- Email: [email protected]
ILLEGAL ABORTION
371
then something more than " encouragement might be required. It is clear that the authors of the report neither advise nor expect their detailed proposals for each region to be realised immediately. But these proposals should, on the one hand, give the Secretary of State for Scotland, and possibly also his colleagues south of the Border, a firm basis on which to build, and, on the other, guide regional boards on the deployment and build-up of the medical staffs as their resources allow. Regional boards will clearly have to ask themselves, however, whether a similar review of other types of staff might not have revealed equal or greater deficiencies. "
WEATHER AND MENTAL STATE
IN the popular imagination, the full moon is a time of doubly barred doors and wholesale cancelling of leave in mental hospitals. Medical interest in the relation of environmental change to mental state now seems to be shifting to variations in the Earth and its climate. To take a negative report first, Pokorny et al.l studied the 67 suicides and 373 attempted suicides which were recorded in Houston, Texas, during 1960, and in which the time of occurrence could be established (there were another 24 suicides and 27 attempts in which the time was unknown). Eleven weather variables were then examined; the distribution of each for all hours of the year was obtained, and this was compared with the distribution at times when a suicide or attempt occurred. No single significant relationship was found. Nor was there any association with the 28 northerly fronts which occurred in 1960, with moon, or with season. Pokorny et al. believe that the many reported claims of such connections are based on poor, inaccurate data, and that apparent relationships disappear when the very uneven distribution of weather conditions throughout a year is carefully examined. " Though the Texas climate is described as highly changeable and strenuous ", the rapid spread in the use of air-conditioning from 1949 to 1961 has not been accompanied by any decrease in suicide-rates. Pokorny et al. acknowledge that people’s mood varies with the weather, but believe that these responses are a far cry from the degree of mental upheaval associated with suicide. In this country, Stengel and Cook2 studied five groups of attempted suicides at London hospitals and found that, in all but one group, there was a peak in one of the spring months. But if the numbers out of each group are added together for each successive month, no significant difference is found throughout the year. On the other side of the coin, Friedman et awl. believe there has not been enough systematic investigation into the relation of physical forces of the natural environment to human behaviour. This, they think, may be due to " the lack of that type of theoretical framework which could permit the inter-relationship of the two parameters to be derived as a logical consequence ". It has been suggested that the direct-current electrical system of an organism could be conceived of as a control system which could be influenced by external forces such as magnetic fields, When psychiatric admissions to two hospitals in Syracuse, New York, were correlated over a four-year period with readings from a magnetic observatory, there 1. Pokomy, A. D., Davis, F., Harberson, W. Amer. J. Psychiat. 1963, 120, 377. 2 Stengel, E., Cook, N. G. Attempted Suicide. London, 1958. 3
Friedman, H., Becker, 200, 626.
R.
O., Backman,
C. H.
Nature, Lond. 1963,
seemed to be a relationship between psychiatric disturbance and some geophysical factor associated with the magnetic field. Friedman et al. now report an extension of this study in which they recorded daily admissions to
eight psychiatric hospitals (totalling 28,642) over a period of four years. For the same period, they studied the K index, which reflects the amplitude of the most disturbed component of the magnetic field. The number of days of magnetic storm in various periods were also correlated with the hospital admissions for the corresponding times. Though owning that there are a host of uncontrolled variables in the situation, Friedman et al. hope that some of the effects of these are reduced by randomisation within a larger sample. They also hope to overcome confusion caused by the unknown interval between a geomagnetic event and its significant effect on the organism by studying various intervals between the two. In fact, a significant linear relationship was found following the periods of magnetic storm, and the commonest interval seemed to be nearer 35 days than 7 days. These workers believe these correlations are surprisingly large in view of the diversity of the two variables under study and the grossness of the measures used. But there was no indication whether or not magnetic field intensity per se was the significant influence. It is certainly a far cry from psychiatry to meteorology, and there will be few who understand enough of both subjects to be able to look at these results critically. Perhaps, as Friedman et al. claim, this is a " hitherto neglected dimension in the complexity of psychopathology...". If so, the new building of the Institute of Psychiatry in London may include a weather station. ILLEGAL ABORTION
ANALYSING the available statistics on illegal abortion, Goodhartat one point reaches the surprising conclusion that at present a woman runs hardly more risk from undergoing criminal abortion than from having a baby. Undoubtedly most doctors, and public opinion in general, would always advise a woman against seeking illegal abortion-on the grounds that she is throwing herself open to the most appalling risks. But is this reason sound ? An answer requires a knowledge of the number of deaths due to criminal abortion and the total number of such abortions. The number of deaths attributable to procured abortion i§ derived by Goodhart mainly from the three successive Reports on Confidential Enquiries into Maternal Deaths in England and Wales for the periods 1952-54, 1955-57, and 1958-60. Their figures are based on death certificates completed by the patients’ own doctors, in which no indication is required of whether the abortion was procured or natural. " Confidential inquiries " later determine, as far as possible, which of them might have been illegally induced abortions, and the proportion is roughly 60%. This is judged to be a reasonably accurate assessment, made by independent assessors who were able to give their opinion without fearing the consequences to the patients. These figures in fact show that the actual number of deaths attributed to illegal abortion has declined during the years under review-from 108 to 82. The number of deaths due to abortion from other causes has also decreased. Goodhart next considers three estimates of the total annual number of illegal abortions-Mr. Aleck Bourne’s 1.
