MATERNITY HOSPITAL REPORTS

As everybody knows, figures can be manipulated to prove anything, even the impossible. Nevertheless, an honest analysis of the results obtained in a large series of cases is of considerablc value. Some complications are of such frequent occurrence that a single observer may, from his own experience, form accurate conclusions, but for the study of the rarer abnormalities it is essential to supplement a limited personal knowledge by combining the published results of several workers. To facilitate this object, a special scheme for the Unification of Maternity Hospital Reports was drawn up some years ago, and the majority of institutions agreed to adopt it. For a time they did so, but of late there has been a tendency for the compilators to depart from it. As a rule they have not improved upon the original, and even if they had, they have defeated the primary object. Hospitals in which a large number of abnormal cases is dealt with are inclined to frame their reports in such a way as to emphasize this fact, whereas others in which few complications are encountered axe tempted to modify the arrangement of their reports to illustrate some point which they believe to be of interest. But it matters nothing a t all that one institution treats five times as many cases of contracted pelvis as another, that a third admits patients from a restricted area, while in still another practically all the patients are “booked”. What does matter is that the experience of all be made available for everyone by uniformity of reporting.

We understand that the British College of Obstetricians and Gynae- cologists is engaged in drawing up a case-sheet on which to report cases treated at Maternity Hospitals and Maternity Departments of General Hospitals. We sincerely hope that this case-sheet will soon be forthcoming, and that the Chiefs of Departments will personally insist on their Registrars using such a case-sheet, and not, as heretofore, being merely satisfied with their own approval of such a case-sheet.

University College Hospital, London REPORT FOR THE YEAR 1935.

THIS report has been prepared with great care, and the facts are presented in great detail. But the Committee’s scheme has not been followed and the value of the report is correspondingly reduced. For some reason not stated the Registrar has introduced a group of “referred” patients, in addition to the agreed classification into ‘ ‘booked” and “emergency” cases. There is no justification for this increased complexity. The total number of patients is small, and very few abnormalities are encountered among them.

This passion for subdivision is evidenced in other directions. Four degrees of placenta praevia are described, although there are only 14 patients

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of this type. If the new classification were good we should welcome it, but in our opinion it is not. Again, there are 128 subdivisions in the table giving a few facts regarding 71 cases of abortion, and no fewer than 63 of the pigeonholes are blank. The methods of anaesthesia and analgesia employed in the different types of case are set out in a table of 138 sub- divisions which is disagreeably reminiscent of permutations and combina- tions. It conveys nothing to the reader and apparently almost as little to those who laboriously compiled it, for the only comment which they add is the simple remark that “in no case did the anaesthetic appear to have any deleterious effect on the mother or child.”

In the gynaecological part of the report the reader is again given much meaningless information, when a less detailed statement of the facts would have served the purpose. We are not told, for instance, that 59 cases of prolapse were treated during the year: we have to add up 59 separate items for ourselves. Yet serial numbers which we cannot use are supplied profusely as follows :

“ 2. Prolapse.

tion of cervix, Z17, 254, 291, 2102, 2116,” and so on. “Anterior colporrhaphy , posterior colpoperineorrhaphy , and amputa-

It is a pity that so much careful work should be wasted in this way, and the reviewer regrets the necessity of devoting so much space to criticism of a report which has been prepared with such diligence. But minute tabula- tion, unaccompanied by a clear summary of the main facts, merely leads to confusion. We are of the opinion that the majority of readers will refuse to take the trouble of resolving the extended tables to a simpler form and will put this report aside unstudied.

Maternity Department of Guy’s Hospital REPORT FOR THE YEAR 1935.

“IN this report the classification has followed the lines adopted in the reports for previous years, and the reasons for departing from the classification recommended by the Sub-committee for the Unification of Reports of Maternity Hospitals remains the same. . . . It has been found impossible to give any useful classification on the basis of ‘ booked ’ and ‘ emergency ’ cases, since practically all cases belong to the first class.” So the Registrar explains in the introduction. The argument does not appear to us to be very convincing, for, so far as we can see, the matter would not be impossible. All that would result from following the recommended scheme is that one group would be large and the other small. But the data could be used in conjunction with the results from other institutions, whereas the figures in their present form are of no use to anyone.

The report as such has been reasonably and accurately compiled, but the abnormalities are so few in number that there is no need to discuss the findings. It seems strange, however, in view of the comparatively simple nature of the cases, that fully g per cent of them should have had a post-

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partum haemorrhage. Incidentally, there is some dubiety as to the actual number, which is given as IIZ on page 6, and as IOI on page 19. From the detailed table we find the number to be 115, or a t least it is so if we correct the faulty addition in the second column.

Liverpool Maternity Hospital REPORT FOR THE YEAR 1935.

OF the 4,080 patients attended by this hospital, 2,416 were treated in the wards, and with these patients the report deals in detail. The proportion of abnormal cases is high, and the reader will find the data of much interest. Particularly satisfactory are the tables on cardiac disease, albu- minuria, antepartum haemorrhage, and induction of labour.

