In besieged Leningrad, the work of the pediatric service was clearly established, thanks to which many children were saved

May 9 is also a big holiday for the children of besieged Leningrad, for those who managed to survive thanks to the fact that adults made immeasurably enormous efforts to save them. Among those rescued is Nikolai Pavlovich Shabalov, now the president of the Union of Pediatricians of St. Petersburg, Doctor of Medical Sciences, head of the department and clinic of childhood diseases of the VMSA, Honored Scientist of the Russian Federation. When the war began, Nikolai Shabalov was only two years old. Fate turned out that he was in our city throughout the blockade, his family was not evacuated.

Due to my age at that time, my memories of the war are somewhat chaotic. We lived in a classic communal apartment on Stolyarny Lane (now Przhevalsky Street). My father immediately went to the front as an infantryman. During the blockade, my mother worked as a cleaner at the Technological Institute. I remember how my mother took me to kindergarten (by the way, all nurseries and kindergartens in the winter of 1941 - 1942 were transferred to round-the-clock services for children, up to 70 percent of boys and girls were left in them for a day). I also remember how, during the shelling, I was dragged into the basement by the hand, how we sat there, huddled together in fear. Once, before my eyes, a school located on the corner of Stolyarny and Plekhanov Street was bombed. This, of course, was a huge shock! And after the blockade, when my mother was leading me into the garden, a shell exploded on the bridge we had just crossed. And miraculously no one was hurt then.

- What about hunger?
- I kept asking: “Heba, heba” (I didn’t pronounce the letter “l” then). Of course, it supported the nutrition in the kindergarten. Mostly they gave us porridge. I really remember the “siege porridge” - made from clover flowers. Another vivid memory dates back to 1944. I, holding the loaf in my hands, walked out of the bakery with my mother. And someone snatched this loaf from me, and I started crying all over the street.

Hunger weakened my body, during the war I suffered from pneumonia nine times (in my entire subsequent life, for reference, never once), and I was in the Pediatric Academy. I remember that the doctors were very kind. Only later, having become a pediatrician myself, did I find out how well the pediatric service worked in the besieged city, and at what cost it was possible to save the children.

My friend, who unfortunately has already passed away, Igor Mikhailovich Vorontsov, who for many years headed the city’s pediatric service and also survived the siege of Leningrad (he was three years older than me), said that in the kindergarten he went to, they gave fried bread with castor oil, sometimes even sweets - they were crushed into pieces.

- Let's list the main things that were done for children in the besieged city...
- The children's network of besieged Leningrad was fully staffed with personnel! During wartime, the Pediatric Institute trained 947 doctors (there were 7 graduates in total - planned and early). Some of the young doctors were sent to the active army, but many were left in Leningrad and the region.

Moreover, in besieged Leningrad, for the first time in the USSR, a “single pediatrician” system was introduced, according to which all children from birth to 15 years were treated by one local pediatrician (before that there was a gradation by age: up to 3 years and after 3 years). By 1944, all 36 children's clinics in Leningrad operated under the system of a single pediatrician, which is still in effect today.

Much has been done to prevent the spread of infectious diseases. In particular, in the besieged city, all preschool children were vaccinated against typhoid fever for the first time.

Now regarding solutions to the problem of hunger. The chief pediatrician of the besieged city, Alexander Fedorovich Tur (the position of chief pediatrician also first appeared only during the siege), insisted, and the city leadership supported him, that children receive more rations than dependents. So, from January 25, 1941, children began to receive 200 grams of bread, from January 24, 1942 - 250 grams, from February 11, 1942 - 300 grams.

I'll give you a few more numbers. To receive food, all small children were assigned to dairy kitchens at clinics. All mixtures were provided only boiled; in 1942, 23 dairy kitchens provided approximately 60 thousand servings daily. And in January 1941, 30 canteens were opened for 30 thousand schoolchildren aged 8 - 12 years. Since November 1942, medical nutrition canteens were opened for 15 thousand children of preschool and school age.

As for the Pediatric Institute, its employees developed children's nutritional regimens, introduced new dishes from substitutes and substances that had not previously been used in children's nutrition. The dairy and food station, which is part of the institute, produced up to 500 liters of porridge per day (in peacetime, 10 to 15 times less).

A very interesting fact: at the end of October 1942, the institute established its own dairy farm for three purebred cows, and by the end of the year they received 870 liters of milk. The following year, 1943, seven more cows were brought to the farm, and the milk yield for the year was already 12 thousand liters! This fresh milk went to Leningrad children.

A separate program to help pregnant women was developed. For them there were food cards with increased standards; through antenatal clinics they were given milk, kefir, and fish oil.

- Was scientific research carried out during the blockade?
- Certainly. One of the first to resume its meetings was the Society of Children's Doctors, headed by Alexander Fedorovich Tur and Yulia Aronovna Mendeleeva. In 1942, the society held 18 meetings, in which 1,900 doctors took part. Here are some of the topics of the society's reports: “Life and nutrition of children under blockade”, “Treatment of severe dystrophies”, “Sulfidine therapy for dysentery”, “About soy milk”, “Blood replacement solutions of the Leningrad Institute of Blood Transfusion and their importance in the clinic of internal diseases " In 1942 - 1944, a number of scientific and methodological manuals on the treatment of children in wartime conditions were published.

- What features of diseases in children were recorded during wartime?
- In the works of Alexander Fedorovich Tur, you can read that during the blockade, bronchial asthma, lobar pneumonia, acute nephritis temporarily disappeared (appeared again in 1943), there was a sharp decrease in tonsillitis, purulent otitis and meningitis, the incidence of scarlet fever, whooping cough, chickenpox sharply decreased, rubella, mumps, measles and acute appendicitis disappeared. But the incidence of diphtheria, dysentery, colitis, acute hepatitis was extremely high, and tuberculosis in children with dystrophy led to extensive damage to all organs.

Naturally, the very nature of the diseases changed during the blockade. Let me give an example from the practice of Alexander Tour: in August 1942, an exhausted 10-month-old child with hydrocephalus, a large belly, and swelling in the legs was admitted to the clinic. There was no indication of previous infections. What happened to the baby? The tour determined that the cause of the serious condition was chronic poisoning with quinoa, which, as it turned out, constitutes the child’s main complementary food.

