12

RHEUMATIC HEART DISEASE. Number of cases in each grade: Grade I ~ 2 2 cases; Grade I I I = l l cases; Grade I V = 7 cases.

Grade I I = 2 8 cases;

Stillbirths :

1. A grade I, mitral stenosis and regurgitation with acute nephritis, at 27 weeks. Intra-uterine death at 32 weeks. 2. Grade I, mitral stenosis, spontaneous onset of labour. No obvious cause for stillbirth. 3. Grade III, mitral stenosis, age 29 years, admitted at 36½ weeks, spontaneous stillbirth 4 weeks later. Weight 3 lb., 7 oz. Grade I I I on discharge. 4. Grade III, mitral stenosis and aortic incompetence. Admitted at 32 weeks with hypertension and a trace of albumin. At 38 weeks induction of labour with acute cyanotic attack following an enema. Spontaneous onset of labour 6 days later. Weight 3 lb., 8 oz. Neonatal Deaths :

1. Grade I, mitral stenosis, forceps at 32 weeks for prematurity in multiple pregnancy. Abortions :

1. At 12 weeks, grade I, mitral regurgitation. 2. At 10 weeks, grade II, mitral stenosis. 3. Grade IV, admitted witk acute bronchitis, pyrexia, cyanosed. 5~%, shocked. Grade III on discharge.

Haemoglobin

Miscarriages :

1. Grade IV at 20 weeks with auricular fibrillation. Congestive heart failure previous pregnancy. An examination of these grades shows that in grade I there were 2 stillbirths, one abortion and one neonatal death ; in grade II there was an abortion ; in grade I I I there were 2 stillbirths and in grade IV, one abortion and one miscarriage. The cases of auricular fibrillation were all grade IV and in these there was just one abortion. One grade I H mitral ster~osis developed paroxysmal tacycardia at term. The results in these cases of rheumatic heart disease can be considered to be extremely satisfactory with the rigidly conservative method of treatment which we use. Only one case needed valvotomy during pregnancy, which was carried out in a general hospital at 20 weeks, and she was delivered spontaneously at 39 weeks. PH ILLIP BRENNAN.

PATHOLOGY. I n t h e preface to his clinical r e p o r t t h e M a s t e r has p a i d t r i b u t e t o t h e w o r k of t h e late Professor J o h n M c G r a t h on b e h a l f of t h e N a t i o n a l M a t e r n i t y H o s p i t a l . H e was P a t h o l o g i s t t o t h e h o s p i t a l u n t i l his d e a t h , a n d t h e p r e s e n t l a b o r a t o r i e s were p l a n n e d a n d e q u i p p e d b y h i m on t h e i n c e p t i o n of t h e n e w d e p a r t m e n t some t w e n t y y e a r s ago. T h e g r e a t e x p a n s i o n of t h e l a b o r a t o r y service w h i c h has b e e n possible o v e r these y e a r s is a t r i b u t e to his vision, a n d w h e n he s u c c e e d e d t o t h e c h a i r of P a t h o l o g y a t U n i v e r s i t y College, t h e link b e t w e e n his u n i v e r s i t y d e p a r t m e n t a n d t h a t at Holles S t r e e t was a source of special satisfaction t o him. H i s g e n e r o s i t y t o w a r d s a j u n i o r colleague was p r o v e r b i a l a n d e v e n in r e c e n t m o n t h s w h e n he n o longer e n j o y e d t h e v i g o r o u s h e a l t h one h a d a l w a y s associated w i t h him, his t i m e a n d energies were e v e r a t our disposal. I t m a y be recalled t h a t it was Professor M c G r a t h w h o i n t r o d u c e d t h e H o g b e n (Xenopus) t e s t to t h e N a t i o n a l M a t e r n i t y H o s p i t a l a t a t i m e w h e n t h e m e t h o d h a d g a i n e d little a c c e p t a n c e as a r o u t i n e d i a g n o s t i c t e s t for pregnancy. H e was confident t h a t in t i m e t h e n e w t e c h n i q u e could s u p p l a n t older and more cumbersome methods, and the department at the National M a t e r n i t y H o s p i t a l was a m o n g t h e first in these islands t o use t h e H o g b e n t e s t in r o u t i n e diagnosis. T h e d e p a r t m e n t was d o u b l y b e r e a v e d b y t h e d e a t h d u r i n g t h e y e a r of Dr. W . P. O ' C a l l a g h a n , a f o r m e r b a c t e r i o l o g i s t t o the h o s p i t a l a n d a close friend a n d colleague of Dr. MeGrath. A long illness h a d k e p t h i m o u t of t o u c h w i t h t h e h o s p i t a l laboratories for some