Goodhart, C.
B.
Eugen. Rev. 1964, 55,
197.
372
50,000,2 Mrs. Margaret Pyke’s 109,500,3 and that of the
Interdepartmental Committee on Abortion (1939), which was 110,000 to 150,000. If the true figure lies between 50,000 and 100,000, the illegal-abortion death-rate is between 35 and 94 per 100,000. The maternal-mortality rate for the same period was 32-6. If the highest figure (150,000) for procured abortion is correct, then the deathrate from abortion is considerably lower than that from childbirth (corrected, of course, to exclude abortion deaths). Clearly surprised himself
at this result, Goodhart is doubt all the estimates of total abortion, and to suggest that the true figure is nearer 10,000 per year. Then the death-rate in illegal abortion would be 350 in the period 1958-60-which is about the same as for normal childbirth in 1928-30. He admits that this figure is only a guess, and is probably too low, but.he thinks it may be no further from the truth than the others five or ten times higher that are now generally accepted. Certainly the total number of deaths from abortion has been dropping. It seems probable that the death-rate has fallen too, parallel with the fall in maternal deathrate, and for the same reason-that is, the gain in new therapeutic agents. Every doctor in general or obstetrical practice has had to treat septic or incomplete abortion probably of criminal origin; and treatment is usually successful. There are certainly no official figures, or even guesses, at the extent of this morbidity of criminal abortion. In any case, even if a healthy young woman contemplating abortion is facing little risk, it is still a tragedy that she should be facing any risk at all.
inclined
to
STERILISATION BY RADIATION
ITEMS of medical and surgical equipment made of plastic or other sensitive materials are hard to sterilise by reliable methods; but many of them are now available as pre-packed sterile disposable products or have been redesigned to permit sterilisation by heat. Nevertheless a number of special items will probably continue to present a sterilising problem for some time-particularly in teaching hospitals or research units where new techniques are being developed. Ethylene oxide is a possible solution, but, as we pointed out," the need for close bacteriological supervision and the high capital cost of suitable equipment limits its usefulness. Irradiation by gamma rays is an obvious alternative; but- in the past this has meant that the hospital must make an individual arrangement with the U.K. Atomic Energy Authority or one of the other operators of a cobalt-60 sterilising unit. Although these requests have always been sympathetically received, there has been an increasing need for an organised irradiation service freely available to all hospitals. We therefore welcome the Radiation Sterilisation Service5 recently opened by the Wantage Research Laboratory of the Atomic Energy Authority. Subject to an upper limit of size and weight, wrapped parcels of material may be sent for irradiation. After they have received a dose of 2-5 megarads, they are returned intact to the senders, normally within 10 days although urgent requests can usually be dealt with in 1-3 days. For this service a small charge is made based on the rate of 13s. 9d. for a standard carton of size 13 by 2. Spectator, March 22, 1963, p. 365. 3. Eugen. Rev. 1963, 55, 71. 4. Lancet, 1962, i, 732. 5. An explanatory leaflet can be obtained free of charge from Irradiation Service (Hospitals), Wantage Research Laboratory (A.E.R.E.),
Wantage, Berks.