- How would you characterize the work of pediatric services in a besieged city?
- I would answer this question with the words of Alexander Fedorovich Tur, the chief pediatrician of besieged Leningrad: “During the siege, we suffered from many deficits, but we did not have a deficit of conscience.” Doctors worked for wear and tear, without any benefits for themselves and their families. Unfortunately, in our time, the concept of selflessness is increasingly leaving medicine.

Birth rate in besieged Leningrad:

1941 - 67,899 children.

1942 - 12,659 children.

1943 - 7,775 children.

400 thousand children remained in the besieged city.

I learned about the beginning of the war from Molotov’s speech on the radio in the Alushta sanatorium, where I spent my vacation before defending my dissertation (at the First Medical Institute of Leningrad, where I completed my graduate studies in the department of pharmacology).

With difficulty we managed to go to the city of Zaporozhye to pick up our daughter, who had been left with her husband’s mother. We became acquainted with the horrors of enemy raids and bombings on the way to Leningrad, when the railway track was destroyed. Trembling with fear, we waited for the train to finally start moving and for us to get to Leningrad.

Bombings and raids occurred daily and mostly in the evening (before 11 p.m.). Objects that were pre-planned based on signals from hostile people were destroyed. We often observed these signals with horror.

Already in the first days of the war, victims of raids and bombings began to arrive at the clinics of the Medical Institute and the Erisman hospital, which turned into hospitals.

Our Medical Institute was evacuated to Novosibirsk, and the remaining teachers and students were sent to the militia. Women who were not immediately mobilized began working in the hospital to help victims of raids and bombings. I also started working in a surgical clinic, where the head was Professor Yu.Yu. Janeladze. Helped receive and treat incoming wounded victims of air raids. Later, I began working as a ward doctor in a hospital where Olga Vladimirovna Bekhtereva was a surgeon. The worst thing was that in the first days of the war the entire sewer system was destroyed. There was no water or heat. With the onset of cold weather, the wounded lay under several blankets, rarely bandaged, so as not to cool them down. The chambers were heated by potbelly stoves with exhaust pipes through the trench windows. The operating rooms where incoming patients were processed were not heated. And in these terrible conditions in winter, surgeon 0.V. Bekhtereva worked, who had frostbite on her hands and then was admitted to a hospital for dystrophics, which was opened only at the beginning of 1942.

Because of the cold weather, dressings were done with long breaks, and white worms were often observed under the bandage, eating pus and thus clearing the wounds of pus. We realized that in such difficult conditions nature helps heal purulent wounds.

The worst disaster struck Leningraders when the Badayev warehouses burned down and famine began. We watched in horror on September 8, when flames shot up over the city with black clouds of smoke rising. All food in stores was running out and the quota of a piece of black bread in 125 was not enough not only for children, but even more so for those working in factories. People died of hunger, often without reaching their place of work. They fell along the road, unable to get up. At first, hungry and weakened men were mistaken for drunks, and only then did they realize that this was the result of hunger.

Early in the morning before work at the hospital, I went out to buy bread and on the way to the bakery I came under fire, taking cover in the entrance. And on the threshold to a bakery or a store I saw women who did not have the strength to get up or who had already died. More than once I saw passing trucks filled with the corpses of the dead. On the way, I saw people lying wrapped in white sheets and left at the hospital fence. Only in the first days of the war were the dead carried on sleds, but later they were left along the road or at the fence.

Having received a piece of black bread on the cards, I left it to my daughter, dividing it into 4 parts. I myself could not eat this piece of bread, leaving it to a four-year-old child. In the basement of our hostel where we lived (at 44 Petrogradskaya Embankment), there was a children’s “hearth.” From it they received a single meal in the form of liquid soup with floating grains - usually wheat. Sometimes Alla, having received this soup and greedily eating it, said: “Mommy, I’ll leave it for you,” but unnoticed she ate all the soup. There wasn't much of it.

We didn't have any food supplies. At first in the fall we had 80 potato tubers, one per day. I cooked peeled potatoes for the child, and cooked peelings from these potatoes for myself. One day I cooked its sprouts along with the peelings. It was a terrible, inedible brew that ruined my stomach. She flavored everything she had to eat with vinegar and thus lost her sense of taste. I boiled the 0.5 kg of oats I received, twisting them through a meat grinder several times. She gave the liquid to the child, and baked cakes from the cake directly on the stove. This food completely clogged my stomach and intestines. My happiness is that I didn’t feel hungry.

All night long I lit the stove so that the kitchen, where we lived with our daughter and an employee who moved in with me with her two sons, twelve and ten years old, would not cool down. I lay there and counted my ribs under the dry skin. There was no sleep, no feeling of hunger.

When I left for work at the hospital, I left Alla in the doorway on a chair. This is the safest place, since the walls were very thick (this is a former royal stable). And in the evening, when there were more firebombings, we often went down to the bomb shelter. She put a fur coat on the child, with a bag on top containing a shirt and a piece of sugar.

In winter I became very weak and had difficulty moving. Luckily for us, the institute opened a hospital for dystrophic patients, where I received a ticket to replenish my strength. These two weeks saved me. This was at the beginning of 1942.

I want to talk about the tragedy of one family. Our department assistant left every morning with his son to catch a dog or cat for food. But they never managed to catch - all the animals were caught and eaten by the hungry. They were somewhat supported by a large dog, which was brought by elderly people to be painlessly euthanized. This dog supported this family for some time. Then his wife and son died. The department staff supported the girl with their crumbs. Then, at the beginning of 1942, when a hospital for dystrophic patients opened, this assistant received a ticket to it. He took what they cooked there home for his daughter, and from the very first portions of this good food, Alexei Ivanovich began to have hungry diarrhea, and he soon died. The remaining girl was supported by the department staff, and she remained alive.

In 1942, the bread standard increased. Family members received 250 g of bread, and workers received 500 g. It was possible to live, although there were no other products. We didn't even have the wood glue that kept our neighbors alive. In March 1942, a misfortune happened - we lost our bread cards. How this happened, I don't know. My troubles did not end in anything. Alla asked: “Mommy, are we going to die now?” At the institute, I met an acquaintance, a regional committee worker, who suggested evacuating with the Krasny Vyborgets plant - it was already loading onto the train. So we evacuated. First in a train, then in a car full of people, along Lake Ladoga to some point, in order to continue further in the train, accompanying the FES guys.

