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Historical records describe patients & their care
the concern that the decisions of panelists may not represent the prevailing medical opinion. This concern was raised in reference to the Joint National Committee. Other concerns included the fact that previous recommendations were different and were deeply ingrained in practice, whereas the Committee’s recommendations were new. What is significant about this study is that physicians have once again shown that they will follow what they perceive to be the best practice, regardless of recommended guidelines. Hopefully we can continue this independence in the forum of managed care.
Study Shows No Associationof HRT Wth Nonfatal Stroke Pedersen AT, Lidegaard 0, Kreiner S, Ottesen B. Hormone replacement therapy and risk of non-fatal stroke. La~~cet 1997; 350:1277-83.
Synopsis: The use of hormone replacement therapy (HRT) has escalated in the past 10 years. These investigators studied the impact of HRT on the risk of hemorrhagic and thromboembolic stroke. Using a case control method, they reviewed records of all Danish women who had a nonfatal stroke between 1990 and 1992 and compared those who used HRT with two age-matched controls. There were 1422 cases and 3171 controls. After adjustment for confounding variables, no significant associations were found. . . .
Commentary: As stated in the review of another article in this spotlight, investigators are continuing to look at individual areas of HRT to see if there is a pattern of side effects attributable to HRT. Fortunately, none was found in this study. Because of the controversy surrounding the oral contraceptive, especially the third-generation pills, the question of the influence of HRT has been raised. In this study there was 12
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May/June
none. Further studies of larger numbers of patients with different backgrounds will be needed to confirm these data, but the initial results are reassuring.
ErroneousReferencesin Ob/Gyn Journals Roach VJ, Lau TK, Ngan Kee WD. The quality of citations in major international obstetrics and gynecology journals. Am J Obstet Gynecol 1997;177:973-5.
Synopsis: In an attempt to determine the error rate in references published in three international journals (/Inzericun Jourmd of Obstetrics and GynecoLogy, Australian and New Zeahzd Journal of Obstetrics und GynaecoIogy, and the British Journal of Obstetrics und Gymecolo&, the authors studied all issues published in 1995. They found errors in the majority of references, the most frequent being in the authors’ names and titles of the articles. They concluded that better editorial review is needed by authors and journal staff.
Commentaryz I agree. ACOG ClinicaL Review editors review approximately 15-20 journals each month to select the 20-30 articles for review. Once an article is selected, it is then reviewed by an independent editor to determine if it will be one of the eight to ten per spotlight that is published. Frequently in reviewing, the article references will be misquoted and in some instances quoted out of context. A major concern is that sometimes conclusions in the abstract and the article itself disagree. In one recent article we reviewed, a decimal point in the abstract indicated a 5.0% success rate. In the results section it was a 0.5% success rate. The implication is clear. If you read only the abstracts, confirm the findings in the article before you accept the results. Even the best authors and the best journals may make errors.
1998
HISTORY Conihued
from p. 16
were much greater than those amon the patients in the rest of his practice. !i He was well acquainted with the leaders of the Humane and Charitable Fire societies and instrumental in persuading them that poor women needed “such comforts and attentions as the necessities of the puerperal state require.“9 Channing and Enoch Hale, Jr, MD, were named attending physicians. John C. Warren, MD, Jacob Bigelow, MD, and George Hayward, MD, were designated consulting physicians. All were prominent members of Boston’s medical establishment. The house physician, appointed from the recent medical school class by the attending physicians, was required to live on the premises.