111/2 by 81/2 in. tainty that the
In view of the time, service saves, this
trouble, and uncercharge is entirely
reasonable. A MEDICAL SCHOOL FOR SIERRA LEONE
IF ever the emerging countries of Africa are to achieve the ideal and man their own medical services with homeproduced graduates, they must have their own medical schools. The difficulties, however, are formidable. A medical school cannot survive in a vacuum. The surrounding areas must provide it not only with money but with teachers, technicians, nurses, and students, In many parts of Africa the only hope of producing these lies in the school itself: and the great difficulty, therefore, is how to begin. Sierra Leone already had an established university college at Fourah Bay, Freetown. The question then arose of providing it with a medical faculty. The Government had planned a national hospital to be built near the college, and the proposed faculty was to be set up in conjunction with this. Faced with the task of drawing a blueprint for the school, Fourah Bay College asked the University of Durham to send out experts to consider whether the idea of a medical school was a good one, whether it was practicable, and if so how it should be realised. Durham sent a surgeon, Prof. A. G. R. Lowdon, and a physiologist, Prof. A. A. Harper, who collaborated with Dr. J. M. Weir of the Rockefeller Foundation. In May, 1962, after studying the issues at first hand, this 3-man commission returned its recommendations to the
college.1 be
A medical school,it agreed, was needed; and this should one able to train its students to an internationally
standard. But, before anything could be done about the school itself, other things would have to be attended to. There were, for instance, not enough properly trained nurses in the country to staff a new teaching hospital. The first step was therefore to set up a national school of nursing at one of the existing hospitals and to find more nursing tutors to staff it. Similarly, there were not the radiographers, physiotherapists, pharmacists, or technicians that would be needed in the hospital. These ancillaries would have to be trained at medical schools in the United Kingdom until the necessary courses could be developed in their own country. Furthermore, teaching at the national would have to be supplemented at some of the hospital in Alterations to these were Freetown. special hospitals be going to required-in particular, the provision of student accommodation-and these should be put in hand at once. The commission suggested that the medical school itself should adopt a five-year integrated curriculum on lines similar to the one recently introduced at Durham. Premedical studies in chemistry, physics, and biology would be succeeded by four years’ instruction in the structure and function of the body in health and disease; and in the fifth year the student’s clinical work in the wards could be intensified by giving him a series of responsible appointments in them. This plan emphasises the essential unity of medical studies, and at the Fourah Bay school it would have the additional advantage of doing away with any splitting of the faculty into
acceptable
1.
Report of the Commission Appointed to Advise on the Possibility of Establishing a Medical Faculty at Fourah Bay College, The University College of Sierra Leone, in conjunction with the Building of a National Hospital. Sierra Leone Government. Pp. 22.
then something more than " encouragement might be required. It is clear that the authors of the report neither advise nor expect their detailed proposals for each region to be realised immediately. But these proposals should, on the one hand, give the Secretary of State for Scotland, and possibly also his colleagues south of the Border, a firm basis on which to build, and, on the other, guide regional boards on the deployment and build-up of the medical staffs as their resources allow. Regional boards will clearly have to ask themselves, however, whether a similar review of other types of staff might not have revealed equal or greater deficiencies. "
WEATHER AND MENTAL STATE
IN the popular imagination, the full moon is a time of doubly barred doors and wholesale cancelling of leave in mental hospitals. Medical interest in the relation of environmental change to mental state now seems to be shifting to variations in the Earth and its climate. To take a negative report first, Pokorny et al.l studied the 67 suicides and 373 attempted suicides which were recorded in Houston, Texas, during 1960, and in which the time of occurrence could be established (there were another 24 suicides and 27 attempts in which the time was unknown). Eleven weather variables were then examined; the distribution of each for all hours of the year was obtained, and this was compared with the distribution at times when a suicide or attempt occurred. No single significant relationship was found. Nor was there any association with the 28 northerly fronts which occurred in 1960, with moon, or with season. Pokorny et al. believe that the many reported claims of such connections are based on poor, inaccurate data, and that apparent relationships disappear when the very uneven distribution of weather conditions throughout a year is carefully examined. " Though the Texas climate is described as highly changeable and strenuous ", the rapid spread in the use of air-conditioning from 1949 to 1961 has not been accompanied by any decrease in suicide-rates. Pokorny et al. acknowledge that people’s mood varies with the weather, but believe that these responses are a far cry from the degree of mental upheaval associated with suicide. In this country, Stengel and Cook2 studied five groups of attempted suicides at London hospitals and found that, in all but one group, there was a peak in one of the spring months. But if the numbers out of each group are added together for each successive month, no significant difference is found throughout the year. On the other side of the coin, Friedman et awl. believe there has not been enough systematic investigation into the relation of physical forces of the natural environment to human behaviour. This, they think, may be due to " the lack of that type of theoretical framework which could permit the inter-relationship of the two parameters to be derived as a logical consequence ". It has been suggested that the direct-current electrical system of an organism could be conceived of as a control system which could be influenced by external forces such as magnetic fields, When psychiatric admissions to two hospitals in Syracuse, New York, were correlated over a four-year period with readings from a magnetic observatory, there 1. Pokomy, A. D., Davis, F., Harberson, W. Amer. J. Psychiat. 1963, 120, 377. 2 Stengel, E., Cook, N. G. Attempted Suicide. London, 1958. 3
Friedman, H., Becker, 200, 626.