These were dystrophic people who suffered from hunger diarrhea. They couldn’t do anything, they could barely breathe, there was no way to change them into dry clothes. And so we rode in the heated vehicles (on the upper shelves). Somewhere on the way to Sverdlovsk we were loaded into class cars. So we got to Sverdlovsk. The journey from Leningrad took 19 days. During this time I recovered and gained strength. But everything I experienced, both in Leningrad and on the way, shocked me so much that when I saw smiling people in Sverdlovsk, I was indignant: “How can you smile in such a terrible, hungry time.”

We lived in Sverdlovsk for several days, received food, until the opportunity arose to go further to my parents at Altaiskaya station. My father worked there on the construction of the Barnaul-Stalinsk road. They lived in a simple heated vehicle without amenities. There I left my 4-year-old daughter with my parents. I found it necessary to go to the military registration and enlistment office to ask to be sent to the front. It was 1942. I was not sent to the front, but was offered to work in the evacuation hospital -3727, located in the village of Troitsky, Altai Territory.

Lidia Pavlovna, how did you come to the conclusion that the grandchildren of blockade survivors suffer from chronic diseases more often than their peers?

Initially, I studied the health of adults who survived the siege of Leningrad as children. And in 1989 I saw archival documents, some of which none of the researchers had seen. In 2002, she defended her doctoral dissertation on the topic: “Peculiarities of somatic diseases in people of older age groups who survived the siege of Leningrad in childhood.” One of the research methods was a survey of more than six hundred blockade survivors who came to see me at city clinic No. 112. Among the large number of questions was a question about the health status of my grandchildren: did they have established chronic diseases, were they hospitalized because of them. After analyzing the results, it turned out that 30% of the grandchildren of the blockade survivors already suffer from chronic diseases, and in the comparison group this percentage was two times lower. At the same time, children of blockade survivors did not differ significantly in health from children born in families from the comparison group.

- Why did they start studying the health status of the siege survivors and their descendants so recently?

Until the beginning of 2000, the structure of official reports on morbidity and mortality of the population of St. Petersburg did not include such a social group as “blockade survivors,” so there was no accurate information necessary for the study.

- What are you going to find out in your new work and how will you carry it out?

I want to find out why the grandchildren of the siege survivors suffered more, and why they were the ones who suffered. The fact that grandparents who experienced hunger in childhood largely determine the health status of their grandchildren was already known before my research using the example of 5 month-long famine in Holland (1944-1945). In collaboration with biologists, I want to conduct genetic and morphological studies. I intend to collaborate with scientists from our city and Novosibirsk. We hope to receive a grant to conduct research.

- How did the blockade past affect the health of St. Petersburg residents in general?

Women who survived the siege of Leningrad as children develop diabetes more than 8 times more often than the comparison group. They are more likely to suffer from obesity and arterial hypertension; for example, women who were under 12 years old during the blockade are more likely to develop arterial hypertension. Male blockade survivors are more likely to have severe atherosclerosis of the coronary arteries and gallstone disease is more likely to occur, but they are diagnosed with arterial hypertension, obesity and diabetes mellitus with the same frequency as in the comparison group. That is, fasting affected boys and girls differently. I believe that these differences arise from differences in the critical developmental periods of boys and girls. At the same time, there are common weaknesses - early development and severe course of aortic atherosclerosis, kidney damage.

It also turned out that if, in general, residents of St. Petersburg are more likely to have ischemic strokes, then blockade survivors are more likely to have hemorrhagic strokes. I believe this is due to the excessive use of table salt in the besieged city - there was enough of it.

- How many days of fasting cause irreparable harm to the body?

Complete fasting for more than 72 hours is already considered long-term and causes a number of changes in the body. Longer periods of fasting result in profound metabolic and homeostatic changes in the body both during and after fasting. For example, children who found themselves in besieged Leningrad at the age of 2-3 stopped walking, talking, and many stopped smiling.

I found out what seemed like a paradox: children who survived the siege of Leningrad were more likely to remain in secondary school for the second year, but at the same time they more often received higher or secondary specialized education and became more successful than their peers. What is the reason? The fact is that after the blockade, the state paid great attention to the health of children who survived in the besieged city, for example, special rehabilitation programs were created, forest schools operated, where children not only studied, but also improved their health. However, in adulthood, former minor residents of besieged Leningrad developed chronic diseases earlier, and they more often retired due to illness and received a disability group earlier. Thus, prolonged fasting affected not only the physical condition of children, it largely determined the state of their health in subsequent adult years of life, since hunger is a powerful factor that changes the regulatory systems of the body. For example, after the blockade, many women of childbearing age returned to normal body weight through obesity, gaining up to 40 kg of adipose tissue.

During the hungry winter of 1941-1942, many Leningrad women did not have periods: the body tried to survive, trying to adapt to extreme conditions. However, from August to December 1942, children were born in the city every month, although there were very few of them: 291, 108, 59, 62, 99 newborns, respectively (for comparison: a year ago, about 5,000-6,000 babies were born in the city every month ).

Hunger was imprinted in people's minds and became their main fear - the blockade survivors with whom I spoke always had food supplies at home, and in the 1990s, during privatization, they invested their vouchers in shares of food enterprises - "Doc-bread", "Petmola", etc.

Now I don’t understand why people are considered blockade survivors only if they stayed in besieged Leningrad for at least four months. There is no medical explanation for this. Every day of fasting caused irreparable harm to the child’s body. Few of those born at the end of 1943 - January 1944 still live in our city. They, Leningraders, were born in a besieged city, but they are not residents of besieged Leningrad. This is the paradox of paradoxes. Now they do not have the official right to be treated in a hospital for survivors of the siege or in a hospital for war veterans.

- If even three days of fasting in childhood can have long-term consequences, how the hungry nineties can affect the health of Russiansyears?

According to experts from the World Health Organization, in the 1990s, every third Russian child under two years of age went hungry. According to the Russian government, only 10% of schoolchildren received hot meals; our children’s diets provided only 20-40% of the total need for vitamins and 70-90% of the need for protein and energy. And this is only officially recognized data. It can be assumed that after some time in our country there will be unfavorable changes in the structure of morbidity and mortality of the adult population due to hungry childhood in the 1990s.

Doctor Peter

Diseases of besieged Leningrad

Yesterday we celebrated the 69th anniversary of the lifting of the siege of Leningrad; day 872 was the last day of hunger for most residents. From September 8, 1941 to January 27, 1944, Leningrad doctors, like everyone else, dying of exhaustion, did not leave medical work, learning a new specialty on the job, because almost all nosologies underwent significant changes and long-forgotten diseases appeared.

