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    "title": "OBSTETRICS",
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    "verified_text": "since ro10 a striking change has occurred in the science of obstetrics and its practice, chiefly as the result of its invigoration by the spirit of preventive medicine. the term “ preventive medicine ” does not connote any special creed or peculiar doctrine in medicine. it is, in fact, merely an attitude of mind, which has developed slowly, but with increas- ing momentum during this century. lip service has always been given to the ancient platitude that ‘‘ prevention is better than cure,” but till a knowledge of the causes of disease and the man- ner of its spread was obtained, the translation of these words into action was scarcely possible. with concrete examples, such as those afforded by the adoption of listerian principles in surgery and midwifery, and generally by the lessened incidence of con- tagious and infectious diseases as their causation was worked out, the development and diffusion of preventive ideals throughout the whole of medicine has become easier and more general. this fresh mental attitude has produced a change of method through- out medicine, which might be described as the observation of the bodily functions in health and watching for the first sign of de- parture from the normal, rather than waiting till disease develops. its first object is to seek out the causes of disordered function and remove them before they can become operative and, in the second place, when these causes are unknown, to detect the early signs of deviation from normality and restore the normal before trouble arises. the maintenance of physiological function in all bodily systems is its aim so that the cure or relief of established disease becomes the final resource of medicine and marks the failure to attain its earlier objectives. ii obstetrics is regarded from this point of view the difference between the new and the old practice will become obvious. its immediate purpose will be to secure normal reproduction by de- tecting and removing all known causes of disorder of function and by observing the healthy pregnant woman from conception on- wards to discover any sign of departure from the normal, though a physiological state, pregnancy imposes a strain on the efficient working of every system of the body, and the thorough examina- tion of the state of health of mind and body of the woman carly in her pregnancy and further observation to see how she is standing the test seem but reasonable precautions. apart from those who have some organic weakness and may break down under the strain, there are disorders of function that may de- velop in those previously of sound physique. a special strain falls on the excretory organs, and the kidneys and the liver may be affected and lead to acute or chronic disease. hence the need 1095 for the routine and repeated examination of the urine. the good health of the mother throughout childbearing increases her re- sistance to infection (e.g., puerperal fever) and her efficiency in the rearing of her family. the care of the pregnancy itself is likewise a matter of greater concern than in the older obstetrics, not only because of the loss of prospective life, but because miscarriage is a prolific cause of operative interference, during or after its occurrence, and of in- fective and other diseased conditions of the reproductive tract and thus of subsequent disability. premature labour results in the birth of weakly infants dimcult to rear and is a prominent factor in the persistent high mortality among new-born infants. another important object of the supervision of the pregnant woman, that of foreseeing and avoiding difficultics and compli- cations during labour, provides the simplest illustration of the changed outlook in obstetrics. earlier methods —the usual custom of a generation ago was for the woman to retain her doctor for attendance on her confine- ment and for the doctor to do little more than note the expected date on which his services might be required. unless consulted by the patient because of some disturbance of health, he might not see her again until summoned at the onset of labour. he then made a thorough investigation to see if all was straight- forward or if there was any malpresentation or other difficulty, and was prepared to do his best to remedy any untoward condi- tion that mizht be present or arise later, often being exceedingly ingenious and resourceful in so doing. his obstetric training as a student had been directed largely toward teaching him the management of normal labour, the emergency treatment of abnormal presentations and obstructions to the passage of the foetus through the birth canal and other complications during | labour, and his reputation as an accoucheur was largely deter- mined by his capacity to cope with emergencies. new methods —the training of the modern student is con- ducted on other lines, and whenever a complication occurs the first question discussed is, “‘ could this have been foreseen? ” and if so, the next question is, ‘‘ what should then have been done? ” and a comparison of the case as he has seen it with what it might have been had the emergency been anticipated is used to impress on him that the sole criterion of sound obstetrics is the securing of natural parturition and the prevention of un- expected difficulties and complications so far as the present state of our knowledge allows. to avoid difficulties in labour, examination is begun about six weeks before the expected date of confinement in order to determine that the child is presenting normally and that there is sufficient accommodation in the bony pelvic canal to allow of its easy passage. this examination is repeated two or three times to make sure that no change has occurred in the presentation and position and that the child does not become unduly largegto pass readily. for the most part these matters can be determined with a fair degree of accuracy by the ordinary methods of ob- stetric examination, but in difficult and special cases examination under anaesthesia and by k-rays may be required. should it be discovered that even at six weeks before full time there will be difficulty in the child being born by the natural passages, because of rickety or other deformity of the pelvic bones, the question arises whether it is better to resign all hope of the delivery of a living child by the natural passages and perform caesarean section or to induce labour and jearn if the natural powers can effect the delivery of a small and premature infant. if there does not appear to be any obstruction at the time of the first examination but at a later one there is evidence of a tight fit, labour should be brought on then to avoid the risk of the child becoming too large to be born without difficulty. by eliminating difficulties due to disproportion in size between the child and the mother’s pelvic canal and such malpresentations as cross births and brow-presentations (which if allowed to 1096 remain instead of being changed would