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HOSPITAL MEDICAL RECORDS
885 were
normal.
All the disturbances in hands and feet, in the
ended proximally without sharp limits, and gave way to normal sensation. She had difficulty in accommodation. There was no impairment of the function of the external ocular muscles. She was given cortisone 100 to 50 mg. daily for a fortnight. The condition improved very much during that period. The allergy department of the central diagnostic clinic "Zamenhoff" of the Workers’ Sick Fund (Dr. Kessler and Dr. Lindenbaum) is kindly trying to find a way of giving the Dr. Itelson, of the same clinic, is the chest patient antibiotics. thanks are due to him as well as and sincere my physician, to my senior medical officer, Dr. Y. Shatal, for their help.
typical stoeking-and-glove distribution,
A. YUVAL. HOSPITAL MEDICAL RECORDS
SIR,—Dr. Skelton (March 30) and Dr. Brocklebank (April 6) both view the problem of preserving medical
records and X-ray films from the standpoint of the space needed for their storage. Staffing difficulties must also be considered. The retention of medical records is not merely a matter of stuffing them into filing cabinets, or stacking them on shelves. To be of value to the clinician or research-worker, records must be suitably indexed and classified (under medical direction), and properly filed by trained clerks. An adequate medical-records service can be extremely expensive in staff. It is not always appreciated (even by doctors) that the increased number of administrative and clerical staff seen in the hospitals since 1948 is due in large measure to the demands of the vastly improved medical-records service now generally offered. Further improvement in this service must result in the employment of yet more clerks. L. W. HUNT Aberystwyth General Hospital.
Hospital Secretary.
STAPHYLOCOCCAL BRONCHOPNEUMONIA
SIR,—The interesting article by Dr. Gresham and Dr. Gleeson-White (March 30) is timely and of great importance. This problem is not confined to one hospital. Although it is widespread, some hospitals are much more aware of the problem than others. We have been studying the general problem of hospital staphylococcal infections and recently have been concentrating on the patients with pneumonia. An analysis of the first 25 cases of staphylococcal pneumonia obtained from the clinical records of the University Hospitals for the past five years shows that 20 of them were fatal and that a majority occurred in debilitated patients. 19 of them were over 50 years of age and there was a slight lessening of incidence in the spring and early summer. In 12 cases the disease was not suspected before death. Fever, cough, dyspnoea, and mental confusion were the commonest signs. A third complained of pleural pain. Sputum production was not prominent. The X-rays of 19 patients showed that pulmonary infiltration was the only constant finding. There were only 4 cases with abscesses and in 2 the hilar glands were enlarged. At necropsy the predominant finding in 20 examinations was a diffuse bronchopneumonia, which in 5 instances was described as necrotic. Haemorrhage in the lung was mentioned only once, but it is of interest that 3 other eases had bloody sputum and 2 others clinical purpura. These cases, of course, are only indicators of an underlying problem. We cannot include patients with undiagnosed antibiotic-cured pneumonia and those who died, undiagnosed, without necropsy. Other studies by this group have shown that in the 1935-41 period there were about 20-30 cases of staphylococcal septicaemia seen yearly, whereas after this until 1953 only 5-10 vyere seen. Since then a gradual climb in numbers is evident and in 1955 we saw 27 patients with staphylococcal septicaemia.
We made some studies of the prevalence of staphylococcal infections in hospitalised patients similar to those made by Finland and J ones.1 In a group of 634 patients 70 (11%) had proved staphylococcal infection compared with 15% of the patients in the Boston study. We had 3% of serious infections compared with 2.6% in their series. 56% of our infections appear to have been acquired in hospital (62% in theirs). In addition a study of last year’s 484 necropsies, through the kind permission of Dr. Emory D. Warner, shows that hemolytic Staphylococcus aureus was the prime cause of death in 3.7% of cases and may have been a secondary cause in 12-5% of
necropsies.