After only two months of the blockade - by November 1941, more than 20% of inpatients suffered from nutritional dystrophy, by the new year of 1942 - 80%, in March cases of scurvy began to be detected, already in May there were tens of thousands of scurvy patients. Tuberculosis, typhus, dysentery and infectious hepatitis were a real disaster, not only because there was no specific treatment, hunger led to an atypical course, however, mortality from infections was low.

During the entire blockade, as a result of bombing and shelling, 50,529 people suffered from shrapnel wounds, of whom 33,728 survived. The average duration of treatment for the wounded was 28 days, the percentage of deaths in surgical hospitals was low, the majority of the wounded recovered, the maximum mortality rate was 20%. recorded in the first half of 1942, which was explained by the large number of patients with nutritional dystrophy.

The number of domestic and industrial injuries has increased due to the involvement of children and adolescents in labor, who fell asleep from fatigue and, due to hunger fainting, fell into working mechanisms. Local sanitary units were created with a wide network of medical stations and sanitary posts, a medical post with a sanitary worker was allocated for 200-300 labor army soldiers, a post with a nurse served 500-600 people, a medical station - 1500-2100. One sanitary doctor had to serve up to 3-4 thousand home front workers.

Chronic diseases did not go away, but hospital treatment was available only in extremely severe cases, which created the illusion of a sharp decrease in, for example, rheumatism. During the blockade, diseases such as myocardial infarction, diabetes mellitus, thyrotoxicosis were noticeably less common; appendicitis, cholecystitis, and gastric ulcers were practically not observed. As a result of exhaustion and edema, ulcers of the lower extremities were extremely extensive, with necrosis and infection, often leading to death.

In the structure of morbidity in 1942 -1945. An increase in cardiovascular diseases was noted, but the increase in the number of patients manifested itself to a greater extent not during the period of the most severe famine, but much later. During the blockade, severe angina pectoris was detected, possibly due to the mobilization of internal resources “for victory”; mild variants were not noticed. But mental disorders, on the contrary, increased; in 1942, 7,500 people were treated in two operating psychiatric hospitals.

In the spring of 1942, an acutely developing form of hypertension sharply increased; ophthalmologists were the first to identify it; since 1943, a significant increase in hospitalizations was noted. Immediately after the end of the war and 5 - 10 years later, cardiologists Z. M. Volynsky and I. I. Isakov examined 40,000 Leningrad residents. The incidence of hypertension among front-line soldiers was 2-3 times higher, among those who survived the blockade without dystrophy - 1.5 times, and after nutritional dystrophy - 4 times.

During the blockade, as a result of 226 air raids and 342 artillery shelling, almost 37 thousand hospital beds were lost, 136 employees were killed, 791 were wounded and shell-shocked.

Dedicated to the 71st anniversary of victory in the Great Patriotic War

Years and decades have passed since the end of the Great Patriotic War. Looking back at those difficult and heroic years, you clearly understand that the Great Victory was, on the one hand, the result of a single national feat, on the other hand, it was formed, like a mosaic, from the daily conscientious work of each person in accordance with his professional and military duty. This is the work and feat of the military on the battlefields, specialists who worked in the rear to support the army, people of all ages and professions who directed their strength and capabilities both to fight the enemy and to preserve the health and vital activity of the people who found themselves in the extreme living conditions of the military time. It is known that during such periods, children are one of the most vulnerable categories of the population, and protecting their health and life became the primary task of pediatricians during the Great Patriotic War.

Undoubtedly, one of the most heroic pages in the history of Russian pediatrics should include the work of pediatricians during the siege of Leningrad. The extreme conditions in which ordinary people unexpectedly and unexpectedly found themselves - residents of the heroic city of all ages, including infants, premature, chronically ill children, as well as medical workers - pediatricians, health care organizers, nurses, etc., abandoned both, it seemed , an insurmountable challenge, the main meaning of which was, in fact, to solve a single question: “Is it possible to survive and maintain living conditions compatible with life for the most vulnerable groups of the population - children?” And now, when the years of the siege have turned for us into the heroic past of the city of Leningrad-Petersburg, it is quite obvious that medical workers fearlessly accepted this challenge, combining intellectual, mental, physical strength and building, perhaps, the strongest line during the war years, which protected many children life from death due to hunger, cold and infectious diseases. A deep study and understanding of the work of the pediatric service of that period is extremely important from several points of view. Thus, practical assistance to children was provided by pediatricians and other medical workers in conditions of high staffing of children's medical institutions, the work of which was organizationally restructured to optimize its results in the changed conditions of wartime. The leaders and ideologists of pediatric care were professors and teachers of the Leningrad Pediatric Institute, who, along with direct participation in the treatment process, carried out an analysis of the health and morbidity of children, scientific research in the field of dietetics, protection against infections, and the possibilities of physiological development of children in changed living conditions. Also, training and raising the level of knowledge of young specialists was constantly carried out. Thus, scientists and doctors of besieged Leningrad carried out a huge amount of work of a clinical, organizational, research, and educational nature. Its results made it possible to save the lives and ensure the development of a large number of children, and also constituted a unique experience in the work of pediatric services in extreme conditions. This experience is undoubtedly a tribute to the heroic people who fought for children's lives during the war. But this experience is also an important scientific and practical heritage, the analysis of which should become the basis of “extreme pediatrics.” This publication describes the most important, in the author’s opinion, aspects of providing assistance to children during the blockade with a special emphasis on nutrition, since it is known that hunger and nutritional dystrophy were the main life-threatening factors of that period.

