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RESUSCITATION OF THE NEWBORN
347
wartime rise and post-war fall in the death-rate was associated with the development and alleviation of a wartime food deficit. The timing and extent of the food deficit are indicated by the wartime decline in food imports, which represented the principal source of staple foods for Ceylon. Following the war, food imports again increased sharply and by 1947 exceeded the pre-war level. The mortality trends were especially correlated with the levels of nutrition rather than availability of health services. The relationship between mortality trends and levels of living is also indicated by comparisons of the direction and timing of concurrent changes in a range of economic and social indices. Thus, in 1947, when the death-rate had returned from a wartime peak to the previous long-term downtrend, personal consumption at constant prices had risen sharply above the level of 1938, whereas per-capita health expenditures had remained at the 1938 level. It is evident that levels of living and mortality trends in Ceylon have displayed a remarkable inverse association. Beginning with 1938, mortality was cut in half when personal consumption had doubled in the course of about 15 years.5 It may seem as if my intention has been to exonerate malaria control from undue blame for a population explosion in Ceylon. Rather, malariologists should not claim undue credit for the reduction in mortality. In fact, a reduction in mortality is a good thing. Aside from humanitarian considerations, increasing longevity provides increasing returns from investments in human resources. Moreover, a reduction in mortality may contribute toward a balancing reduction in fertility.s Aside from environmental factors that influence the size of family needed, wanted, or accepted, one might consider those factors that influence the active or passive achievement of a given family size. In the face of declining mortality or increasing survival of children, parents will need and may want to limit fertility to achieve the customary or a more practical family size. The incipient reduction of island-wide fertility, following the reduction in mortality, suggests that Ceylon is repeating the historic process of economic and demographic transition from low to high levels of consumption and production, and from high to low levels of mortality and fertility. As levels of living rise, mortality declines. In a balancing movement, fertility tends toward approximate equilibrium with mortality. The feedback mechanism of this system of hommostasis has been obscured by attempts to relate reductions in fertility exclusively to improvements in economic and social components in the levels of living; in fact a deliberate reduction in fertility may be a sequel to a reduction in mortality, which develops individual and collective motivation, as well as need, for a commensurate restraint of fertility. Population and Program Analysis Division, Population Service, Agency for International Development,
Washington,
D.C.
HARALD FREDERIKSEN.
HEALTH AND SOCIAL SERVICES SIR,-It is with concern that I have read the paragraph in the Seebohm report on the social services7 dealing with the proposed future of the local-authority child-guidance services. These at present provide a full psychiatric service, including treatment, for the greater part of the child population of this country; the National Health Service provides few childguidance clinics, except in the big cities. The Seebohm report proposes that the new social-services department of the local authority should take over the staffs of the childguidance centres, that the role of the psychiatrist should be largely advisory, and that children needing treatment should be referred elsewhere, presumably to clinics run by the N.H.S., which do not exist in most areas. Unless the Government is willing and able to provide and staff such clinics, the adoption 7. Report of the Committee on Local Authority and Allied Personal Social Services. H.M. Stationery Office, 1968. See Lancet, July 27,
1968, p. 201.
of this report will
that children in need of psychiatric be able to get it. Enfield Child Guidance Clinic, ALAN S. CLARK. Enfield, Middlesex.
treatment will no The
mean
longer
RESUSCITATION OF THE NEWBORN SiR,ńThe debate on the recommendation of the Central Midwives Board, that all midwives should be taught to intubate the apnoeic newborn infant as part of their routine training, ought surely to be settled in terms of the effects on the clinical status of the potential patients rather than on the professional status of the potential midwives.2 The essential point was made by Dr. Rosen and Professor Mushing and I should like to strongly support them. Inflation by bag and mask with an oropharyngeal airway in position is a procedure which can be easily learnt and safely and efficiently carried out by the occasional operator (as we have proved in the special-care nursery of this hospital over the past 5 years): intubation is not (as anyone knows who has the responsibility of training a succession of new resident medical staff). Only when faced with the need to apply the procedure almost daily (and nightly) in a wide variety of babies in real life-or-death situations can anyone, whatever his background, acquire the necessary skill and judgment, which can then be maintained by regular but relatively infrequent repetition. A very few midwives working in certain very active hospital units may need to be trained to intubate, at the discretion of those who are clinically responsible for the welfare of the patients: the remainder, who form the vast majority, are much more likely to do an efficient job without the same risk of causing harm, if they are taught to use a bag and mask to deal with the very occasional unforeseen emergency. How occasional this should be for the domiciliary midwife is illustrated by the finding of the Newcastle Maternity Survey,3 carried out at a period (1960-62) before the city’s midwives had been equipped with bag and mask. It was found that in only one out of every thousand deliveries in the home could a more effective method of resuscitation conceivably have been of benefit: this would be once in a professional lifetime in domiciliary midwifery. Our midwives are now equipped with such a method-bag and mask, and oro-
pharyngeal airway. Paediatric Research Unit, Princess Mary Maternity Hospital, Great North Road, Newcastle upon Tyne 2.