A continuing study of staphylococcal infection is being carried out by a more intensive survey of the wards for incidence and ecology of staphylococcal disease. In this study, one of us, a member of the nursing staff, is making observations on nursing and medical procedures and the relationship of these activities to cross-infection. IAN MACLEAN SMITH MARY E. GODFREY Infectious Disease Division, Department of Internal Medicine, A. BARBARA VICKERS State University of Iowa, JEAN HATCH. Iowa City, Iowa. CÆSAREAN SECTION
SIR,—I think the conclusions in your leading article section (April 6) are rather misleading. I
on caesarean
have discussed the
problem of the indications for caesarean
length,2 and since my conclusions would seem to be at variance with your own I would like to make the following comments. You say that half the foetal deaths in deliveries by caesarean section are attributable to the risks inherent in the operation itself. This is certainly not my experience ; in fact, I cannot remember a single case in which this was clearly so. In some cases where the baby died, earlier resort to caesarean section might have prevented the death. Your recommendation that we should hesitate before deciding to operate solely in the interests of the section at
child therefore needs amplification. Between the periods 1938-47 and 1953-56 the perinatal mortality-rates in booked hospital primigravidae in Aberdeen fell by more than a third, and the decrease was greatest in the older women ; in those of 30 years or more it fell by 75%. Perinatal mortality 15-19
Age-group 1938-47 1953-56
36 .. 40 ..
20-24 35 26
per 1000 births
25-29 57 28
30-34 76 17
The caesarean-section rate in booked
35 101 25
All ages 45 28
primigravidæ
was
1-3% in 1938-47 and 4% in 1953-56. The increase was least in younger and most in older primigravidae ; in those of 35 years or more the caesarean-section rate is now about 30%. After about 25 years of age, primigravidae show a progressive deterioration in uterine function which shows itself in a tendency to intra-uterine death of the foetus and to prolonged labour due to disordered uterine action. These dangers are increased if labour does not take place by the 40th week, and may be further increased if preeclampsia is present. The avoidance of protracted pregnancy by induction of labour and of protracted labour by the more liberal use of caesarean section seems to have been successful in preventing many such deaths without increasing the risks to the mother. The overall maternal mortality of 0-99% following caesarean section, reported by Marshall and Cox 3 for the years 1943--47, no longer applies, since in many maternity hospitals in Britain it is now by no means unusual to perform several hundred consecutive cæsarean sections without a death. 1. Ann. N.Y. Acad. Sci. 1956, 65, 191. 2. Baird, D. Brit. med. J. 1955, ii, 1159. 3. Marshall, C. M., Cox, L. W. Transactions of the 12th British Congress of Obstetrics and Gynæcology, 1949 ; p. 30.
normal.
All the disturbances in hands and feet, in the
ended proximally without sharp limits, and gave way to normal sensation. She had difficulty in accommodation. There was no impairment of the function of the external ocular muscles. She was given cortisone 100 to 50 mg. daily for a fortnight. The condition improved very much during that period. The allergy department of the central diagnostic clinic "Zamenhoff" of the Workers’ Sick Fund (Dr. Kessler and Dr. Lindenbaum) is kindly trying to find a way of giving the Dr. Itelson, of the same clinic, is the chest patient antibiotics. thanks are due to him as well as and sincere my physician, to my senior medical officer, Dr. Y. Shatal, for their help.
typical stoeking-and-glove distribution,
A. YUVAL. HOSPITAL MEDICAL RECORDS
SIR,—Dr. Skelton (March 30) and Dr. Brocklebank (April 6) both view the problem of preserving medical
records and X-ray films from the standpoint of the space needed for their storage. Staffing difficulties must also be considered. The retention of medical records is not merely a matter of stuffing them into filing cabinets, or stacking them on shelves. To be of value to the clinician or research-worker, records must be suitably indexed and classified (under medical direction), and properly filed by trained clerks. An adequate medical-records service can be extremely expensive in staff. It is not always appreciated (even by doctors) that the increased number of administrative and clerical staff seen in the hospitals since 1948 is due in large measure to the demands of the vastly improved medical-records service now generally offered. Further improvement in this service must result in the employment of yet more clerks. L. W. HUNT Aberystwyth General Hospital.
Hospital Secretary.
