The Prevention of Disease in Infancy and Childhood

Kai Tiaki : the journal of the nurses of New Zealand, Volume XVI, Issue 4, 1 October 1927, Page 178

The Prevention of Disease in Infancy and Childhood

M. WILSON

ARTHUR

D.S.O. M.D. B.S.

Lecturer m Obstetrics and Gynaecology, Melbourne University, Senior Hon. Obstetric Surgeon, Women's Hospital, Melbourne.

THE PROBLEM. (This subject will be approached and treated from the viewpoint of the obstetrician.) The causes of foetal " dead-births " are intimately related to the causes of neonatal deaths and of disease m infancy and childhood. Unfortunately — except from hospital statistics — owing to the inefficient registration and notification of " dead-births," the actual causes of the " dead-births " cannot be ascertained. The position would be greatly improved if a certificate showing the cause of the " dead-birth " had to be given with all viable foetuses. The fcetal existence may be divided into three stages : — (a) Ante-natal: i.e., m the quiescent uterus. (b) Intra-natal : i.e., during labour. (c) Post-natal: i.e., after birth before the pulmonary respiration has been established. Pulmonary respiration is the test to apply m deciding whether the fcetus has been dead-born or not. The continance of the heart-beat is merely the extrauterine continuance of the normal intrauterine condition. Foetal Death: This may occur during any stage of its existence : — (a) Ante-natal death: i.e., during pregnancy . In this condition the foetus is born m a macerated or mummified condition. (b) Intra-natal death: i.e., during labour. In this condition the foetus appears quite normal. (c) Post-natal death: i.e., after labour but before the establishment of pulmonary respiration. In this condition the fcetus is born with its heart still beating. Ante-Natal Causes of Death: (1) Maternal; Chronic nephritis; syphilis : toxaemias, especially eclampsia

— acute febrile infections; trauma; sudden shock or fright. (2) Placental: Degenerative conditions of Placenta, especially if associated with eh. nephritis ; premature separation of the placenta with cases of A.P.H. (3) Fostal: Very rarely is it due to foetal conditions, but it sometimes occurs with malformations. Chronic nephritis, syphilis and Toxaemias are by far the commonest causes. Repeated habitual ante-natal death of the foetus has been described. Sometimes no cause can be assigned, usually one of the three above-mentioned conditions may be found. A full-time macerated foetus m the absence of chronic nephritis, Toxaemia, or Trauma is very suggestive of syphilis. Intra-Natal Death: This is practically always due to asphyxia or birth injury. Asphyxial Death: Any condition causing interference with the placental respiration will ultimately cause fcetal death. If it is not severe enough to cause death, the foetus will be born m a condition described as asphyxia neonatorum. Owing to the disturbance of the placental respiration, there is an increase of CO2 m the blood and the respiratory centre may be first stimulated before it becomes paralysed. As a result the foetus makes premature attempts at inspiration and may suck into its lungs liquor amnii or blood. This stimulation of the respiratory centre is more likely to occur where the interference with the placental respiration has been rapid. The increased intra-thoracic pressure causes venous obstruction all over the body, and if the condition persists the cardiac centre is also paralysed and the foetus dies. The Causes of Asphyxial death: (1) Premature detachment of the placenta. (2) Compression of the Cord.

(3) Compression of Placenta. (4) Compression of Foetus. Deaths from Injuries: The commonest causes are head injuries — associated with cerebral haemorrhage. Fractures of the bones, even if depressed do not as a rule cause death, unless. they are associated with cerebral haemorrhage, the commonest accompanying lesion being a laceration of the tentorium cerebelli. One quarter of all intra and post-natal foetal deaths is due to injury — the remaining three-quarters are due to asphyxia. Cerebral injury and haemorrhage are usually caused by extreme compression and moulding of the head, but occasionally they occur m apparently normal labours. Causes: (1) Forceps delivery, especially if much traction is used, also if forceps are applied m the wrong position on the head, and if applied too early before the head is well moulded. The tip of the blade, if it lies m the wrong situation, may actually cause a depressed fracture. A depressed fracture associated with haemorrhage may also occur when the head is pulled past the promontory. (2) By compression of the head, m rapid delivery of the after-coming head m ing a precipitate labour. (3) With abnormally soft foetal heads, especially with premature infants, and also m attempts to rotate a P.O.P. Postal-Natal Foetal Death: This is due either to occlusion of the respiratory tract by mucus sucked m by premature attempts at respiration or by paralysis of the respiratory centre either by asphyxia, birth injuries, or drugs given late m labour .(especially morphia). The foetal death rate is alarmingly high, as the following figures show: — Dead PerPlace. Confinement. Births, centage. Victoria (1923) .' . 35,876 1,056 2.9 Victoria (1924); .. 26,139 1,087 3 Women's Hospital, Melb., (1925-1926) 2,717 149 5.5 The causes of foetal ''dead-birth" have been discussed m some detail as minor degrees of the same causative conditions