G. A. NELIGAN.
SIR,-Endotracheal intubation is invaluable for babies who need it, but dangerous, whether they need it or not, when
clumsily performed or attempted, as Dr. Towers points out (July 27, p. 218). Professor Scott (July 20, p. 167), and Dr. Barrie and the Central Midwives Board4 apparently consider that midwives should add this skill to their repertoire. Certainly a midwife can become just as dexterous as a doctor, but how can this proficiency be achieved and maintained ? Setting aside the actual selection of cases deemed to require intubation, the technique can be fairly easily demonstrated on models and cadavers, but to carry it out in the living patient with dexterity, speed, and gentleness, is an art not easily come by. Only by sustained endeavour can the essential skill be reached, and by constant practice maintained. Dr. Rosen and Professor Mushin1 have made this quite clear. To remain proficient the operator must be doing endotracheal intubation every day, preferably several times a day. Here in this small unit which deals only with abnormal midwifery, of the roughly 500 babies delivered annually by midwives (coesarean sections and other deliveries by doctors, such as
forceps
and breech
extractions, excluded)
about
1%might
Rosen, M., Mushin, W. W. Lancet, 1968, i, 1307. Scott, J. S. ibid. July 20, 1968, p. 167. Russell, J. K., Fairweather, D. V. I., Millar, D. G., Brown, A. M., Pearson, R. C. M., Neligan, G. A., Andersen, G. S. ibid. 1963, i, 711. 4. Barrie, H. ibid. 1968, i, 1103.
1. 2. 3.
348 benefit from intubation. Some of them get it, usually from a handy anxsthetist, if one is around. Each midwife therefore might expect a chance to do it once in 6 years. Who then but an anaesthetist, an E.N.T. surgeon, or a dedicated pxdiatrician with a zest for intubation, working in a large unit, can hope to keep in practice ? The provision of a plentiful and regular supply of infant cadavers for practice might provoke critical comment, and I gravely doubt the efficacy of such models as are available in reproducing the actual difficulties of the
procedure. The recommendation of the C.M.B. is impracticable, and therefore a potential danger. It were better to aim at having an expert on ready call, or in small units where this is not possible to instruct the midwives in keeping the airway clear, and in mouth-to-mouth respiration and/or the use of the Blease-Samson respirator, in combination with Williams’ cuffed stomach tube.5 This latter simple device can be used by any midwife, and prevents gastric distension and regurgitation of stomach contents during insufflation of the lungs. Tyrone County Hospital, Omagh, Co. Tyrone, N. Ireland.
J. H. PATTERSON.
MORTALITY AND HARDNESS OF WATER SIR,-Dr. Crawford and her colleagues (April 20, p. 827) showed a relation between hardness of water and mortality, but gave no evidence as to the duration of exposure to soft water which might be necessary to produce the effect. Although the closest correlation found was with calcium the possibility that the effect was due to some other constituent of hard water was not
disproved.
Since 1958 the naturally hard water from chalk boreholes in part of north Lincolnshire has been softened by base-exchange resins which replace the calcium ions with sodium, and adjusted to a calcium level of about 40 p.p.m., before distribution. The neighbouring part of north Lindsey, served by a different water board, has continued to distribute hard water from boreholes in the same aquiferous layer. In an attempt to ascertain whether or not artificial softening of water might be detrimental
compared the mortality-rates, for men and aged 45-64, in local-authority areas served by the two water boards, and the results are given in the accompanying table. Unfortunately the details of deaths by age and sex necessary to make such comparisons have been issued to medical officers of health by the Registrar General only since 1964. The figures for 1964-67 represent on the average the effect of exposure to an artificially softened water for 7 years, to
health I have
women,
but a small part of the area continued to receive a hard water from a limestone source until 1959, since when a water softened by a modified Clarke’s process has been distributed. Thus part of the population had been exposed to soft water for only 6 years by the middle of the period for which mortality figures Williams, G. F., Beasley, W. H. ibid. 1964, ii, 443; 860. Williams, G. F. Personal communication.
