, especially medical students, and this should stress the early phases of alcohol rather than the late and relatively rare physical complication "I never heard about alcoholism as an undergraduate except about liver cirrhosis in pathology", an alcoholic consultant remarked last week. Yet medical students can take an interest in the subject, as shown by our experiences of teaching Locoes undergraduates with the help of recovered or still "actil’t alcoholic patients. Doctors often share the misconceptions90 prevalent among the general public. A doctor equating 1.

Stein, Z., Susser, M., Saenger, G., Marolla, F. Famine and Human Development: the Dutch Hunger Winter of 1944-1945. New York, 1975. 2. Glatt, M. M. Br. J. Addict. 1955, 52, 55.

Letter: Maternal nutrition and low birth-weight.

196 somewhat higher than at other times and in control areas. The sharp reduction in fertility among these cohorts, however, combined with weak famine...
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