OBSTETRICS UNDER DIFFICULTIES
1
880 wrecked men. They emphasise the need for ensuring that life-craft are launched, and that men succeed in boarding them. McCance et al. analysed the effects of many factors influencing the chance of survival in life- craft. The most important was the temperature. On seas below 5°C the mortality in life-craft was 25% ; the low mortality in life-craft in the whole series was partly due to the fact that only a small proportion of the sinkings were in very cold waters. In cold regions the mortality was 20% in lifeboats compared with 40% on rafts. Evidently the degree of protection afforded by the life-craft is very relevant, and there is ample justification for the work that has gone into developing the modern tented life- raft.3 Water-supplies in life-craft were almost as important as the temperature. The death-rate varied from 33% where no water was available to 2% where there was a plentiful supply. A supply of 4-8 oz. per man per day .seems to be the least for avoiding a high death-rate from dehydration. One of the most striking features was the disastrous effect of drinking sea-water. In 163 craft for which data were available, 39% of the occupants died in craft where sea-water is known to have been drunk, compared with 3% in craft where there was no report of sea-water drinking-a difference which, it was found, was not due to differences between the two groups in the duration of the voyage, the environmental temperature, or the amount of fresh water. This grim warning should become widely known. As McCance et .al. show, provision of enough fresh water in life-craft will remove most of the temptation to drink sea-water. 3. See Lancet, Oct. 13, 1956, p. 770. OBSTETRICS UNDER DIFFICULTIES THOSE of us who feel tired and fractious after a busy outpatient session or a long surgery should read about antenatal clinics in Ibadan, Nigeria, at which up to 500 patients attend each session. Dr. J. B. Lawson and Dr. Una Lister have compiled a clinical report of the work of the department of obstetrics of University College, Ibadan, in the period from April 1, 1953, to Dec. 31, 1954. The new University College Hospital should be completed next year and will provide 110 beds for obstetrics and gynaecology. Meanwhile 45 obstetrical beds in the Adeoyo Hospital have had to serve as the principal, maternity unit for a population of about 750,000. In these beds 5582 patients were delivered in the twenty-one months covered by the report. At the start of the period the medical staff of the unit consisted of the two consultants and a junior house- surgeon holding a local qualification. Record-keeping in Ibadan is difficult because only a small minority of patients know their age or the date of their last menstrual period. In telling their histories, patients and interpreters give the answers which they think would be the most acceptable, and it is usual to :suppress unhappy incidents such as stillbirths. If a previous pregnancy has resulted in a stillbirth, a patient may not only conceal this information but give a different name in the hope of changing her luck. In such circum- :stances the obstetricians might well have despaired of producing a clinical report. Not so Dr. Lawson and Dr. Lister, whose account is of great value. In the twenty-one months there were 76 maternal deaths (13 per 1000 total births). The stillbirth and neonatal-death rates were 70-4 and 61-8 per 1000 total births. For emergency cases the maternal mortality was 49.6 per 1000 and the stillbirth-rate 207 per 1000. Anaemia is perhaps the biggest individual problem. Because hospital beds were so few, anaemic patients could be admitted only if their haemoglobin level was less than 50% ; there were 182 such cases. There were 35 cases of ruptured uterus with 14 deaths, and 175 .cases of obstructed labour with 23 deaths. The incidence of toxaemia of pregnancy was low, and rheumatic cardiac disease and pulmonary embolism were not observed. It is gratifying to know that the superintendent mid- wife received recognition from the people of lbadan in that she was installed by the Olubadan as chief lya Abiye (mother of all living children). For the whole staff the chief sources of encouragement have been the erection of the new building and the growing confidence of the people, which is leading them to seek advice earlier in their pregnancies. 1. Sulkin, S. E., Pike, R. M. Amer. J. publ. Hlth, 1951, 41, 769. 2. Smadel, J. E. Ibid, p. 788. 3. Long, E. F. Ibid, p. 782. 4. Anderson, R. E., Stein, L., Moss, M. L., Gross, N. H. J. Bact. 1952, 64, 473. 5. Wedum, A. G. Amer. J. publ. Hlth, 1953, 43, 1428. 