5.
Br. med.
J. 1965, ii,
Death-rates (per 100,000) from cardiovascular disease (figures from article by Dr. Crawford and her colleagues) and from all causes in men, aged 45-64, compared with these rates in Scunthorpe (after 7 years’ supply of artificially softened water) and Grimsby and Cleethorpes (supplied with hard water).
available. Although a similar comparison between the two before the introduction of softening is desirable in order to ascertain whether their mortality-rates already differed as a result of social or environmental influences, the necessary data are not at present available to me. Without these data these results cannot be taken to prove the case, but their close agreement with the findings of Dr. Crawford and her colleagues (see figure) is highly suggestive. The closeness of agreement between figures from areas where the water is artificially softened by the mere substitution of sodium ions for calcium ions and those from areas with natural supplies having the same calcium-ion concentration strongly supports the hypothesis that calcium is the element responsible. In addition, since these figures relate to a population which has had softened water for so short a period as 7 years it seems that the effect may result from the water currently consumed and does not require a lifetime of exposure. I hope later to be able to make comparisons between the figures for these areas before the introduction of softening. If any other areas where artificial softening is practised could be compared the resulting informaare
areas
COMPARISON BETWEEN DEATH-RATES IN AREAS WHERE A NATURALLY HARD WATER HAS BEEN ARTIFICIALLY SOFTENED FOR A PERIOD OF 7 YEARS WITH ADJACENT POPULATIONS CONSUMING SIMILAR UNSOFTENED WATER
Populations taken from *
the 1966 Sample Census. Deaths taken from the Registrar General’s form S.D.25 for the years Calcium level decreased by base-exchange process from 119 p.p.m. down to 40 p.p.m. since 1958.
1964, 1965, 1966, and 1967.
wartime rise and post-war fall in the death-rate was associated with the development and alleviation of a wartime food deficit. The timing and extent of the food deficit are indicated by the wartime decline in food imports, which represented the principal source of staple foods for Ceylon. Following the war, food imports again increased sharply and by 1947 exceeded the pre-war level. The mortality trends were especially correlated with the levels of nutrition rather than availability of health services. The relationship between mortality trends and levels of living is also indicated by comparisons of the direction and timing of concurrent changes in a range of economic and social indices. Thus, in 1947, when the death-rate had returned from a wartime peak to the previous long-term downtrend, personal consumption at constant prices had risen sharply above the level of 1938, whereas per-capita health expenditures had remained at the 1938 level. It is evident that levels of living and mortality trends in Ceylon have displayed a remarkable inverse association. Beginning with 1938, mortality was cut in half when personal consumption had doubled in the course of about 15 years.5 It may seem as if my intention has been to exonerate malaria control from undue blame for a population explosion in Ceylon. Rather, malariologists should not claim undue credit for the reduction in mortality. In fact, a reduction in mortality is a good thing. Aside from humanitarian considerations, increasing longevity provides increasing returns from investments in human resources. Moreover, a reduction in mortality may contribute toward a balancing reduction in fertility.s Aside from environmental factors that influence the size of family needed, wanted, or accepted, one might consider those factors that influence the active or passive achievement of a given family size. In the face of declining mortality or increasing survival of children, parents will need and may want to limit fertility to achieve the customary or a more practical family size. The incipient reduction of island-wide fertility, following the reduction in mortality, suggests that Ceylon is repeating the historic process of economic and demographic transition from low to high levels of consumption and production, and from high to low levels of mortality and fertility. As levels of living rise, mortality declines. In a balancing movement, fertility tends toward approximate equilibrium with mortality. The feedback mechanism of this system of hommostasis has been obscured by attempts to relate reductions in fertility exclusively to improvements in economic and social components in the levels of living; in fact a deliberate reduction in fertility may be a sequel to a reduction in mortality, which develops individual and collective motivation, as well as need, for a commensurate restraint of fertility. Population and Program Analysis Division, Population Service, Agency for International Development,
Washington,
D.C.