STAPHYLOCOCCAL BRONCHOPNEUMONIA
SIR,—The interesting article by Dr. Gresham and Dr. Gleeson-White (March 30) is timely and of great importance. This problem is not confined to one hospital. Although it is widespread, some hospitals are much more aware of the problem than others. We have been studying the general problem of hospital staphylococcal infections and recently have been concentrating on the patients with pneumonia. An analysis of the first 25 cases of staphylococcal pneumonia obtained from the clinical records of the University Hospitals for the past five years shows that 20 of them were fatal and that a majority occurred in debilitated patients. 19 of them were over 50 years of age and there was a slight lessening of incidence in the spring and early summer. In 12 cases the disease was not suspected before death. Fever, cough, dyspnoea, and mental confusion were the commonest signs. A third complained of pleural pain. Sputum production was not prominent. The X-rays of 19 patients showed that pulmonary infiltration was the only constant finding. There were only 4 cases with abscesses and in 2 the hilar glands were enlarged. At necropsy the predominant finding in 20 examinations was a diffuse bronchopneumonia, which in 5 instances was described as necrotic. Haemorrhage in the lung was mentioned only once, but it is of interest that 3 other eases had bloody sputum and 2 others clinical purpura. These cases, of course, are only indicators of an underlying problem. We cannot include patients with undiagnosed antibiotic-cured pneumonia and those who died, undiagnosed, without necropsy. Other studies by this group have shown that in the 1935-41 period there were about 20-30 cases of staphylococcal septicaemia seen yearly, whereas after this until 1953 only 5-10 vyere seen. Since then a gradual climb in numbers is evident and in 1955 we saw 27 patients with staphylococcal septicaemia.
We made some studies of the prevalence of staphylococcal infections in hospitalised patients similar to those made by Finland and J ones.1 In a group of 634 patients 70 (11%) had proved staphylococcal infection compared with 15% of the patients in the Boston study. We had 3% of serious infections compared with 2.6% in their series. 56% of our infections appear to have been acquired in hospital (62% in theirs). In addition a study of last year’s 484 necropsies, through the kind permission of Dr. Emory D. Warner, shows that hemolytic Staphylococcus aureus was the prime cause of death in 3.7% of cases and may have been a secondary cause in 12-5% of
necropsies.
A continuing study of staphylococcal infection is being carried out by a more intensive survey of the wards for incidence and ecology of staphylococcal disease. In this study, one of us, a member of the nursing staff, is making observations on nursing and medical procedures and the relationship of these activities to cross-infection. IAN MACLEAN SMITH MARY E. GODFREY Infectious Disease Division, Department of Internal Medicine, A. BARBARA VICKERS State University of Iowa, JEAN HATCH. Iowa City, Iowa. CÆSAREAN SECTION
SIR,—I think the conclusions in your leading article section (April 6) are rather misleading. I
on caesarean
have discussed the
problem of the indications for caesarean
length,2 and since my conclusions would seem to be at variance with your own I would like to make the following comments. You say that half the foetal deaths in deliveries by caesarean section are attributable to the risks inherent in the operation itself. This is certainly not my experience ; in fact, I cannot remember a single case in which this was clearly so. In some cases where the baby died, earlier resort to caesarean section might have prevented the death. Your recommendation that we should hesitate before deciding to operate solely in the interests of the section at
child therefore needs amplification. Between the periods 1938-47 and 1953-56 the perinatal mortality-rates in booked hospital primigravidae in Aberdeen fell by more than a third, and the decrease was greatest in the older women ; in those of 30 years or more it fell by 75%. Perinatal mortality 15-19
Age-group 1938-47 1953-56
36 .. 40 ..
20-24 35 26
per 1000 births
25-29 57 28
30-34 76 17
The caesarean-section rate in booked
35 101 25
All ages 45 28
primigravidæ
was
1-3% in 1938-47 and 4% in 1953-56. The increase was least in younger and most in older primigravidae ; in those of 35 years or more the caesarean-section rate is now about 30%. After about 25 years of age, primigravidae show a progressive deterioration in uterine function which shows itself in a tendency to intra-uterine death of the foetus and to prolonged labour due to disordered uterine action. These dangers are increased if labour does not take place by the 40th week, and may be further increased if preeclampsia is present. The avoidance of protracted pregnancy by induction of labour and of protracted labour by the more liberal use of caesarean section seems to have been successful in preventing many such deaths without increasing the risks to the mother. The overall maternal mortality of 0-99% following caesarean section, reported by Marshall and Cox 3 for the years 1943--47, no longer applies, since in many maternity hospitals in Britain it is now by no means unusual to perform several hundred consecutive cæsarean sections without a death. 1. Ann. N.Y. Acad. Sci. 1956, 65, 191. 2. Baird, D. Brit. med. J. 1955, ii, 1159. 3. Marshall, C. M., Cox, L. W. Transactions of the 12th British Congress of Obstetrics and Gynæcology, 1949 ; p. 30.