6. Reitman, M., Wedum, A. G. Publ. Hlth Rep., Wash. 1956, 71, 659. LABORATORY INFECTIONS IT used to be said that the late Sir John Ledingham was the only bacteriologist in England who had worked with Pasteurella tularensis and escaped infection. There are few bacteria with a reputation so evil and most of these are rarely met with in this country. It has long been known that all species of brucella and rickettsia should be handled carefully.1 2 Enteric fever is commoner among bacteriologists than it should be. Some recent evidence suggests that those who work in hospital laboratories may acquire tuberculosis rather commonly compared with those in other jobs.3 Bacteriology has had its martyrs, but the death of many’ of these was due to one disease-yellow fever-and the bacteriologist would have to admit that some of his infections have been due to carelessness and nothing more. Accidental infections in the laboratory have now become the subject of renewed interest. Some of this arises from catastrophes whose history is well known, and some from more speculative reasoning based on new observations on the distribution of bacteria. The airborne dispersal of bacteria has been assumed for many years, but such exact knowledge as we have of it is comparatively recent. Not only may the viable bacteria in aerial suspension be identified and counted, but it is possible on occasion to show that these may initiate both local and systemic infections. The route of infection for the latter has generally been assumed to be through the lungs-and the history of anthrax confirms this-but experimentally it has been shown that infec- tions with brucella and salmonella may occur by way of the eyes. The methods used for studying the bacterial content of the air in operating-theatres have been applied to the bacteriological laboratory and the findings have caused some alarm.4-6 Removing the rubber bung from a tube containing a fluid culture ; blowing the last few drops from a pasteur pipette ; even spreading a culture on a petri dish-each of these simple manoeuvres dis- perses a certain number of bacteria. Centrifuging a culture is safe enough-until the tube breaks-and, not surprisingly, a homogeniser will release a substantial bacterial cloud if the fit of its parts is imperfect. One of the most nephelogenic operations is the post-mortem examination of an infected animal, and there is reason to fear that the same may be true of human necropsy. All these are only examples of everyday procedures which have been shown to produce bacterial aerosols; there may be others. Some infections acquired in the laboratory are almost certainly due to airborne bacteria, but the quantitative aspects of this peril are obscure. If the risk were a grave one, the bacteriologist should stand between the merchant seaman and the bartender in the tables of morbidity. He seems, in fact, to have much the same health as his colleagues in other departments. Yet it would be foolish to be too complacent. Few have noticed how bacteriological technique has altered within living
Transcript of OBSTETRICS UNDER DIFFICULTIES
880
wrecked men. They emphasise the need for ensuringthat life-craft are launched, and that men succeed inboarding them. McCance et al. analysed the effects ofmany factors influencing the chance of survival in life-craft. The most important was the temperature. On seasbelow 5°C the mortality in life-craft was 25% ; the lowmortality in life-craft in the whole series was partly due tothe fact that only a small proportion of the sinkings werein very cold waters. In cold regions the mortality was20% in lifeboats compared with 40% on rafts. Evidentlythe degree of protection afforded by the life-craft is veryrelevant, and there is ample justification for the workthat has gone into developing the modern tented life-raft.3
Water-supplies in life-craft were almost as importantas the temperature. The death-rate varied from 33%where no water was available to 2% where there was aplentiful supply. A supply of 4-8 oz. per man per day.seems to be the least for avoiding a high death-rate fromdehydration. One of the most striking features was thedisastrous effect of drinking sea-water. In 163 craftfor which data were available, 39% of the occupantsdied in craft where sea-water is known to have beendrunk, compared with 3% in craft where there was noreport of sea-water drinking-a difference which, it wasfound, was not due to differences between the two groupsin the duration of the voyage, the environmental
temperature, or the amount of fresh water. This grimwarning should become widely known. As McCance et.al. show, provision of enough fresh water in life-craft willremove most of the temptation to drink sea-water.
3. See Lancet, Oct. 13, 1956, p. 770.
OBSTETRICS UNDER DIFFICULTIES
THOSE of us who feel tired and fractious after a busyoutpatient session or a long surgery should read aboutantenatal clinics in Ibadan, Nigeria, at which up to 500patients attend each session. Dr. J. B. Lawson andDr. Una Lister have compiled a clinical report of thework of the department of obstetrics of UniversityCollege, Ibadan, in the period from April 1, 1953, to Dec.31, 1954. The new University College Hospital shouldbe completed next year and will provide 110 beds forobstetrics and gynaecology. Meanwhile 45 obstetricalbeds in the Adeoyo Hospital have had to serve as theprincipal, maternity unit for a population of about
750,000. In these beds 5582 patients were deliveredin the twenty-one months covered by the report. Atthe start of the period the medical staff of the unitconsisted of the two consultants and a junior house-surgeon holding a local qualification.
