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418 MATERNAL MORTALITY IN AUSTRALIA. THE number of maternal deaths which occur in connexion with every thousand live births in Australia shows a steady rise since 1922, having remained more or less stationary during the previous ten years. The maternal death-rate in 1928 was 5’ 98, the highest yet recorded, and the Commonwealth of Australia invited Dame Janet Campbell, senior medical officer for maternity and child welfare at the Ministry of Health, to visit each of the States and to advise what measures should be tried to cope with the distressing situation. Dame Janet has now returned and her report, of which the substance was com- municated verbally on Tuesday to a group of interested people, has been issued as a white papery In it she deals comprehensively with the local problem, review- ing existing facilities for maternal and child welfare and making pertinent suggestions for future action. The steady reduction of the infantile mortality of Australia from 96 per 1000 births at the beginning of this century to 52 in 1928 is an achievement to which she accords due praise. The neonatal death- rate (deaths under one month) is, however, less encouraging, and a table of death-rates of infants under one week shows that this rate is actually higher now in Australia as a whole and in all the States except Western Australia than it was 20 years ago. The significance of these deaths within a few days of birth is their association with obstetric and developmental, rather than with paediatric causes, and it is through care of the parturient mother that improvement in the infantile mortality will be obtained. Though certain hospitals in Australia (for example, the Queen Victoria Memorial Hospital in Melbourne) have a well-organised prenatal department, prenatal work has scarcely developed at a 1 in connexion with the fairly numerous infant welfare centres. Dame Janet Campbell’s suggestions for further action include the provision of improved professional education in midwifery and antenatal and infant hygiene, since much advance will have to be made before all doctors practising in Australia are willing and competent to undertake the regular supervision of pregnant women. The expansion of the place occupied by midwifery in the medical curriculum offers more hope than the organisation of post- graduate instruction in such a large continent, where isolated practitioners may find it difficult to take advantage of any facilities provided in the great towns. As to the midwive?, though the regulations for their training are similar in the different States, the practice varies considerably and the laxity of administration in certain schools requires attention. Dame Janet condemns small training schools, where the lecture or coaching is merely an incident in the work of a busy practitioner or matron and gives cogent reasons why maternity hospitals for private patients only should not be recognised as training schools. It would be better in the long run, she holds, to train a smaller number of midwives than to allow certification after instruction which falls far below the accepted minimum requirements. In connexion with training in mothercraft, emphasis is laid on the desirabi ity which would hardly be questioned in this country of leaving to the discretion of those responsible in each recognised institution for mother- craft the question of modifying or varying the details of instruction. " Diversity of medical opinion and practice in regard to infant feeding in Australia and elsewhere indicates that there can be no sterotyped or standard method applicable to every infant under all circumstances and suggests that the ordinary baby is tolerant of, and can even thrive upon, comparatively widely different dietaries." The administrative changes advised concern mainly the need for revision on uniform lines of the returns required on death certificates, the desirability of registration of still- 1 births, of compulsory notification of births to the 1 1929. Commonwealth of Australia Department of Health. 32 foolscap pages. Canberra : H. J. Green, Government printer. authorities concerned with infant welfare (not yet in force in all parts of Australia), and of puerperal fever. 3. The establishment of a maternity service whereby i, any woman can obtain facilities for the satisfactory ,. conduct of a normal or a difficult confinement and the 3 development of infant and child welfare services "under ; medical supervision " are also recommended. In the absence of a completely organised public health service ’ under local authorities, Dame Janet advises: (a) the establishment in each State of a Division of maternity and child welfare, in charge of a whole-time medical director responsible to the chief medical l officer of health ; this Division might design a . general and comprehensive scheme of action which . should not necessarily be applicable at once in its i entirety. Propaganda publicity should be encouraged and the cooperation of women’s organisations : enlisted. The other major recommendations made are : (b) the granting of subsidies, properly conditioned and adequately supervised, towards the extension and improvement of the work for maternal, infant, and child hygiene; and (c) the encouragement and subsid sing of research into various aspects of such activities. TETRACHLORETHYLENE AND HOOKWORMS. IT is at last becoming possible to form a fairly sound opinion of the value for a hookworm campaign of tetrachlorethylene, the anthelmintic introduced by Maurice C. Hall and J. E. Shillinger 1 about five years ago. P. D. Lamson and his colleagues 2 have studied its anatomical and physiological effects on animals. The hepatic neccs’s, so pronounced after administration of carbon tetrachloride (CCl, is quite absent in dogs after tetrachlorethylene (O,Cl4). This is so even when the stomach has been filled up by the drug, when it has been given in doses of 2 c.cm. per kg. every second or third day for several months, or when the dog has been kept anaesthetised by its inhalation for several hours. Fatty change had previously been noted in the liver, but Lamson’s report suggests that it is no greater in these drugged dogs than in ordinary animals. The kidneys were unaltered in structure, nor could changes be detected in hepatic function. The experiments show further th it normally the drug does not pass the dog’s liver, and that this organ disposes of it without evident damage to itself. If, however, the dog be fed with fat symptoms of absorp- tion appear ; and such symptoms are indeed the rule, apart from diet, in puppies, and to an even greater degree in certain other animals. Clearly the experi- mental evidence cannot exclude the suggestion that absorption may take place in man. From the clinical side P. A. Maplestone and A. K. Mukerji 3 have studied tetrachlorethylene at the Carmichael Hospital, Calcutta. Giddiness, vomiting, or drowsiness occurred in 8 of 38 hospital cases receiving 3 c.cm. of the drug. When it was combined witt 1 c.cm. of oil of chenopodium these toxic symptoms appeared in 26 of 37 cases. The drugs were given in capsules, so it must be assumed that absorption occurred from the alimentary canal and that the drug passed through the liver ; clinical evidence upholds the caution that the effects on the full-grown dog cannot be held fully evidential for man. These writers also investi- gated the worth of tetrachlorethylene against hook- worms, using more exact diagnostic methods than had hitherto been employed. Counting by Stoll’s caustic soda method the number of hookworm eggs passed before and after the treatment mentioned, the relative figures led to the conclusion that 60 per cent. of the worms had survived. By Clayton Lane’s direct centrifugal floatation (D.C.F.) they obtained the added information that 80 per cent. of their patients remained infected, and they cite one series of 12 cases in 8 of whom Stoll’s technique discovered no eggs after treatment, whereas D.C.F. showed that actually 11 of them remained infected. It is pointed out that 1 Amer. Jour. Trop. Med., 1925, v., 229. 2 Amer. Jour. Hyg., 1929, ix., 430. 3 Ind. Med. Gaz., 1929, lxiv., 424.