13 years before his death but in its formative years the department benefited immeasurably from his association with it. To have lost two such colleagues within a year is a grievous blow. As in previous years the volume of material reaching the laboratories continued to increase. The routine haematological and serological investigations now required for every patient availing of the ante-natal service have been concentrated in the new laboratory on the roof. This has proved a highly successful arrangement, and in addition, all the laboratory procedures attendant on blood transfusion are dealt with there. I m p r o v e d detection of Rh. immunisation in the mother seems to be reflected in the stillbirth and neonatal death rates attributed to haemolytic disease. We take this opportunity of thanking the new Master, Dr. Coyle and his predecessor, Dr. Barry, for their good offices in bringing to the notice of the hospital executive, the necessity for this new department. The hospital blood b a n k continues to operate successfully and results in a considerable saving in the annual cost of blood for transfusion. However, it was also necessary to avail largely of the services of the National Blood Transfusion, and we thank the medical director, Dr. O'Riordan, and his staff for their continued assistance during the year. All genotype determinations required in cases of Rhesus iso-immunisation are referred to Pelican House and without the technical resources of Dr. O'Riordan's organisation our investigation of these cases could not be maintained at an adequate level. I t is hoped that as a quid pro quo a reasonable supply of potent test sera will accrue to the National Blood Transfusion laboratories. The use of triple and quadruple strength reconstituted plasma (also supplied b y the National Transfusion Service) continued to yield satisfactory results in the management of fibrinopenia. In this connection it is interesting to note that a t t e m p t s to conserve expensive plasma b y employing lower strengths of the reconstituted material can prove wasteful. Unless the level of circulating fibrinogen can be raised fairly abruptly above a critical level no therapeutic effect m a y be apparent. Consequently it has been found that double strength plasma is often quite ineffective. Although the haemorrhagic complications associated with depletion of plasma fibrinogen seem now to be well controlled, a case of fatal anuria associated with accidental haemorrhage occurred during the year. The post-mortem findings are recorded in the appropriate table in this report. I t is interesting to note t h a t only tubular lesions were found and there was no glomerular destruction. I t is difficult to escape the conclusion t h a t given a sufficient period of survival this lesion is a reversible one. In obstetric practice at a n y rate, conventional methods of management in anuric patients do not seem adequate and the hospital authorities have recently been asked b y the Master to re-examine the question of securing some form of artificial kidney, or at least ensuring that the use of such a n apparatus with appropriately trained staff would be available to the hospital if required. A case of fatal haemorrhagic adrenal cortical necrosis was seen during the year. Details of the case are set out in the table dealing with maternal mortality. I t was interesting to compare the autopsy findings with those of a case of Waterhouse Friderichsen syndrome encountered in the hospital two years ago. In this most recent case, there were no pnrpuric phenomena, the adrenals while necrotic and haemorrhagic were not significantly enlarged and nothing in the clinical history or findings suggested a septicaemic basis for the adrenal lesion. The aetiology of these entirely spontaneous cases of acute adrenal lesions complicating pregnancy remains obscure. The routine autopsies in cases of stillbirth and neonatal death were extended during the past year to include a higher proportion of cases of

14 macerated stillbirth. However, during the closing montns of 1956 the hospital was invited to co-operate in a s t u d y of the causes of perinatal death, sponsored b y the World Health Organisation, to be undertaken simultaneously in this country, in Sweden and the Netherlands. I t is hoped t h a t in the course of the next two years every case of perinatal death occurring in the hospital will be subjected to intensive scrutiny. Hitherto it has been impracticable to m a k e extensive histopathological studies in the majority of these cases. I t will be interesting to see how much additional information as to the causes of death can be expected as a result of more detailed microscopic studies. During the .past year a monthly review of stillbirths and neonatal deaths occurring in the hospital was initiated b y Dr. Coyle at the commencement of his Mastership. Even without recourse to intensive histological studies a high proportion of cases examined yielded a clear cut cause of foetal death. Four cases of congenital interventricular septal defect were seen among the infants examined, and there was one case of extreme pulmonary stenosis. As in previous years intracranial haemorrhage, due to iniury to the dural septat, foetal anoxia resulting in failure of pulmonary expansion, and congenital anomalies accounted for the highest proportion of fresh stillbirths and neonatal deaths. Haemolytic disease of the foetus remains a formidable problem. With the increasing success of the Paediatricians in the management of icterus gravis neonatorum it is interesting to note the shift of emphasis which tends to take place towards the role of Rhesus isoimmunisation in the causation of stillbirth. The Staff of the infant's department are to be congratulated on the small amount of staphylococcal infection experienced among the babies. This seems to be a growing problem in modern hospital nurseries and on the gynaecological side of the hospital we were unfortunate enough to see a death from staphylococcal enterocolitis following the pre-operative prophylactic use of a broad spectrum antibiotic. The problem of breast abscess remains a m a j o r one. In virtually every case a coagulase positive staphylococcus aureus is isolated, but phage typing is not yet available to us. The antibiotic sensitivity patterns suggest t h a t a limited number of strains is involved. The routine diagnostic work of the department has become so extensive that during the past year it became necessary to recruit two additional trainee technicians, Miss Rosemary Kerrigan and Miss Brona Cusack joined the staff in the earlier months of the year and it is hoped that in time a proper subdivision of the work of the d e p a r t m e n t into its several categories will be achieved. Some additional structural work will be necessary and we were glad to have the co-operation of the Master in recommending the need for this to the hospital authority. A considerable number of patients referred b y general practitioners under the Health Act now attend the department for laboratory investigations, and while we have endeavoured to co-operate so far as possible, smooth working of the Act, so far as laboratory services are concerned has not yet been achieved. I t is hoped t h a t this will soon be reme~iied. Once again, we m u s t t h a n k Messrs. Roche Products, London, for their assistance in arranging the shipment of supplies of xenopus toads from Capetown for use in the pregnancy diagnosis laboratory. No pathology department could be more fortunate in its choice of technicians than t h a t of the National Maternity Hospital and it is once again a pleasant d u t y to t h a n k Mr. C. J. Conway and his Staff for their untiring service to the hospital throughout the year. Dr. C. J. V. Coyle as Master, in the best tradition of his predecessors, maintained the w a r m relations which have always existed between the pathology d e p a r t m e n t staff and our colleagues on the clinical side. F. GEOGHEGAN.