may cause neo-natal death and a still lesser degree may result m some disability, disease or disorder during infancy and childhood. Neo-Natal Death: There is some divergence of opinion as to what constitutes the neo-natal period. Some authorities reserve the term for the first fortnight after the birth of the child. On the other hand, it is much more convenient to count this period as extending over the first four weeks as undoubtedly the commonest causes of death during this period are obstetrical rather than nutritional. It is quite obvious, however, that though many of the obstetrical causes of death are preventable, many are quite unavoidable. In dealing with the causes of neo-natal death, the vital statistics are of some value, as m these cases the obstetrician is required to give a certificate stating the cause of death. Causes of Neo-Natal Death: (a) Under-development of the vital centres owing to prematurity, especially if associated with malnutrition of the infant due to some existing maternal disorder, especially Toxaemia of pregnancy, syphilis and chronic nephritis. (b) Malnutrition and debility of the infant owing to the presence of the above constitutional disorders. (c) Birth injuries, especially cerebral haemorrhage. The severity of the problem of neonatal .death may be gauged from the following figures : — NoeNatal PerPlace. Live Births. Deaths, centage. Victoria (1925) .. 35,922 *1,110 3.09 Victoria (1924) .. 36,139 +1,159 3.21 Women's Hospital, Melb., (1925-1926) 2,568 f72 8.8 *First month. fFirst two weeks. Of the 1,159 neo-natal deaths occurring m Victoria m 1924, 751 died within the first week. The causes of death were given as follows : — Prematurity . . . . . . 568 Wasting Diseases . . . . 137 Diarrhoeal Diseases . . . . 14

Bronchitis and Pneumonia . . 47 Convulsions . . . . . . 27 Congenital Defects .. .. 110 Violence . . . . . . . . 4 Other Causes (including Birth injuries) . . . . - • 246 At the Melbourne Women's Hospital, out of 152 cases of neo-natal death specially investigated, the causes of death were as follows : — Prematury . . . . . . 60 Birth Injuries . . . . . . 35 In considering the statistics of the State, I am strongly of the opinion that the proportion of deaths from birth injuries is greater than would appear from the statistics. The classical signs and symptoms (increased tension of anterior fontanelle, head retraction, convulsions, meningeal cry), are often absent. The baby may lie perfectly quiet and flaccid refusing to suck, the anterior fontanelle may be depressed, and there may be rapid loss of weight. The cause of death m such a case is frequently given as congenital debility, heart disease, or malformation. Here again the question of neo-natal death has been somewhat fully discussed, as it is quite evident that many infants, after surviving some neo-natal illness or disorder are condemned therefrom to various diseases and disabilities not only of childhood, but also of adult life. The problem to be solved may be approximately stated to be as follows : — For every 100 births, there are three dead births ; of the surviving infants another three die within the first month, and another two die within the next eleven months, some a result of neo-natal disturbance, others from nutritional and infectious disorders. The prevention of the " dead-births," neo-natal deaths, and a small proportion of the deaths occurring within the 2-12 month period, are m the hands of the obstetrician — the remainder m the hands of the pedriatrician. In comparing infantile vital statistics, especially as regards dietetics, a much fairer test is the mortality m the 2-12 month period, as I believe that very few of the deaths occurring during the first month are due to improper feeding — though undoubtedly