HISTORICAL RECORDS DESCRIBE PATIENTS & THEIRCARE Data regarding the patients come from two sources: a hospital case book that recorded 253 admissions from 1832 to 1844 and a numerical analysis of 45 1 deliveries from 1832 to 1850. The case book gives each patient’s history and a daily record of her condition throughout her stay in the hospital. Entries were made by the resident physician and included prescriptions ordered by the attending physician and details of the labor and delivery. The numerical analysis, by David H. Storer, MD, one of the subsequent attending physicians, was based on the original case book and those books that followed. lo Unfortunately, the later records are no longer extant, so it is not possible to confirm Storer’s analysis. His data included comparative length of male and female babies, length of the funis, presentation of the baby, and information from 18 other categories. Data from 1850 onward also are not available. Despite the apparent urgency, the hospital was never fully occupied. During the first 22 years, there were only 650 atients, an average of 27 per year. c? Most months only four or five were in residence. Patients tended to stay for long periods, 01996 by the Amwcan College01Obstetrwos and Gynecotwists PublIshedby Elwer Sctenceinc. 1085-686Z9t3/$550
arriving many weeks before term and remaining for 3-4 weeks after delivery. The house physician frequently wrote “reckoning doubtful” in case histories. Perhaps those women did not know when they had had their last menstrual period or had first felt “quickening.” Perhaps they wanted the seclusion of the hospital in the final weeks of pregnancy, especially if they were unmarried. The women were expected to help with housekeeping and other chores while awaiting the onset of labor. The requirement that patients be married or recently widowed was honored in the breach: the number of women claiming widowhood or desertion by unworthy husbands was unusually high, and the management made little or no attempt to verify their stories. The directresses and trustees also tried to demonstrate Christian compassion by placing patients in good homes, either as domestics or wet nurses, if they had no place to go following discharge. If some of the women did not fulfill the requirement regarding wedlock, all were poor. “On account of great poverty, has been subject for a few days to many and great privations” was the notation in one case history.’ Another mother, 19 years old, was admitted 8 days postpartum,:ibecause of her destitute situation. Mercy Sparhawk Goodenow “is at present in a delicate state of health caused by laborious exertions for the support of her family, has had 5 children, including twins.“’ A 47-year-old woman, among the oldest ever admitted, had given birth to 11 children, ofwhom only six still were living. She recently had been abandoned by her husband, uan intemperate man. 291 Hospital records also reveal women who had been beaten by their husbands and a recent immigrant, fearful and frequently delirious, who had been told by “an old hag” that she would die in childbirth and her baby would be given to strangers to be raised. Neither occurred.’ Most patients were satisfied, and some returned for a subsequent confinement. A few resented the strict rules, which included limitations on Ql998 by the AmericanCollegeof Obstetruans and GYWCO~OQIS~S Publishedby EIWW Science lnc 108W362/98/$5.50
visitors, and one left “without permission from the attending hysician as required by the by-laws. J But on the whole they found good care and sympathetic attendants who provided decent food and shelter during the weeks of waiting, encouraged them through labor, and gave advice and medical care as needed to mother and child during the postpartum weeks. Hospital records reveal daily attention to their complaints and disorders, with particular regard for proper diet and prevention of constipation. Procedures during labor and delivery were similar to those in private obstetric practice. Patients usually delivered on the left side, but there were exceptions. Some preferred to be on their knees. Poor women could be as modest as their wealthier sisters, and the physicians had to rely on the nurse for information about the patient’s condition. In most cases, physicians did not examine the cervix until labor had been under way long enough for dilation to have begun. If the amniotic sac was protruding but had not broken, they ruptured it with their fingernails, as was common practice. Ergot was given for long labors, especially when contractions were not forcing the child through the birth canal. If convulsions threatened or occurred, the usual treatments were attempted: bleeding, cathartics, blisters, sinapisms, ice to the head, or antispasmodic drugs such as valerian and assafoetida.
INSTRUMENTS & OPERATIVE DELIVERIES Instruments were used infrequently. Of the 451 cases analyzed in 1850, there were eight forceps cases and two craniotomies. In a few instances, the lever was used to assist delivery. We might expect poor women to have increased rates of nutritional deficiencies and pelvic deformities and thus to require more instrumental deliveries, but this seems not to have been true. In several cases labor continued for many days, but the notes do not explain why instruments were not used. Five forceps babies were born
dive. One of the women whose babies were delivered following craniotomy died, probably from infection, but the other survived peritonitis, which appeared the day after delivery.
PATIENT OUTCOME Maternal mortality was also lower than might be expected, especially because puerperal fever was always a threat in hospital settings. Six maternal deaths were reported among 253 case-book patients, less than 3%. Four were caused by infection, one by convulsions, and the other by underlying disease that predated the pregnancy. In at least a dozen more cases, symptoms of infection were noted, some very severe, but the women recovered. These records predate Holmes’ important article on puerperal fever with its impassioned plea for physician cleanliness. It may be that the Lying-in already was taking precautions or that the physicians were able to avoid puerperal fever in their private practices and thus did not transmit it to the hospital patients. One thing that favored the Boston Lying-in over most urban maternity clinics, in which epidemic puerperal fever was more frequent, was the small number of patients present at any one time. Infant mortality was also lower than might be expected. Among the first 166 cases, fewer than 11% were stillborn or died shortly after birth. During the early years of Channing’s private practice, with many poor women as his patients, 23% of the babies died. The care provided by the hospital during the weeks prior to delivery, the relative cleanliness during and after delivery, and the decent food and shelter during convalescence contributed to the successful record. This does not mean that there were no mistakes or tragedies. Storer found four cases of lacerated perineum. Some stillbirths occurred because there was no way to foresee the umbilical cord tightly wound round the babies’ necks. Other babies suffered trauma that might have been avoided if instruments had been used or used more promptly. Three premature babies, each
!viay/lune 1998
J l
ACOG
CLINICAL
REVIEW
l
13
Study Shows No Associationof HRT Wth Nonfatal Stroke Pedersen AT, Lidegaard 0, Kreiner S, Ottesen B. Hormone replacement therapy and risk of non-fatal stroke. La~~cet 1997; 350:1277-83.