Experience of providing care to children of all ages by a single pediatrician

During the years of the blockade, a reasonable reorganization of the pediatric service was carried out, which was dictated by the changing living conditions of the population. Thus, in 1942, a decision was made to provide services to the entire child population aged 0 to 16 years by a single pediatrician. The prerequisites for this decision were the following points: the evacuation of the child population sharply reduced the population density in the areas, increasing them spatially; families demanded unified service, unified deep care, just as the method of advisory work - preventive patronage - needed to be introduced into work with older children. Thus, children's clinics that previously served young children were merged with children's clinics. At the preparatory stage, it was extremely important to resolve the issue of theoretical training of both medical and nursing staff to work with infants (care of a newborn, dietetics of an infant, features of diseases of children in the first year of life). The second point of the preparatory work was a general door-to-door census of the children's population by visiting nurses to identify the true number of living children, record their attendance at child care institutions, and distribute them according to the profile of the areas. United children's clinics and clinics provided consultations to unorganized children of all ages (from 0 to 16 years old), supervised medical work in organized children's groups (nurseries, kindergartens, schools, secondary educational institutions, orphanages), had connections with antenatal clinics and maternity hospitals, and district enterprises where teenage workers worked. Thus, as a result of the transition to service by a “single pediatrician,” the quality of both preventive and therapeutic work has increased. District pediatricians carried out continuity in monitoring children of all ages, had information about newly born babies, the health status of children of organized groups, and carried out dispensary observation of teenagers working at enterprises. The latter is even more important from the point of view that adolescence is associated with significant hormonal changes and an increased need for plastic and energy resources. An extremely important task was to ensure the completion of functional maturity and the formation of the reproductive capabilities of the adolescent body. A special section of the work has always been the organization of children's nutrition, and not only infants, but also all older children were assigned to receive dairy products in accordance with the recipe. Moreover, by decision of a special selection committee of the consultation/children's clinic, children 3-16 years old were sent to canteens for enhanced nutrition, where they were under constant medical supervision. Medical personnel were assigned to the canteens full time, and their responsibilities included not only in-depth control over the quality and quantity of products received by children, but also regular, twice a month, examinations with assessment of the health and changes in the weight of children, laboratory tests, including assessment hemoglobin level, etc. The canteen doctors also carried out all the necessary anti-epidemic measures. Thus, the tasks of the joint consultation-polyclinic had an extremely wide range, starting from antenatal care and covering all children's populations. Of particular importance to the work on the “single pediatrician” system was the fact that, based on information about all children living in the areas, it was possible to timely identify and supply children of older age groups with dairy products and additional nutrition. In general, such joint consultation clinics have become centers that organize and unite all medical and preventive services for the population aged 0 to 16 years, including the management of medical care in all children's institutions in the region.

Nutritional dystrophy in children

Life in Leningrad under the siege, accompanied by constant malnutrition, prolonged cold, physical and mental fatigue, inevitably had to affect the health and development of the children remaining in the city. According to Professor A.F. Tour, since the end of 1941, the bulk of patients passing through children's clinics and clinics were children with symptoms of nutritional dystrophy of varying degrees of severity. Starvation, which grossly disrupts all functions of the body at any age, has a particularly disastrous effect on the health of a child, since for children nutrition is one of the main factors that ensures the normal course of progressive processes - growth, physical and mental development. Chronic eating disorders are a well-known pathology of childhood, to which the chapters of the study of a sick child of an early age are devoted. The basis of nutritional dystrophy, regardless of the etiological factor, is always endogenous or exogenous starvation. The description of the clinical picture of a patient with nutritional dystrophy was figuratively given by Professor A.F. Tur, who had extensive experience in observing and treating this pathology. “The clinical picture of well-defined nutritional dystrophy in children is quite peculiar. Patients are lethargic, lie huddled and covered with a blanket; sometimes they are apathetic and indifferent to everything around them, in other cases they are irritable, capricious and do not allow themselves to be explored; They usually complain of feeling cold and hungry and can’t get warm and satisfied. In very severe cases, appetite disappears, children refuse to eat; Relatively often there is a need for salty or sour food, much less often - taste perversions. The skin is dry, pale, and often peels; the presence of hemorrhagic phenomena indicates an insufficient supply of vitamin C; dermatitis or pigmentation of the skin of the hands, feet and neck indicate pellagra. Mucous membranes are pale, somewhat dry, often with stomatitis or gingivitis (skorbut); In children without teeth, the oral mucosa, as a rule, does not suffer. Edema is an almost constant symptom in the clinical picture of nutritional dystrophy. The degree of swelling is very different, from slight puffiness to pronounced total edema (anasarca); sequence - first the face and feet, later - the legs, hands, torso. The swelling is soft, painless, and easily moves with the patient changing position. Hydropericardium and ascites are common. Mild and moderate edema sometimes go away very quickly with improved nutrition; severe edema can persist for a very long time even with a significant improvement in the patient’s general condition. The degree of swelling is not a significant indicator of the severity of the condition and does not predetermine the outcome of the disease. The rapid disappearance of severe edema is a prognostically unfavorable sign. Prolonged diarrhea, as a rule, increases swelling or contributes to its detection in non-edematous cases. Muscle atrophy is one of the earliest and most persistent symptoms in the clinic of child starvation. This is manifested by weakness in the legs, rapid fatigue when moving, and muscle atrophy smoothes out much more slowly than weight increases and the general condition of the child improves when nutrition is restored. In older children, intramuscular hemorrhages (vitaminosis C) are relatively common; in children of the first years of life they are relatively rare. Relatively often observed contractures of the lower extremities (the child walks on his toes) are a symptom of group B vitamin deficiency. Most children complain of pain in the bones of the lower leg, often worsening at night. With dystrophy, complications from the respiratory system are common - bronchitis, bronchopneumonia, exacerbation of the tuberculosis process. The cardiovascular system is noticeably affected: the percussion boundaries of the heart usually remain within normal limits or are even slightly reduced; the latter is observed especially often in children suffering from diarrhea and severely malnourished young children. It is much less common to observe an increase in cardiac dullness. Heart sounds are muffled, and functional murmurs are often heard. The pulse in young children is often increased, while in older children there is moderate bradycardia. Characteristic is pulse lability with frequent alternation of bradycardia and tachycardia. Blood pressure is reduced. From the peripheral blood - moderate hypochromic anemia; in many cases, true oligemia is masked by blood thickening. Relatively rarely, anemia reaches severe degrees and, according to bone marrow puncture, approaches aplastic. Always - anisocytosis and polychromasia, relatively rarely - poikilocytosis. The number of white blood cells is reduced, almost always - relative lymphocytosis, absolute and relative neutropenia. It should be noted that the leukocyte formula is extremely unstable in dystrophic children. With nutritional dystrophies in children, the function of the gastrointestinal tract is sharply disrupted. Very often one has to observe diarrhea; in some cases they are in the nature of enteritis, in others - colitis, more often we should talk about enterocolitis. The abdomen is moderately swollen, the abdominal walls are sometimes very tense. Abdominal pain is rare; acute abdomen must be excluded in rare cases. From the gastric contents - a decrease in general acidity and a decrease in the strength of enzymes. In stool there is almost always mucus, less often - blood. Bacteriological examination of stool in the vast majority of cases gave negative data regarding bacteria of the dysentery and paratyphoid group. From the urinary system, pollakiuria and nocturia should be noted. True polyuria occurs only during the period of subsidence of edema. Albuminuria is relatively common and passes quickly and without leaving a trace. Almost always there is a violation of the excretion of chlorides; in several severe cases, a picture of diabetes insipidus had to be observed. In children with nutritional dystrophy, the endocrine-autonomic system suffers greatly, which gives the right to talk about pluriglandular syndrome in the clinical picture of nutritional dystrophy in children (hypothyroidism, hypoadrenal function, hypogonadism). Body temperature is normal or low; in some cases, it was necessary to observe increases in temperature, for which it was not possible to find sufficient data in the clinical status of the patients. From the above it is clear how polymorphic the clinical picture of nutritional dystrophy in children is. It closely intertwines and cannot always be differentiated by the symptoms of simple exhaustion, vitamin deficiencies, the influence of the nature of nutrition, random infections, concomitant diseases, age and constitutional characteristics of the child.” This description of the clinical picture of nutritional dystrophy, based on extensive experience and careful observation of children with this pathology, was compiled by professors A.F. Tur and A.B. Volovik (Fig. 1).

