Neonatal use of hexachiorophene To the editor: The editorial by Dr. E.M. Cooperman and the article by Dr. SI. Hnatko (Can Med Assoc J 117: 205, 223; 1977) illustrate very well the continuing controversy regarding the use of hexachlorophene. Although, as Dr. Cooperman points out, Dr. Hnatko's observations do not include the incidence of sepsis, the colonization rates tend to support the claim that there are effective methods for the control of neonatal sepsis other than the use of an agent known to be toxic, such as hexachlorophene. This is borne out also by the report of McHattie, Crossan and Talukdar.1 Others have reported failure to control outbreaks when hexachlorophene bathing is reinstituted and have suggested other control SA In the reports of outbreaks of staphylococcal infections epidemiologic evidence, supported by that of phage typing, has demonstrated that outbreaks caused by particularly virulent, invasive strains are much harder to control than are infections caused by the strains commonly found in any community. Unfortunately we have no laboratory methods for assessing relative virulence and therefore colonization rates have to be used as an indicator of relative risk to groups of infants; this leads to the question of the relative importance of different sites of colonization - for example, the nose, axilla, umbilical cord and perineum. Of these the umbilical cord stump appears to be of major importance. Dr. Cooperman advises the application to the cut surface of the cord of isopropyl alcohol or povidone iodine, and Dr. Hnatko uses chlorhexiContributions to the Correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten double spaced and, except for case reports, should not exceed 1½ pages in length.
dine combined with Cetrimide. Neither article mentions the routine use of triple dye, which has been the subject of a number of favourable reports.5-9 Considerable literature exists on the effectiveness of other antiseptics for the cord stump such as chiorhexidine in alcoholic solution, but the studies have been less conclusive. To the microbiologist the menace of any source depends on whether the number of potential pathogens is great or small. The warm, moist gel of the fresh cord stump is an excellent culture medium; if it is not treated effectively, large numbers of bacteria will be produced quickly. General body bathing has little effect on bacterial proliferation in the gel of the cord, as has been shown in several reports.2'3'7 D.H. STARKEY, Ml), FRC PATh, FRcP[c] Queen Mary Veterans Hospital Montreal, P0
References 1. McHATTIE JC, CROSSAN M, TALUEDAR C: A comparison of hexachiorophene and Lactacyd on growth of skin flora in healthy term newborn infants. Can Med Assoc J 110: 248, 1974 2. GEHLBACH SH, GUTMAN LT WILFERT CM, et al: Recurrence of skin disease in a nursery: ineffectuality of hexachiorophene bathing. Pediatrics 55: 422, 1975
3. HYAMS PJ, COUNTS GW, MONKUS E, et al: Staphylococcal bacteremia and hexachiorophene bathing: epidemic in a newborn nursery. Am J Dis Child 129: 595, 1975 4. Liowr IJ, SUTHERLAND JM: What is the evidence that hexachiorophene is not effective? Pediatrics 51: 345, 1973
5. JELLARD J: Umbilical cord as reservoir of infection in a maternity hospital. Br Med .1 1: 925, 1957
6. HARDYMENT AF, WILSON RA, COcKCROFT W,
et al: Observations on the bacteriology and epidemiology of nursery infections. I. Staphylococcal skin infections. Pediatrics 25 (suppl): 907, 1960 7. KATZMAN GH: Effects of triple dye in a staphylococcal outbreak (C). J Pedialr 86: 313, 1975 8. PILDEs RS, RAMAMURTHY RS, VIDYASAGAR D:
Effect of triple dye on staphylococcal colonization in the newborn infant. J Pediatr 82:
9. HARDYMENT AF, WILSON RA, COCKCROFT W, et al: Observations on the bacteriology and
epidemiology of nursery infections. III. Bacterial contamination of the umbilicus. Pediatrics 25 (suppl): 921, 1960
Management of cardiac arrest To the editor: I read with interest the article by Dr. Alam S. Khan (Can Med Assoc J 117: 162, 1977), in which he reviews many of the currently recommended steps in the management of cardiac arrest. However, there are major discrepancies from the present standards for basic life-support as recommended by the Canadian Heart Foundation and the American Heart Association. They stated that the initial step should be the recognition of unconsciousness followed by the opening of the airway, not the examination of the patient for such signs as a pulse, heart sounds or pupillary dilatation, as Khan recommends. Khan also states that the first step should include the determination of whether the patient should be resuscitated, and recommends that all this should be done before attending to the airway, breathing and circulation. Khan's recommendations for advanced life-support differ from those of the American Heart Association. These standards have not yet been adopted in Canada. Having recently completed instructor courses in basic and advanced cardiopulmonary resuscitation, I find that Khan's views are not in agreement with those taught in these training programs. Some of the inconsistencies may be debatable, particularly in the area of advanced life-support, but the standards for basic life-support recommended by the Canadian Heart Foundation should invariably be observed. All Canadian physicians should be familiar with these standards and it is highly desirable that as many as possible receive training in this important subject. While Khan should be congratulated for his attempt to introduce standards
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for cardiopulmonary resuscitation into Canadian medicine, it must be stated that they conflict with those generally recognized. K.G. FERGUSON, MD, FRCPIIC] Chief, department of emergency medicine Victoria Hospital London, Ont.