Synopsis: The use of hormone replacement therapy (HRT) has escalated in the past 10 years. These investigators studied the impact of HRT on the risk of hemorrhagic and thromboembolic stroke. Using a case control method, they reviewed records of all Danish women who had a nonfatal stroke between 1990 and 1992 and compared those who used HRT with two age-matched controls. There were 1422 cases and 3171 controls. After adjustment for confounding variables, no significant associations were found. . . .
Commentary: As stated in the review of another article in this spotlight, investigators are continuing to look at individual areas of HRT to see if there is a pattern of side effects attributable to HRT. Fortunately, none was found in this study. Because of the controversy surrounding the oral contraceptive, especially the third-generation pills, the question of the influence of HRT has been raised. In this study there was 12
l
ACOG
CLINICAL
REVIEW
l
May/June
none. Further studies of larger numbers of patients with different backgrounds will be needed to confirm these data, but the initial results are reassuring.
ErroneousReferencesin Ob/Gyn Journals Roach VJ, Lau TK, Ngan Kee WD. The quality of citations in major international obstetrics and gynecology journals. Am J Obstet Gynecol 1997;177:973-5.
Synopsis: In an attempt to determine the error rate in references published in three international journals (/Inzericun Jourmd of Obstetrics and GynecoLogy, Australian and New Zeahzd Journal of Obstetrics und GynaecoIogy, and the British Journal of Obstetrics und Gymecolo&, the authors studied all issues published in 1995. They found errors in the majority of references, the most frequent being in the authors’ names and titles of the articles. They concluded that better editorial review is needed by authors and journal staff.
Commentaryz I agree. ACOG ClinicaL Review editors review approximately 15-20 journals each month to select the 20-30 articles for review. Once an article is selected, it is then reviewed by an independent editor to determine if it will be one of the eight to ten per spotlight that is published. Frequently in reviewing, the article references will be misquoted and in some instances quoted out of context. A major concern is that sometimes conclusions in the abstract and the article itself disagree. In one recent article we reviewed, a decimal point in the abstract indicated a 5.0% success rate. In the results section it was a 0.5% success rate. The implication is clear. If you read only the abstracts, confirm the findings in the article before you accept the results. Even the best authors and the best journals may make errors.
1998
HISTORY Conihued
from p. 16
were much greater than those amon the patients in the rest of his practice. !i He was well acquainted with the leaders of the Humane and Charitable Fire societies and instrumental in persuading them that poor women needed “such comforts and attentions as the necessities of the puerperal state require.“9 Channing and Enoch Hale, Jr, MD, were named attending physicians. John C. Warren, MD, Jacob Bigelow, MD, and George Hayward, MD, were designated consulting physicians. All were prominent members of Boston’s medical establishment. The house physician, appointed from the recent medical school class by the attending physicians, was required to live on the premises.