Forty-one cases of heart disease were treated, and although many of them were obviously of a severe type, only one ended fatally. Caesarean section was chosen as the method of delivery in 16 of them, hysterectomy was per- formed on two occasions, while abortion was induLed in one case by means of X-rays. The results in the g o cases of albuminuria are equally good. Only one mother died, and i t would have been surprising had she recovered, since she suffered from a severe degree of nephritis and a super-added pyelonephritis. There were only three cases of pernicious vomiting, but one of them is most interesting. Her history and treatment are reported in full, the unusual feature being the successful employment of decapsula- tion of the kidney in overcoming an almost complete anuria. Another series of cases reflecting great credit upon staff is the group of 13 patients in whom the placenta was removed manually. There were no maternal deaths, and only one patient developed pyrexia. It is instructive to note how long the placenta was allowed to remain in the uterus before extraction. In one instance the interval was 54 hours.

A special section of the report deals with infant mortality, clinical causes oE death, post-mortem findings, congenital deformities, birth injuries, diseases of the newborn, infant feeding, prematurity, and abnormally large infants. This portion is very good indeed. It does not lend itself to summary, but it will repay a most careful study.

In view of the general excellence of the report it seems almost ungracious to draw attention t o some minor slips which mar its perfection. There are, however, a number of arithmetical errors, and inattentive proof-reading has allowed several mistakes in the spelling of technical words to pass uncorrected.

The Princess Mary Maternity Hospital, Newcastle REPORT FOR THE YEAR 1935.

DURING the year under review approximately 2,500 patients were treated in this hospital. Over 1,000 cases were admitted as emergencies, and in many the complications were of a severe type and of extreme degree. This i s evidenced by the summarized case-histories and by the foetal death-rate

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in abnormalities such as accidental and unavoidable haemorrhage. The standard of obstetrics in the surrounding district would not appear to be very high, as no fewer than 38 cases were sent in to hospital after failure to deliver with the forceps. I n this group the over-all maternal mortality was 22 per cent, and the foetal mortality over jo per cent. The hospital staff in such circumstances must undoubtedly work at high pressure, and this may explain the incompleteness of the records which is apparent in certain sections of the report. For instance, the blood-pressure is not recorded in several of the albuminuric patients, and the amount of albumin is indicated as +, + +, + + +, solid, or trace, and never as so many parts on the Esbach scale. Forty-three cases of eclampsia occurred during the year, and of these three were “booked” cases. In the foreword it is stated that “two of them died, and from their histories it is evident that antenatal care could not have saved them.” Unless the history given omits one very important item, then this assertion cannot be held as proved. One of the two patients attended the antenatal clinic five days before admission. The urine did not contain any abnormal constituent, and the patient did not have any toxic symptoms. She was perfectly well until nine hours before admission . . . etc. . . . So far so good, but it is not stated in the report that her blood-pressure w@s taken at the t ime of her visit.

Thexe is nothing of special note in the rest of the report, except that it is somewhat curious to find vaginal sepsis, pelvic cellulitis, perineal sepsis, uterine sepsis, pelvic abscess, salpingitis, phlegmasia alba dolens, mastitis, and breast abscess, included under the heading ‘non-morbid conditions”. In calculating the percentages of the foetal deaths the Registrar frequently omits to make allowance for the fact that some of the patients in a given series are not delivered, while others have twins. Apart from this oversight the report is well drawn up.

County Borough of Croydon REPORT OF THE COUNCIL’S OBSTETRIC SERVICE FOR 1935.

“The obstetric scheme in Croydcn is perhaps the most complete of any of the schemes conducted by local authorities. It aims at the ideal of complete antenatal, natal, and post-natai medical supervision under the same whole-time medical officer. The antenatal clinics, Mayday Hospital, and St. M q ’ s Maternity Hospital are all links in the chain, working with one another under the clinical guidance of the specialist Assistant Medical Officer of Health for Obstetrics.” Detaiis are given in the appendices of the organization of the clinics, of the management of the two hospitals, and of the different methods of staffing them. These notes should be of much interest to all who have to organize a similar service.

Apparently the arrangement works well in practice, for the results obtained are vexy good. These results are fully set out according to the scheme for the Unification of Maternity Hospital Reports, and those who believe that the special conditions prevailing in their particular hospital

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preclude the use of this unified plan, should reconsider their attitude when they find that the scheme can be adopted with perfect satisfaction to embrace the work carried on by the Croydop service.

The report itself is carefully compiled, and the completeness of the iables shows that the record-keeping in both the antenatal clinics and in the hospitals is unusually efficient. A special set of tables has been devised lor the septic cases. These are excellently conceived and might well be copied by other registrars. Curiously enough, although this report is issued by a Public Health Authority, the standard of puerperal pyrexia employed is not that of the Ministry of Health. And here we may remark that in the five reports reviewed above four different standards of morbidity have been used.

John Hewitt.