Report of the coronary artery surgery task force To the editor: The members of the task force deserve thanks for presenting an objective factual summary of the published data on aortocoronary bypass surgery (Can Med Assoc J 117: 451, 1977). They allude to the need for further study on the effect of this operation on mortality from ischemic heart disease, and suggest that some answers will be forthcoming from national randomized studies.1 Unfortunately none of the studies that are quoted are from Canadian centres, nor do they address themselves to the situation of the patient who is at risk from ischemic heart disease and is not "lucky" enough to suffer angina before his or her fatal myocardial infarction. He or she belongs to a much larger group than that under discussion in the published review. The need for a clinical indicator of ischemic heart disease is obvious angina is one that is easily recognized - so that patients may be assigned to a subset and subjected to randomized trials. In our concern for the obvious, we have been timid in approaching the less obvious, but larger, population of patients who die suddenly without premonitory symptoms. It is extremely unusual for a patient who is not having cardiac pain to undergo surgery. An internationally known and respected cardiac surgeon was recently criticized for operating on a group of patients with critical coronary artery stenosis in the absence of cardiac symptoms (40% had had an unheralded myocardial infarction). This criticism is unjustified if one asks the question Should one wait for the development of angina or the patient's acute myocardial event before recommending surgery? and Could aortocoronary bypass delay or forestall this event? Unfortunately, in this review randomization was not carried out into control and treatment groups so these questions are not answered. Canada is in an excellent position to consider this large subset. The communication that exists between our medical schools and their cardiovascular disciplines and, in turn, their affiliation with the Canadian Cardiovascular Society and the Canadian Heart Foundation put an onus on our
spokesmen in these organizations to initiate cooperative trials in Canada. DAVID A. MURPHY, MD Maritime Heart Centre Halifax, NS
Reference I. RUSSELL RO, MORASKI RE, KoucHouKos N, et al: Unstable angina pectoris: national cooperative study group to compare medical and surgical therapy. I. Report of protocol and patient population. Am I Cardiol 37: 896, 1976
Is gynecology good for obstetrics? To the editor: I agree wholeheartedly with Dr. H.B. Atlee's comments on this subject (Can Med Assoc J 117: 287, 1977). The medical profession has made pregnancy and delivery much safer for both mother and baby than they were 50 years ago, but has intervened, sterilized and monitored to the point of dehumanization. In the search for high-risk pregnancies we often lose sight of the fact that most pregnancies are "normal". In how many normal pregnancies are the risks increased by such common forms of intervention as elective induction, artificial rupture of the membranes, prescription of diuretics or sedatives, and the use of epidural anesthesia and the consequent necessity of forceps delivery? The average mother-to-be begins labour unprepared to meet its stresses. How many of us answer her questions and deal with her worries with a hearty back-slap and a "Don't worry about a thing my dear. We'll look after everything for you"? She arrives at hospital in the grip of tremendous physical and emotional forces. Instead of being supported and encouraged she is immediately stripped of husband, clothes, dignity and pubic hair. If she becomes upset she is sedated or given epidural anesthesia. In reaction to this dehumanizing process (or is it in self-defence?) more and more parents-to-be are turning to groups such as the International Childbirth Education Association to become informed about the normal processes of pregnancy, labour and delivery, the dangers of unnecessary intervention, and how they as a team can help themselves maintain control of their labour and delivery. An increased number of couples are even demanding home confinement to preserve the beauty and dignity of their childbirth. Marshall Klaus's well publicized work on maternal-infant bonding is causing many couples to question our hospital postpartum practice of almost immediate separation of child from mother and only brief, scheduled contacts thereafter. We doctors who practise obstetrics
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must watch for risk factors, complications and problems (including psychologic). In a normal pregnancy we must assume a lifeguard role - we cannot swim for our mothers-to-be but must be ready to save them if they need us. Normal pregnancy is not a disease demanding a cure from us; it is a tremendously powerful creative force requiring our support. As Dr. Atlee suggests, we must emphasize its physiology, not its pathology. PHILIP E. SHEA, MD 833D Upper James St. Hamilton, Ont.
Is there any lasting effect of foreign medical development? To the editor: From 1964 to 1968 a group of Canadian physicians and nurses were involved in a service and hospital development program in Kluang, Ja hore, Malaysia. The Kluang District Hospital is situated 129 km north of Singapore and serves a population of 50000. This project was supported by private Canadian donors and administered through CAREMEDICO. Many of the volunteers were influenced by the work and books of Dr. Tom Dooley. After his death Dooley's medical service organization in Vietnam and Laos was taken over by CARE and the program was expanded rapidly to include hospital development and teaching as well as direct patient care. Over the 4-year period of service by the Canadian group many changes were made in the hospital in Kluang. A central sterile supply room to service the operating facilities was designed and built and the local staff was instructed in its use. A modern sterilizer was added. An intensive care unit was provided that introduced a new concept to the staff. The laboratory, which hitherto had been able to carry out only simple tests, was upgraded to include within its scope a wide range of biochemistry, bacteriology and hematology. A blood bank was established. These changes were instituted only after the spending of much time in consultation with the Malaysian physicians in attendance at the hospital. During the time in which the new developments were taking place, Malaysian and MEDICO physicians provided medical services in the wards and outpatient department. Canadian nurses and laboratory technicians worked with their Malaysian counterparts. The MEDICO team believes that any development project should operate a complete preplanned course that includes a deliberate phase-out period in order that MEDICO may serve to in-