Thus, realizing the full depth and severity of the consequences of starvation in childhood, it was necessary to find an answer to the question as quickly and effectively as possible: “How is it possible to organize nutrition for children of all ages, so that, in conditions of a sharp limitation in the supply and supplies of food products in a besieged city, the maximum possible meet the needs of a growing body in calories and basic ingredients?” The answer to this, at first glance, insoluble question was brilliantly found by a group of scientists led by Professor A.F. Tur, and practitioners led by the head of the dairy and food station of the Leningrad Pediatric Institute, Dr. S.I. Polyakova.

Operation of dairy stations in conditions of insufficient food supply

This section should begin with the fact that during the Patriotic War and the blockade of the city, the milk and food station of the Leningrad Pediatric Institute did not stop its activities for a single day, despite the great difficulties that arose in connection with the blockade (interruptions in the water supply, disruption of normal work of boiler and steam facilities, incomplete, unusual range of raw materials, difficulties with transport); all points and contingents of children attached to the station were fully satisfied with all types of mixtures. The dairy station had to first think and work on how to prepare mixtures from existing products without compromising the quality in terms of nutritional value, i.e. the content of proteins, fats, carbohydrates, their calorie content and corresponding taste. To solve the assigned problems, the station staff carried out a number of experimental brews in a laboratory setting. In addition, given the scarcity of certain types of raw materials, all children under 3 years of age were divided into three groups: from 0 to 5 months, from 5 months to 1 year, and from 1 year to 3 years. This differentiation made it possible for a very early age to select semolina for the preparation of 5% porridge using the most complete varieties of milk. When the percentage of fat in milk was low, 10% cream was added to the porridge. The amount of milk entering the station often determined the technological process of preparing porridge. When there was a sufficient supply of milk, porridges were prepared with whole milk. When there were interruptions in the supply of milk, the calorie content of the porridge was covered mainly by adding butter. The question of what could replace cow's milk for preparing baby food was quite serious. The shortage of cow's milk was especially acute in the winter months of 1941/1942, when the lactation capacity of mothers dropped to a minimum and almost all infants were bottle-fed. The Executive Committee of the Leningrad City Council provided all possible support; the reserves of powdered milk and condensed cow's milk available in Leningrad were used; Soy milk was also widely used in the diet of children. Employees of the First Dairy Plant persistently sought and achieved improvement in the quality of soy milk produced, and employees of the Leningrad Pediatric Institute (Professors Tur, Lukyanchikova, Doctor Polyakova) developed issues of rational use of soy milk, in particular, recipes for preparing medicinal mixtures from soy milk and condensed cow's milk: buttermilk, protein milk, yogurt, kefir, fat mixtures. When making mixtures, it was often necessary to prepare the same mixture from several types of milk - soy, sweet, malt, reconstituted. So, for example, the “protein milk” mixture was prepared as follows: the cottage cheese included in the mixture was prepared from soy milk, while all other components - skim milk (churning) - from sweet or reconstituted milk. For churning, skim milk was, in turn, prepared from sweet milk, adding partially reduced milk to it. Practice has shown that when making different types of curdled milk (plain, acidophilus and Bulgarian) from sweet milk, the culture for fermentation is consumed twice as much, since sweet milk contains a larger amount of carbohydrates, which have a depressing effect on the growth of lactic acid streptococcus. Also, observations have shown that to prepare calcium curd from sweet milk, less calcium chloride is required than when made from natural milk, namely 0.7% instead of 1%, and for soy and reconstituted milk - 1.5%. In the technology of preparing decoctions and mixtures, some rationalization measures were applied. Thus, mixture No. 2 began to be prepared from sweet or reconstituted milk without the addition of soy and malt milk and to provide this mixture to children in the first six months of life, premature and seriously ill children. At the same time, mixture No. 3 was prepared in combination: part of the broth, part of the sweet and part of the soy (or malt) milk, adding reconstituted milk or cream. Repeated checks of the ingredients and calorie content of physiological mixtures in the laboratory showed that their content is almost close to the norm of pre-war times. Thus, they tried to feed children in the first six months of life with formulas without the addition or with a low content of soy milk, while children older than one year received reconstituted cow's milk or malt (soy) milk enriched with it, as well as soy kefir that was satisfactory in taste. When producing the mixtures, the tastes of children and their attitude towards the products offered were taken into account. Thus, in an effort to improve the taste of the product, instead of soy kefir, which children often refused, a recipe for “tvoris” was developed, which was made on the basis of kefir: chocolate - 20 g, concentrated rice - 40 g, kefir cottage cheese - 40 g, sugar - 10 g, whey from sweet milk - 20 g. From 1 liter of kefir, 330 g of curd was obtained.