HISTORICAL RECORDS DESCRIBE PATIENTS & THEIRCARE Data regarding the patients come from two sources: a hospital case book that recorded 253 admissions from 1832 to 1844 and a numerical analysis of 45 1 deliveries from 1832 to 1850. The case book gives each patient’s history and a daily record of her condition throughout her stay in the hospital. Entries were made by the resident physician and included prescriptions ordered by the attending physician and details of the labor and delivery. The numerical analysis, by David H. Storer, MD, one of the subsequent attending physicians, was based on the original case book and those books that followed. lo Unfortunately, the later records are no longer extant, so it is not possible to confirm Storer’s analysis. His data included comparative length of male and female babies, length of the funis, presentation of the baby, and information from 18 other categories. Data from 1850 onward also are not available. Despite the apparent urgency, the hospital was never fully occupied. During the first 22 years, there were only 650 atients, an average of 27 per year. c? Most months only four or five were in residence. Patients tended to stay for long periods, 01996 by the Amwcan College01Obstetrwos and Gynecotwists PublIshedby Elwer Sctenceinc. 1085-686Z9t3/$550
arriving many weeks before term and remaining for 3-4 weeks after delivery. The house physician frequently wrote “reckoning doubtful” in case histories. Perhaps those women did not know when they had had their last menstrual period or had first felt “quickening.” Perhaps they wanted the seclusion of the hospital in the final weeks of pregnancy, especially if they were unmarried. The women were expected to help with housekeeping and other chores while awaiting the onset of labor. The requirement that patients be married or recently widowed was honored in the breach: the number of women claiming widowhood or desertion by unworthy husbands was unusually high, and the management made little or no attempt to verify their stories. The directresses and trustees also tried to demonstrate Christian compassion by placing patients in good homes, either as domestics or wet nurses, if they had no place to go following discharge. If some of the women did not fulfill the requirement regarding wedlock, all were poor. “On account of great poverty, has been subject for a few days to many and great privations” was the notation in one case history.’ Another mother, 19 years old, was admitted 8 days postpartum,:ibecause of her destitute situation. Mercy Sparhawk Goodenow “is at present in a delicate state of health caused by laborious exertions for the support of her family, has had 5 children, including twins.“’ A 47-year-old woman, among the oldest ever admitted, had given birth to 11 children, ofwhom only six still were living. She recently had been abandoned by her husband, uan intemperate man. 291 Hospital records also reveal women who had been beaten by their husbands and a recent immigrant, fearful and frequently delirious, who had been told by “an old hag” that she would die in childbirth and her baby would be given to strangers to be raised. Neither occurred.’ Most patients were satisfied, and some returned for a subsequent confinement. A few resented the strict rules, which included limitations on Ql998 by the AmericanCollegeof Obstetruans and GYWCO~OQIS~S Publishedby EIWW Science lnc 108W362/98/$5.50
visitors, and one left “without permission from the attending hysician as required by the by-laws. J But on the whole they found good care and sympathetic attendants who provided decent food and shelter during the weeks of waiting, encouraged them through labor, and gave advice and medical care as needed to mother and child during the postpartum weeks. Hospital records reveal daily attention to their complaints and disorders, with particular regard for proper diet and prevention of constipation. Procedures during labor and delivery were similar to those in private obstetric practice. Patients usually delivered on the left side, but there were exceptions. Some preferred to be on their knees. Poor women could be as modest as their wealthier sisters, and the physicians had to rely on the nurse for information about the patient’s condition. In most cases, physicians did not examine the cervix until labor had been under way long enough for dilation to have begun. If the amniotic sac was protruding but had not broken, they ruptured it with their fingernails, as was common practice. Ergot was given for long labors, especially when contractions were not forcing the child through the birth canal. If convulsions threatened or occurred, the usual treatments were attempted: bleeding, cathartics, blisters, sinapisms, ice to the head, or antispasmodic drugs such as valerian and assafoetida.
INSTRUMENTS & OPERATIVE DELIVERIES Instruments were used infrequently. Of the 451 cases analyzed in 1850, there were eight forceps cases and two craniotomies. In a few instances, the lever was used to assist delivery. We might expect poor women to have increased rates of nutritional deficiencies and pelvic deformities and thus to require more instrumental deliveries, but this seems not to have been true. In several cases labor continued for many days, but the notes do not explain why instruments were not used. Five forceps babies were born
dive. One of the women whose babies were delivered following craniotomy died, probably from infection, but the other survived peritonitis, which appeared the day after delivery.
PATIENT OUTCOME Maternal mortality was also lower than might be expected, especially because puerperal fever was always a threat in hospital settings. Six maternal deaths were reported among 253 case-book patients, less than 3%. Four were caused by infection, one by convulsions, and the other by underlying disease that predated the pregnancy. In at least a dozen more cases, symptoms of infection were noted, some very severe, but the women recovered. These records predate Holmes’ important article on puerperal fever with its impassioned plea for physician cleanliness. It may be that the Lying-in already was taking precautions or that the physicians were able to avoid puerperal fever in their private practices and thus did not transmit it to the hospital patients. One thing that favored the Boston Lying-in over most urban maternity clinics, in which epidemic puerperal fever was more frequent, was the small number of patients present at any one time. Infant mortality was also lower than might be expected. Among the first 166 cases, fewer than 11% were stillborn or died shortly after birth. During the early years of Channing’s private practice, with many poor women as his patients, 23% of the babies died. The care provided by the hospital during the weeks prior to delivery, the relative cleanliness during and after delivery, and the decent food and shelter during convalescence contributed to the successful record. This does not mean that there were no mistakes or tragedies. Storer found four cases of lacerated perineum. Some stillbirths occurred because there was no way to foresee the umbilical cord tightly wound round the babies’ necks. Other babies suffered trauma that might have been avoided if instruments had been used or used more promptly. Three premature babies, each
!viay/lune 1998
J l
ACOG
CLINICAL
REVIEW
l
13