R.
O., Backman,
C. H.
Nature, Lond. 1963,
seemed to be a relationship between psychiatric disturbance and some geophysical factor associated with the magnetic field. Friedman et al. now report an extension of this study in which they recorded daily admissions to
eight psychiatric hospitals (totalling 28,642) over a period of four years. For the same period, they studied the K index, which reflects the amplitude of the most disturbed component of the magnetic field. The number of days of magnetic storm in various periods were also correlated with the hospital admissions for the corresponding times. Though owning that there are a host of uncontrolled variables in the situation, Friedman et al. hope that some of the effects of these are reduced by randomisation within a larger sample. They also hope to overcome confusion caused by the unknown interval between a geomagnetic event and its significant effect on the organism by studying various intervals between the two. In fact, a significant linear relationship was found following the periods of magnetic storm, and the commonest interval seemed to be nearer 35 days than 7 days. These workers believe these correlations are surprisingly large in view of the diversity of the two variables under study and the grossness of the measures used. But there was no indication whether or not magnetic field intensity per se was the significant influence. It is certainly a far cry from psychiatry to meteorology, and there will be few who understand enough of both subjects to be able to look at these results critically. Perhaps, as Friedman et al. claim, this is a " hitherto neglected dimension in the complexity of psychopathology...". If so, the new building of the Institute of Psychiatry in London may include a weather station. ILLEGAL ABORTION
ANALYSING the available statistics on illegal abortion, Goodhartat one point reaches the surprising conclusion that at present a woman runs hardly more risk from undergoing criminal abortion than from having a baby. Undoubtedly most doctors, and public opinion in general, would always advise a woman against seeking illegal abortion-on the grounds that she is throwing herself open to the most appalling risks. But is this reason sound ? An answer requires a knowledge of the number of deaths due to criminal abortion and the total number of such abortions. The number of deaths attributable to procured abortion i§ derived by Goodhart mainly from the three successive Reports on Confidential Enquiries into Maternal Deaths in England and Wales for the periods 1952-54, 1955-57, and 1958-60. Their figures are based on death certificates completed by the patients’ own doctors, in which no indication is required of whether the abortion was procured or natural. " Confidential inquiries " later determine, as far as possible, which of them might have been illegally induced abortions, and the proportion is roughly 60%. This is judged to be a reasonably accurate assessment, made by independent assessors who were able to give their opinion without fearing the consequences to the patients. These figures in fact show that the actual number of deaths attributed to illegal abortion has declined during the years under review-from 108 to 82. The number of deaths due to abortion from other causes has also decreased. Goodhart next considers three estimates of the total annual number of illegal abortions-Mr. Aleck Bourne’s 1.
Goodhart, C.
B.
Eugen. Rev. 1964, 55,
197.
372
50,000,2 Mrs. Margaret Pyke’s 109,500,3 and that of the
Interdepartmental Committee on Abortion (1939), which was 110,000 to 150,000. If the true figure lies between 50,000 and 100,000, the illegal-abortion death-rate is between 35 and 94 per 100,000. The maternal-mortality rate for the same period was 32-6. If the highest figure (150,000) for procured abortion is correct, then the deathrate from abortion is considerably lower than that from childbirth (corrected, of course, to exclude abortion deaths). Clearly surprised himself
at this result, Goodhart is doubt all the estimates of total abortion, and to suggest that the true figure is nearer 10,000 per year. Then the death-rate in illegal abortion would be 350 in the period 1958-60-which is about the same as for normal childbirth in 1928-30. He admits that this figure is only a guess, and is probably too low, but.he thinks it may be no further from the truth than the others five or ten times higher that are now generally accepted. Certainly the total number of deaths from abortion has been dropping. It seems probable that the death-rate has fallen too, parallel with the fall in maternal deathrate, and for the same reason-that is, the gain in new therapeutic agents. Every doctor in general or obstetrical practice has had to treat septic or incomplete abortion probably of criminal origin; and treatment is usually successful. There are certainly no official figures, or even guesses, at the extent of this morbidity of criminal abortion. In any case, even if a healthy young woman contemplating abortion is facing little risk, it is still a tragedy that she should be facing any risk at all.