HARALD FREDERIKSEN.
HEALTH AND SOCIAL SERVICES SIR,-It is with concern that I have read the paragraph in the Seebohm report on the social services7 dealing with the proposed future of the local-authority child-guidance services. These at present provide a full psychiatric service, including treatment, for the greater part of the child population of this country; the National Health Service provides few childguidance clinics, except in the big cities. The Seebohm report proposes that the new social-services department of the local authority should take over the staffs of the childguidance centres, that the role of the psychiatrist should be largely advisory, and that children needing treatment should be referred elsewhere, presumably to clinics run by the N.H.S., which do not exist in most areas. Unless the Government is willing and able to provide and staff such clinics, the adoption 7. Report of the Committee on Local Authority and Allied Personal Social Services. H.M. Stationery Office, 1968. See Lancet, July 27,
1968, p. 201.
of this report will
that children in need of psychiatric be able to get it. Enfield Child Guidance Clinic, ALAN S. CLARK. Enfield, Middlesex.
treatment will no The
mean
longer
RESUSCITATION OF THE NEWBORN SiR,ńThe debate on the recommendation of the Central Midwives Board, that all midwives should be taught to intubate the apnoeic newborn infant as part of their routine training, ought surely to be settled in terms of the effects on the clinical status of the potential patients rather than on the professional status of the potential midwives.2 The essential point was made by Dr. Rosen and Professor Mushing and I should like to strongly support them. Inflation by bag and mask with an oropharyngeal airway in position is a procedure which can be easily learnt and safely and efficiently carried out by the occasional operator (as we have proved in the special-care nursery of this hospital over the past 5 years): intubation is not (as anyone knows who has the responsibility of training a succession of new resident medical staff). Only when faced with the need to apply the procedure almost daily (and nightly) in a wide variety of babies in real life-or-death situations can anyone, whatever his background, acquire the necessary skill and judgment, which can then be maintained by regular but relatively infrequent repetition. A very few midwives working in certain very active hospital units may need to be trained to intubate, at the discretion of those who are clinically responsible for the welfare of the patients: the remainder, who form the vast majority, are much more likely to do an efficient job without the same risk of causing harm, if they are taught to use a bag and mask to deal with the very occasional unforeseen emergency. How occasional this should be for the domiciliary midwife is illustrated by the finding of the Newcastle Maternity Survey,3 carried out at a period (1960-62) before the city’s midwives had been equipped with bag and mask. It was found that in only one out of every thousand deliveries in the home could a more effective method of resuscitation conceivably have been of benefit: this would be once in a professional lifetime in domiciliary midwifery. Our midwives are now equipped with such a method-bag and mask, and oro-
pharyngeal airway. Paediatric Research Unit, Princess Mary Maternity Hospital, Great North Road, Newcastle upon Tyne 2.
G. A. NELIGAN.
SIR,-Endotracheal intubation is invaluable for babies who need it, but dangerous, whether they need it or not, when
clumsily performed or attempted, as Dr. Towers points out (July 27, p. 218). Professor Scott (July 20, p. 167), and Dr. Barrie and the Central Midwives Board4 apparently consider that midwives should add this skill to their repertoire. Certainly a midwife can become just as dexterous as a doctor, but how can this proficiency be achieved and maintained ? Setting aside the actual selection of cases deemed to require intubation, the technique can be fairly easily demonstrated on models and cadavers, but to carry it out in the living patient with dexterity, speed, and gentleness, is an art not easily come by. Only by sustained endeavour can the essential skill be reached, and by constant practice maintained. Dr. Rosen and Professor Mushin1 have made this quite clear. To remain proficient the operator must be doing endotracheal intubation every day, preferably several times a day. Here in this small unit which deals only with abnormal midwifery, of the roughly 500 babies delivered annually by midwives (coesarean sections and other deliveries by doctors, such as
forceps
and breech
extractions, excluded)
about
1%might
Rosen, M., Mushin, W. W. Lancet, 1968, i, 1307. Scott, J. S. ibid. July 20, 1968, p. 167. Russell, J. K., Fairweather, D. V. I., Millar, D. G., Brown, A. M., Pearson, R. C. M., Neligan, G. A., Andersen, G. S. ibid. 1963, i, 711. 4. Barrie, H. ibid. 1968, i, 1103.