Record-keeping in Ibadan is difficult because only asmall minority of patients know their age or the dateof their last menstrual period. In telling their histories,patients and interpreters give the answers which theythink would be the most acceptable, and it is usual to
:suppress unhappy incidents such as stillbirths. If a
previous pregnancy has resulted in a stillbirth, a patientmay not only conceal this information but give a differentname in the hope of changing her luck. In such circum-:stances the obstetricians might well have despaired ofproducing a clinical report. Not so Dr. Lawson andDr. Lister, whose account is of great value.
In the twenty-one months there were 76 maternaldeaths (13 per 1000 total births). The stillbirth andneonatal-death rates were 70-4 and 61-8 per 1000 totalbirths. For emergency cases the maternal mortalitywas 49.6 per 1000 and the stillbirth-rate 207 per 1000.Anaemia is perhaps the biggest individual problem.Because hospital beds were so few, anaemic patientscould be admitted only if their haemoglobin level wasless than 50% ; there were 182 such cases. There were35 cases of ruptured uterus with 14 deaths, and 175.cases of obstructed labour with 23 deaths. The incidence
of toxaemia of pregnancy was low, and rheumatic cardiacdisease and pulmonary embolism were not observed.
It is gratifying to know that the superintendent mid-wife received recognition from the people of lbadanin that she was installed by the Olubadan as chief lyaAbiye (mother of all living children). For the wholestaff the chief sources of encouragement have been theerection of the new building and the growing confidenceof the people, which is leading them to seek advice earlierin their pregnancies.
1. Sulkin, S. E., Pike, R. M. Amer. J. publ. Hlth, 1951, 41, 769.2. Smadel, J. E. Ibid, p. 788.3. Long, E. F. Ibid, p. 782.4. Anderson, R. E., Stein, L., Moss, M. L., Gross, N. H. J. Bact.
1952, 64, 473.5. Wedum, A. G. Amer. J. publ. Hlth, 1953, 43, 1428.6. Reitman, M., Wedum, A. G. Publ. Hlth Rep., Wash. 1956,
71, 659.
LABORATORY INFECTIONS
IT used to be said that the late Sir John Ledinghamwas the only bacteriologist in England who had workedwith Pasteurella tularensis and escaped infection. Thereare few bacteria with a reputation so evil and most ofthese are rarely met with in this country. It has longbeen known that all species of brucella and rickettsiashould be handled carefully.1 2 Enteric fever is commoneramong bacteriologists than it should be. Some recentevidence suggests that those who work in hospitallaboratories may acquire tuberculosis rather commonlycompared with those in other jobs.3 Bacteriology hashad its martyrs, but the death of many’ of these wasdue to one disease-yellow fever-and the bacteriologistwould have to admit that some of his infections havebeen due to carelessness and nothing more. Accidentalinfections in the laboratory have now become the subjectof renewed interest. Some of this arises from catastropheswhose history is well known, and some from more
speculative reasoning based on new observations on thedistribution of bacteria.The airborne dispersal of bacteria has been assumed
for many years, but such exact knowledge as we haveof it is comparatively recent. Not only may the viablebacteria in aerial suspension be identified and counted,but it is possible on occasion to show that these mayinitiate both local and systemic infections. The route ofinfection for the latter has generally been assumed to bethrough the lungs-and the history of anthrax confirmsthis-but experimentally it has been shown that infec-tions with brucella and salmonella may occur by wayof the eyes. The methods used for studying the bacterialcontent of the air in operating-theatres have been appliedto the bacteriological laboratory and the findings havecaused some alarm.4-6 Removing the rubber bung froma tube containing a fluid culture ; blowing the last fewdrops from a pasteur pipette ; even spreading a cultureon a petri dish-each of these simple manoeuvres dis-perses a certain number of bacteria. Centrifuging aculture is safe enough-until the tube breaks-and, notsurprisingly, a homogeniser will release a substantialbacterial cloud if the fit of its parts is imperfect. Oneof the most nephelogenic operations is the post-mortemexamination of an infected animal, and there is reasonto fear that the same may be true of human necropsy.All these are only examples of everyday procedures whichhave been shown to produce bacterial aerosols; there
may be others.Some infections acquired in the laboratory are almost
certainly due to airborne bacteria, but the quantitativeaspects of this peril are obscure. If the risk were a
grave one, the bacteriologist should stand between themerchant seaman and the bartender in the tables of
morbidity. He seems, in fact, to have much the samehealth as his colleagues in other departments. Yet itwould be foolish to be too complacent. Few have noticedhow bacteriological technique has altered within living