Thus, by providing differentiated mixtures in different age groups, experimentally developing mixtures equivalent in calorie content and ingredients, using soy and malt milk in older age groups of children, improving the taste of dairy products, as well as the continuous dedicated work of all employees of the dairy and food station The main goal was achieved - maintaining children's nutrition at a certain quality, almost pre-war level. The scale of work of the dairy station during the blockade can be characterized by some statistics: during the war, 487,132 portions of all products were supplied. Compared to the pre-war period: if before the war mixture No. 3 was prepared at 90-100 l/day, then during the war it was prepared at 1500 l/day; porridge was prepared in pre-war times at 30-40 l/day, during the war up to 500 l/day. The employees of the dairy station actively and systematically passed on their experience to other medical institutions, training nutritionists in dairy kitchens and doctors serving nurseries in the city.

Principles of therapeutic nutrition for nutritional dystrophy

There is no doubt that the main and decisive method of treating nutritional dystrophy in children is the correct diet, strictly individualized depending on the age of the child, the degree of exhaustion, the nature of fasting, concomitant diseases and complications. We present some recommendations made by Professor A.F. Tur based on his own experience in treating children with nutritional dystrophy. At the start of prescribing nutritional therapy, it is recommended to assess tolerance to food load. This is especially important in the treatment of severe grade III dystrophy. Thus, in the treatment of nutritional dystrophy of the third degree, but without significant swelling and diarrhea, during the first 2-3 days a limited diet should be prescribed, easily digestible, mechanically and chemically gentle, mainly liquid and semi-liquid. Meals are frequent, 5-6 times or more often. In the first days of treatment, until the patient’s tolerance for proteins and fats is determined, overload with these ingredients should not be allowed; the amount of carbohydrates can be quite large. Prescribed per 1 kg of patient's weight: proteins 1.0-1.5 g, fats no more than 1.5 g, carbohydrates 10-12 g. From the first days of treatment, food should contain a sufficient amount of vitamins. For this purpose, patients were prescribed an infusion of pine needles, fish oil, and vitamin concentrates, even in the absence of obvious signs of hypovitaminosis. After 1-2-3 days, if the patient coped well with such a limited diet, he was transferred to a full diet: per 1 kg of weight up to 2.0-2.5 g of proteins, the same amount of fat and 12-14 g of carbohydrates. This diet option should not provide mechanical sparing of the intestines. Considering the somewhat capricious appetite of dystrophic children, it was recommended to include herring, sprat, roach, etc. in the diet. For less malnourished children (I-II degree of dystrophy), this diet can be prescribed from the 1st day of treatment. If after 8-12 days the child’s weight did not begin to increase regularly, then it was recommended to prescribe an enhanced diet rich in complete proteins and fats. This diet contained up to 4.0-4.5 g of protein, about 4.5-5.0 g of fat and 12.0-15.0 g of carbohydrates per 1 kg of weight. The calorie coefficient for such a diet was 100-200 kcal or more per 1 kg of weight. The diet was enriched with vitamins and mineral salts. For dystrophy with edema, but without diarrhea, the same diet was recommended, since dry eating and a salt-free diet are unnecessary and can be harmful. Some restriction of fluid and salt was recommended only for very severe edema. At the same time A.F. Tur specifically emphasized that the presence of a moderate amount of protein and leukocytes in the urine should not be a reason to limit animal proteins in the diet. For diarrhea in dystrophic children, strict individual diet therapy was required. In the first days of treatment, a food regimen indicated for acute gastritis and gastroenteritis was prescribed. After a few days, without waiting for a sharp improvement or complete disappearance of the dyspeptic syndrome, the children were gradually transferred to a fairly nutritious diet by increasing the amount of proteins, fats and carbohydrates, free from a significant amount of fiber and other gross residues. In case of diarrhea, special attention was paid to the restoration of hypo- and avitaminosis. In addition to dietary nutrition, in the treatment of nutritional dystrophy it was extremely important to create physical and mental rest, warm the patient and constantly maintain the temperature; Hot food was also recommended, and black coffee and wine were allowed for children.

Testimonies of medical workers - eyewitnesses who took part in saving the lives of children of besieged Leningrad

Immersing yourself in the study of the historical evidence of those years that has survived to this day, you understand that the activities and actions of both medical workers and other people who cared about preserving the health and lives of the children of besieged Leningrad undoubtedly went beyond the limits of human capabilities in normal peacetime conditions. . However, it is an obvious fact that incredible difficulties and inhuman trials have united the ranks of pediatricians, discovering, perhaps previously unknown to them, physical, personal, characterological qualities and properties aimed at fulfilling their professional duty and making them unbending on this difficult and long path. One of the first to resume its meetings in Leningrad was the Society of Children's Doctors, headed by professors Yu. A. Medeleva and A. F. Tur. The society's meetings were held weekly, the interest in them was great, and the auditorium was always filled. Professors A. B. Volovik, A. N. Antonov and many others took an active part in the work of the society. The children's network was fully staffed, but the presence of a large number of young doctors and nurses required continuous work to improve their qualifications. In 1942, in conditions of insufficient nutrition, unheated classrooms, and frequent shelling, the Pediatric Medical Institute organized advanced training courses for young doctors. To judge the situation in which the classes took place, it is worth mentioning the following eyewitness accounts: Professor Danilevich had to complete one of his lectures in a dark trench, where the cadets went during an air raid raid and where they continued to listen to the professor with great attention. According to the testimony of the deputy head of the Leningrad City Health Department for Child Protection, Associate Professor S.I. Volchok, in the harsh winter of 1941/1942. “The number of children left by their mothers in nurseries and kindergartens around the clock reached 70%. The staff of the nurseries and orphanages worked so selflessly that at times one could forget that we were living in besieged Leningrad. The premises of the nursery were warm, clean and comfortable. Additional difficulties were overcome by the dairy kitchen staff. Due to a lack of gasoline, milk could not be delivered to dairy kitchens in a timely manner, and it had to be delivered on skids or carts; The lack of fuel, electricity, water and utensils created enormous difficulties with boiling milk and preparing infant formula. But the dairy kitchen workers overcame these difficulties: they themselves brought water, provided the kitchens with fuel, dismantling wooden houses intended for scrapping; they brought this fuel themselves; They themselves delivered food from the bases and, as a result, ensured that the dairy kitchens operated uninterruptedly” (Fig. 2 (A, B)).