1. 2. 3.
348 benefit from intubation. Some of them get it, usually from a handy anxsthetist, if one is around. Each midwife therefore might expect a chance to do it once in 6 years. Who then but an anaesthetist, an E.N.T. surgeon, or a dedicated pxdiatrician with a zest for intubation, working in a large unit, can hope to keep in practice ? The provision of a plentiful and regular supply of infant cadavers for practice might provoke critical comment, and I gravely doubt the efficacy of such models as are available in reproducing the actual difficulties of the
procedure. The recommendation of the C.M.B. is impracticable, and therefore a potential danger. It were better to aim at having an expert on ready call, or in small units where this is not possible to instruct the midwives in keeping the airway clear, and in mouth-to-mouth respiration and/or the use of the Blease-Samson respirator, in combination with Williams’ cuffed stomach tube.5 This latter simple device can be used by any midwife, and prevents gastric distension and regurgitation of stomach contents during insufflation of the lungs. Tyrone County Hospital, Omagh, Co. Tyrone, N. Ireland.
J. H. PATTERSON.
MORTALITY AND HARDNESS OF WATER SIR,-Dr. Crawford and her colleagues (April 20, p. 827) showed a relation between hardness of water and mortality, but gave no evidence as to the duration of exposure to soft water which might be necessary to produce the effect. Although the closest correlation found was with calcium the possibility that the effect was due to some other constituent of hard water was not
disproved.
Since 1958 the naturally hard water from chalk boreholes in part of north Lincolnshire has been softened by base-exchange resins which replace the calcium ions with sodium, and adjusted to a calcium level of about 40 p.p.m., before distribution. The neighbouring part of north Lindsey, served by a different water board, has continued to distribute hard water from boreholes in the same aquiferous layer. In an attempt to ascertain whether or not artificial softening of water might be detrimental
compared the mortality-rates, for men and aged 45-64, in local-authority areas served by the two water boards, and the results are given in the accompanying table. Unfortunately the details of deaths by age and sex necessary to make such comparisons have been issued to medical officers of health by the Registrar General only since 1964. The figures for 1964-67 represent on the average the effect of exposure to an artificially softened water for 7 years, to
health I have
women,
but a small part of the area continued to receive a hard water from a limestone source until 1959, since when a water softened by a modified Clarke’s process has been distributed. Thus part of the population had been exposed to soft water for only 6 years by the middle of the period for which mortality figures Williams, G. F., Beasley, W. H. ibid. 1964, ii, 443; 860. Williams, G. F. Personal communication.
5.
Br. med.
J. 1965, ii,
Death-rates (per 100,000) from cardiovascular disease (figures from article by Dr. Crawford and her colleagues) and from all causes in men, aged 45-64, compared with these rates in Scunthorpe (after 7 years’ supply of artificially softened water) and Grimsby and Cleethorpes (supplied with hard water).
available. Although a similar comparison between the two before the introduction of softening is desirable in order to ascertain whether their mortality-rates already differed as a result of social or environmental influences, the necessary data are not at present available to me. Without these data these results cannot be taken to prove the case, but their close agreement with the findings of Dr. Crawford and her colleagues (see figure) is highly suggestive. The closeness of agreement between figures from areas where the water is artificially softened by the mere substitution of sodium ions for calcium ions and those from areas with natural supplies having the same calcium-ion concentration strongly supports the hypothesis that calcium is the element responsible. In addition, since these figures relate to a population which has had softened water for so short a period as 7 years it seems that the effect may result from the water currently consumed and does not require a lifetime of exposure. I hope later to be able to make comparisons between the figures for these areas before the introduction of softening. If any other areas where artificial softening is practised could be compared the resulting informaare
areas
COMPARISON BETWEEN DEATH-RATES IN AREAS WHERE A NATURALLY HARD WATER HAS BEEN ARTIFICIALLY SOFTENED FOR A PERIOD OF 7 YEARS WITH ADJACENT POPULATIONS CONSUMING SIMILAR UNSOFTENED WATER
Populations taken from *
the 1966 Sample Census. Deaths taken from the Registrar General’s form S.D.25 for the years Calcium level decreased by base-exchange process from 119 p.p.m. down to 40 p.p.m. since 1958.
1964, 1965, 1966, and 1967.