inclined
to
STERILISATION BY RADIATION
ITEMS of medical and surgical equipment made of plastic or other sensitive materials are hard to sterilise by reliable methods; but many of them are now available as pre-packed sterile disposable products or have been redesigned to permit sterilisation by heat. Nevertheless a number of special items will probably continue to present a sterilising problem for some time-particularly in teaching hospitals or research units where new techniques are being developed. Ethylene oxide is a possible solution, but, as we pointed out," the need for close bacteriological supervision and the high capital cost of suitable equipment limits its usefulness. Irradiation by gamma rays is an obvious alternative; but- in the past this has meant that the hospital must make an individual arrangement with the U.K. Atomic Energy Authority or one of the other operators of a cobalt-60 sterilising unit. Although these requests have always been sympathetically received, there has been an increasing need for an organised irradiation service freely available to all hospitals. We therefore welcome the Radiation Sterilisation Service5 recently opened by the Wantage Research Laboratory of the Atomic Energy Authority. Subject to an upper limit of size and weight, wrapped parcels of material may be sent for irradiation. After they have received a dose of 2-5 megarads, they are returned intact to the senders, normally within 10 days although urgent requests can usually be dealt with in 1-3 days. For this service a small charge is made based on the rate of 13s. 9d. for a standard carton of size 13 by 2. Spectator, March 22, 1963, p. 365. 3. Eugen. Rev. 1963, 55, 71. 4. Lancet, 1962, i, 732. 5. An explanatory leaflet can be obtained free of charge from Irradiation Service (Hospitals), Wantage Research Laboratory (A.E.R.E.),
Wantage, Berks.
111/2 by 81/2 in. tainty that the
In view of the time, service saves, this
trouble, and uncercharge is entirely
reasonable. A MEDICAL SCHOOL FOR SIERRA LEONE
IF ever the emerging countries of Africa are to achieve the ideal and man their own medical services with homeproduced graduates, they must have their own medical schools. The difficulties, however, are formidable. A medical school cannot survive in a vacuum. The surrounding areas must provide it not only with money but with teachers, technicians, nurses, and students, In many parts of Africa the only hope of producing these lies in the school itself: and the great difficulty, therefore, is how to begin. Sierra Leone already had an established university college at Fourah Bay, Freetown. The question then arose of providing it with a medical faculty. The Government had planned a national hospital to be built near the college, and the proposed faculty was to be set up in conjunction with this. Faced with the task of drawing a blueprint for the school, Fourah Bay College asked the University of Durham to send out experts to consider whether the idea of a medical school was a good one, whether it was practicable, and if so how it should be realised. Durham sent a surgeon, Prof. A. G. R. Lowdon, and a physiologist, Prof. A. A. Harper, who collaborated with Dr. J. M. Weir of the Rockefeller Foundation. In May, 1962, after studying the issues at first hand, this 3-man commission returned its recommendations to the
college.1 be
A medical school,it agreed, was needed; and this should one able to train its students to an internationally
standard. But, before anything could be done about the school itself, other things would have to be attended to. There were, for instance, not enough properly trained nurses in the country to staff a new teaching hospital. The first step was therefore to set up a national school of nursing at one of the existing hospitals and to find more nursing tutors to staff it. Similarly, there were not the radiographers, physiotherapists, pharmacists, or technicians that would be needed in the hospital. These ancillaries would have to be trained at medical schools in the United Kingdom until the necessary courses could be developed in their own country. Furthermore, teaching at the national would have to be supplemented at some of the hospital in Alterations to these were Freetown. special hospitals be going to required-in particular, the provision of student accommodation-and these should be put in hand at once. The commission suggested that the medical school itself should adopt a five-year integrated curriculum on lines similar to the one recently introduced at Durham. Premedical studies in chemistry, physics, and biology would be succeeded by four years’ instruction in the structure and function of the body in health and disease; and in the fifth year the student’s clinical work in the wards could be intensified by giving him a series of responsible appointments in them. This plan emphasises the essential unity of medical studies, and at the Fourah Bay school it would have the additional advantage of doing away with any splitting of the faculty into
acceptable
1.
Report of the Commission Appointed to Advise on the Possibility of Establishing a Medical Faculty at Fourah Bay College, The University College of Sierra Leone, in conjunction with the Building of a National Hospital. Sierra Leone Government. Pp. 22.