The unique experience of organizing the work of the departments of the physiological hospital for young children and the department for premature babies of the clinic of the Pediatric Medical Institute under conditions of war and blockade was described and analyzed by Professor A.F. Tur. Thus, due to the increasing frequency of air raids, from November 20, 1941, for almost six months, children from early childhood departments were transferred to a bomb shelter for permanent stay. “The conditions of the bomb shelter left much to be desired: there was about 1.8 square meters per child. m of floor surface and approximately 3.4 cubic meters. m room volume; the only lockable manhole window could only be used to ventilate the room on those days when it was not very cold outside and the children were taken out for a walk. The air temperature was maintained within 12-15 degrees. Dampness began to develop relatively quickly. To this it should be added that there was no separate potty area, there was no running water or sufficient warm water, and there was nothing to think about using any additional playpen space during the children's waking hours. However, working in such conditions, we set ourselves the task of not only preserving the life and health of children, but also achieving the possible normal physical and psychomotor development,” wrote Professor A.F. Tur in his memoirs. To achieve this goal, a set of measures was carried out, the mention of which is of undoubted interest. Thus, the total daily duration of sleep was increased by 1-1.5 hours, which ensured savings in energy consumption. The children of the older group were switched to a regime with one daytime nap, while the younger group spent the entire winter and spring on a regime of three daily naps lasting 2 hours with 2-hour intervals of wakefulness after each feeding. The lack of a playpen and walking area, which made it difficult to organize the normal wakefulness of children, forced the widespread use of playpen boards. 2-3 children were placed in such a playpen bed, with whom classes were organized. The systematic use of massage and gymnastics did not stop. The harsh winter of 1941 made it difficult for children to walk, and ventilation was dangerous due to the risk of weakened children catching a cold. A thorough analysis of the children's regime deserves deep respect. Thus, Professor A.F. Tur provides data that for the entire period from November 20, 1941 to April 1, 1942, children walked for 65 days, slept with the window open for 26 days, and remained without a walk and slept with the window closed for 41 days; Since April, the children have been walking every day. To ensure the possibility of proper mental and motor development in a dark bomb shelter, the children of the older group were transferred to prolonged wakefulness in the interval between 15 and 19 hours, when there was light in the bomb shelter and classes were possible. The nutrition of children was of enormous importance. According to Professor A.F. Tour, in October and November 1941, the children’s diet differed little from the usual diet in the infant department; in December, children began to receive fewer vegetables, rice was rarely given, and oatmeal predominated. From the second half of December, black bread and bread casseroles had to be included in the children's menu; The quality of the bread left much to be desired. The menu became more and more monotonous, flour rye porridge, black bread and bread casseroles predominated. During this period, children in the older group received almost no whole milk; porridge, most often buckwheat, was prepared in water, butter and sugar were added, and in the evening the children received soy milk or formula No. 2. Approximately from the second half of February, the supply of milk improved, which made it possible to prescribe some kind of milk formula at least 1-2 times a day and children of the older age group. In March, the food supply improved significantly, the supply of butter increased, cheese and eggs were available from time to time, children regularly began to receive white bread, and meat was available more often. Throughout this difficult period, the children regularly received vitamin juices prepared in the summer and autumn by the staff of the pediatric institute. Was the goal achieved? Here is how Professor A.F. Tur answered this question in his scientific publications: “Of the 27 children transferred to the air-raid shelter, five died due to the addition of infectious diseases, one was taken by the mother, and the remaining 21 children were healthy; 16 of them could well be classified as eutrophics; four children had very mild malnutrition and one child had grade II malnutrition. A detailed analysis of the developmental characteristics of each child showed that body weight and length increased regularly all the time, however, assessment of perimeters and anthropometric indices indicated slight deviations towards a decrease in fatness. Signs of rickets occurred in most children, but its manifestations were no more pronounced than among Leningraders of this age in general; not a single child had noticeable deformities of the limbs, chest or skull. Contrary to expectations, the quantitative and qualitative composition of red blood remained almost unchanged during the period of life in the bomb shelter. More than normal results were also obtained for the children's motor skills. In 7 children, motor skills were completely normal; they walked on a smooth floor; 11 children had moderate delays in motor skills from the norm, and only three children had a more or less significant delay in the development of motor skills, and two of them had congenital developmental anomalies. As for the premature babies who received treatment and care in the clinic of the Pediatric Institute, it should be noted that out of 34 premature babies aged from 7 days to 4 months who were in the department at the beginning of the war, only one died, even before moving to the bomb shelter. As for the rest, they were in quite satisfactory condition after many months of living in a bomb shelter and were discharged home or transferred to other children’s institutions.” The situation was different with premature babies admitted to the clinic in the coldest months. They arrived very cold, with symptoms of scleredema, and often already suffering from pneumonia. Of 15 such children, only one survived, the rest died, while, as Professor A.F. Tur emphasized, the main cause of death for such children lay not so much in their congenital inferiority, but in maintenance defects, such as poor nutrition and extreme cold, in the first hours and days after birth.

Thus, despite the enormous difficulties associated with the war and the blockade, the Leningrad pediatric service lived and worked in extreme conditions, saving not only lives, but also fighting for the physical and mental development of children close to normal. Answering the question of what underlay and helped to achieve such results, it seems most correct to quote Professor A.F. Tour, who can rightfully be considered not only a great specialist in pediatrics and nutrition in peacetime, but also an ideologist of pediatrics during an extreme historical period, which includes the years of war and blockade: “What means and measures did we use to achieve these, in our opinion, quite satisfactory results? The first and most important thing is the impeccably dedicated, conscientious and loving attitude of all staff; without this it would be impossible to achieve more or less good results. The second is the correct construction of a child’s lifestyle and upbringing in relation to unusual living conditions, with fairly strict consideration of the individual characteristics of each child. Third, and very important, is proper, strictly individual nutrition for children.”

Years and decades have passed, generations have grown and changed. Scientists today continue to study the health of people who survived the siege and the health of their descendants. We still have to learn and analyze quite a lot of important and interesting observations. However, the selfless and heroic work of pediatricians, scientists and practitioners who fought for children’s lives in besieged Leningrad is a unique scientific heritage that laid the foundations for pediatrics in extreme conditions, and at the same time a symbol of almost limitless human capabilities on the way to achieving this goal.

In preparing this article, materials from the Russian National Library and the State Memorial Museum of the Defense and Siege of Leningrad were used.

Literature

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I. L. Nikitina, Doctor of Medical Sciences

FSBI Northwestern Federal Medical Research Center named after. V. A. Almazova Ministry of Health of the Russian Federation, Saint Petersburg