the foundation of the nutritional disorder is laid extremely frequently during this period. The Prevention: The three cardinal rules of obstetrics are :— (1) Care m the ante-natal period. (2) Care m the intra-natal period. (3) Care m the post-natal period. We all do not have the same operative ability, or manual dexterity, neither do we all possess m equal degree that indefinable quality known as "brains"; yet we should all have an equal capacity for being careful with our patients. In obstetrics carefulness counts more on most occasions than skilfulness. I believe that at present the great hope of improvement m the foetal (and also maternal) mortality rate lies m the development of a strong obstetric conscience m all practitioners and nurses, and m the education of the public to seek efficient medical and nursing attention under suitable conditions. Ante-Natal Care: During pregnancy the border line between the physiological and pathological is very slender ; therefore all patients must be carefully watched for the appearance of the pathological. Dame Janet Campbell's words are worth quoting: — "Until ante-natal supervision is accepted by patients and their advisers as the invariable duty of the professional attendant engaged for the confinement, we shall never make sustantial progress toward the reduction of maternal death and injury. It is the key to success m any scheme of prevention and it must be insisted on, until it is recognised as a necessary and integral part of the management of every confinement case."

The details of the routine ante-natal examinations have been so frequently discussed that it is hardly necessary to reiterate them again. However, a note of warning should be sounded. Antenatal care should not mean increased interference on the part of the obstetrician. The early diagnosis of some pathological condition should m many cases enable the obstetrician by treatment to Once again convert the case from the abnoj-

mal to the normal, and thus should limit the appearance of an acute obstetrical emergency necessitating some hasty, drastic treatment. Very briefly may be mentioned the most important conditions which should be sought for are: — Disproportion, pelvic deformity, malpresentations and malpositions, toxaemias of pregnancy, constitutional complications of pregnancy (especially chronic nephritis), cardiac and pulmonary disease, and venereal disease. Limiting the further remarks to the constitutional disorders, I would like to a breech. This may also occur durIncidentally, Fowler and Fairley showed the almost impossibility of converting a positive test itno a negative test during pregnancy. Nevertheless, efficient treatment would undoubtedly improve the prognosis both for mother and child. The value of ante-natal care is well exemplified by the results obtained at the Melbourne Women's Hospital last year. Number of Cases, Maternal Deaths, Foetal Deaths (Dead Births & Neo-Natal Deaths). Ante-natal Cases .. 1,281 2 84 6.6% Emergency Cases .. 1,399 26 127 10% Intra- Natal Care: Watchful expectancy and masterly inactivity on the part of the obstetrician will bring most cases to a successful termination. Nine cases out of ten will be perfectly normal if they are only left alone. The normal case will be much better off without a doctor than with one that interferes unnecessarily. The abuse of the obstetrical forceps leaves behind a ghastly train of dead, dying and damaged infants. This is neither the time nor the place to enter into a dissertation upon the uses and abuses of the obstetrical forceps, yet the commonest causes of difficult forceps deliveries may be mentioned: — (a) Premature application of forceps. (b) Faulty application of the forceps. (c) Unrecognised disproportion. The Prevention: (a) Waiting until it is apparent that no further descent of the foetal head will occur. (b) Correct application of forceps. (c) Ante-natal supervision.

Too often is it assumed that because a primigravida has entered the second stage of labour that she is " ready." There is only one almost safe forceps operation, i.e., the head-on-perineum operation. Especially should two types of foetuses be delivered without forceps if possible — the premature foetus, and the foetus with the abnormally soft head. Whilst admitting that birth injuries associated with cerebal haemorrhage do. occur m normal deliveries, nevertheless it must be admitted that the majority occur with forceps and breech deliveries. The elimination of these injuries would limit to a great degree many of the neonatal disasters and the disorders and diseases of infancy. Post- Natal Care: Unfortunately there is a tendency amongst some obstetricians to regard their work as finished once the infant has been safely delivered, and their subsequent attentions are devoted to the mothers whilst the infants are left to the tender mercies of the nurses. The causes of death during the postnatal period are mainly obstetrical — this period marks the commencement of various nutritional disorders which may cause many months of disease and disorder m infancy and childhood. The importance of breast feeding simply cannot be over-estimated. In many infants — after an exhausting and difficult labour — the sucking reflex may be weak owing to some slight cerebral haemorrhage m oedema. Unfortunately, m many cases it is assumed that the breast secretion is at fault and the infant is promptly put on to some artificial food, whereas, with the exercise of some patience, this difficulty would be overcome. Here also must be deprecated the indiscriminate giving of castor oil, brandy, artificial foods during the first week of the infant's life. A few of the commoner neo-natal disorders may be mentioned. The immense death rate m premature infants calls for some comment. Undoubtedly the slender chance of survival m many of these infants is lost m the first five minutes subsequent to their birth, They are allowed

to get cold, and the greatest difficulty is then experienced m getting their temperature up again. A warmed blanket and crib should be prepared before their arrival, and immediately after birth the infant should be wrapped up m the blanket whilst the obstetrician Avaits for the cord to stop pulsating. It is astonishing how well these infants do — even m spite of severe syncopal attacks during the first few weeks — provided that efficient care is given to them. In my own practice I never give brandy to premature infants. With regard to the treatment of cerebral haemorrhage m the new-born, I have seen infants improve and survive after a lumbar puncture, but I have yet to see one that has grown up into a perfectly normal child. The morbus haemorrhagica neonatorutn is very satisfactorily treated by muscular injections of the mother's "whole" blood. Umbilical sepsis accounts for far more deaths and ill-health during the ante-natal period than is usually supposed, and consequently m the management of the stump-cord, rigid aseptic precautions should be adopted. In conclusion, I should like to call your attention to the following table which has been copied from Dr. Marshall Allan's interim report on maternal morbidity and mortality m Victoria. TABLE V.— INFANT MORTALITY, VICTORIA.

It will be noted that the number of deaths under one month has remained practically constant, whereas the number over one and under twelve months has been considerably reduced. It has been remarked that the chief causes of death m the first month are due to syphi-

lis and slovenly obstetrics, and m the next eleven months to food and flies. The pedriatricians have accomplished much — the next great improvement m the infant mortality must come from the obstetricians, and this can only be obtained by the exercise of increased care during the ante-natal, intra-natal and post-natal periods. lay great stress on the importance of chronic nephritis during pregnancy. Apart from the danger to the mother, chronic nephritis is one of the most common causes of premature labours and of dead-births. During the year 1925-1926 at the Women's Hospital, Melbourne, out of 28 maternal deaths, 11 cases (confirmed P.M.) showed evidence of chronic nephritis or toxaemia. With regard to the venereal diseases, the treatment of gonorrhoea during pregnancy is most unsatisfactory. However, by prophylactic treatment, the incidence of ophthalmia neonatorum should be negligible. During the puerperium, gonorrhoea, whilst being a potent cause of maternal morbidity, is not a great cause of maternal mortality. Syphilis presents a most interesting problem. Fowler and Fairley reported m the A.M.J. of December 24th, 1921, a series of 750 consecutive Wasserman tests done on patients at the Women's Hospital; 53 (7.5%) were positive.

These figures agreed closely with a smaller series taken at the Women's Hospital some years previously by Allen Robertson. The most striking fact elicited was the latency of the condition. Many of the pregnant women could give no history of infection. They had no symptoms and showed no signs, and many of the infants appeared quite healthy at birth.

There is only one solution of this problem. The Wasserman test should be made on all women attending the antenatal clinics and also the foetal blood obtained from the umbilical cord could be tested. The expense and the technical difficulties would be great — but the return would be far greater.

Number of Period. 1881-1890 1891-1900 1900-1904 1905-1909 1910-1914 1915-1919 1920-1924 1925 E D )eaths per Thousand Births. Over 1 and Under 1 Under 12 Under 1 Month. Months. Year. 37.2 89.4 126.6 33.8 77.9 111.7 34.3 63.7 98.0 32.9 48.0 80.9 32.6 41.2 73.8 33.4 32.7 66.1 33.0 32.3 65.3 30.9 26.1 57.0