result in complete ob- struction) most of the serious difficulties in labour can be obviated in some way or other. the change in presentation and position of the child can be effected by manipulation through the ab- domen, if done before the child is too large to be moved readily, and in favourable cases and under anaesthesia sometimes even up to and after the onset of labour, but if left until the waters have broken or labour is advanced, requires internal opcrative procedures with their additional risks of injury and infection. in these instances the cause of difficulty can be anticipated and removed before labour begins, but there are also many con- ditions of which the cause is unknown so that the obstetrician must fall back on the second line of defence, that of discovering the earliest signs of disturbance, taking them as a warning of danger ahead and making the best possible dispositions. pre- mature detachment of the after-birth commonly shows itself by haemorrhage and all pregnant women whilst under supervision are warned to report at once any blecding, so that immediate measures may be taken to lessen the chances of serious conse- quences. albuminuria, discovered by frequent examination of the urine, oedema, excessive vomiting and visual disturbances are warnings of possible complication. prematernity supervision is in its infancy, but with experience of its working much more will be possible in the way of preven- tion. many of its problems have scarcely begun to be worked out and an example of one of the most outstanding of them is worth a little consideration as an example of the problems that obstetrics has to face. merely to accept the principle that its primary objective is to secure natural reproduction is not sufficient to change practice. it is also necessary to show where the methods hitherto adopted are harmful. by the infusion of preventive ideals the vision is widened beyond the treatment of the individual case and the nation’s maternal and infantile mortality and disability are brought under review. the success of obstetric methods must be tested by asking what price the nation pays in maternal mortality and disability for its new lives, and whether it obtains full value in new lives for the price paid. when those wider questions are looked into, there is little ground for complacency among those responsible for the obstet- ric practice of the country. there has been no reduction in maternal mortality equivalent to the drop in the general death- rate or to the remarkable fall in the infantile mortality, which has been halved since the beginning of this century. further analysis of the registrar-general’s figures in england and wales shows that septicaemia, a form of blood-poisoning practically eliminated from general surgery by the antiseptic and aseptic technique, is still too prevalent and still causes (as puerperal sepsis) about a third of the deaths in childbearing. the annual rate of maternal deaths per 1,000 live births registered in england and wales is a little under four mothers. in the bad years immediately after the war, the rate was over four per 1,000. this may not appear large but it means that about 3,000 women in the prime of life die in childbearing with the loss of their maternal care to many more young children, and of these mothers over 1,000 die from puerperal sepsis, a preventable disease. its prevention is a more complicated matter than, and a somewhat different problem from, that of surgical sepsis, because septic organisms may be present in the lower genital tract and spread upwards and into the blood stream, apart from any question of failure of aseptic technique on the part of the attendant. _ the statistics of all maternity hospitals show that fever in childbed increases with all complications and difliculties calling for internal manipulation, all of which tend to the introduction or upward spread of infective organisms. the more prolonged and the higber up the tract the manipulation, the greater is the incidence of fever. by far the commonest operative interference is delivery by the forceps because it is advocated by many merely in order to shorten the patient’s suffering. instead of trying to secure natural delivery in cases of weak utcrine action, a sub- stitute for the uterine power is adopted in the shape of the muscular power of the attendant exerted through the obstetric ocihanta forceps. the causes of weak uterine power are difficult to de- termine and often impossible to foresee, but here is a direction in which investigation is necessary. what is the meaning of the enormous increase in artificial deliveries, and, is the shortening of her time of pain worth the price of the additional risk? particularly calling for solution are the questions, how far modern social conditions have lessened the power of the woman of to-day to stand the hardship, fatigue, and mental and physical strain of child-birth and rendered her less capable of completing the expulsion of the child naturally than the mothers in the days before anaesthesia and frequent forceps delivery; what are the factors tending to produce this lessened capacity; and, how far are they removable? the obstetrical centre of gravity has thus been shifted back- wards from the care of labour to the supervision of pregnancy and a wider outlook over the reproductive cycle is taken so that the part played by obstetrics is seen as but part of the wider subject that is concerned with securing the health of the new gencration at the minimum of cost to the old. the prematernity supervision looks forward to the nursing of the child and the rearing of the family. it anticipates the natural feeding of the infant by removing all causes that may interfere with breast feeding. it has an educational side and endeavours to inculcate sound principles of hygiene in the preparation for, and the care of, the babe when born, because success in this direction will mean a better start for the new generation. the observation of the developing child falls to paediatrics and the two subjects, as maternity and child welfare, have become a duty and charge to local health authorities, and as such are well known to the public. in conclusion a tribute should be paid to the late dr. bal- lantyne of edinburgh, as the advooate of prematernity super- vision and the pioneer of the antenatal clinic, which more than anything else has served to further the permeation of obstetrics by the spirit of preventive medicine. see j. s. fairbairn, gynae- cology with obstetrics (1926). (j. s. fa.) oceania or oceanica (see 19.988).—this name, in cither form, is conveniently and not uncommonly used to cover all the small islands of the south pacific ocean which are not closely neighbouring to any of the larger lands, such as eastern asia and new guinea. the name is thus approximately equivalent to the former title south sea islands. the previous general survey of these islands is given under the heading pactric ocean (see 20.436). the war period.—ocearia was not wholly free of incident during the world war. very soon after the outbreak (aug. 30 1914) a new zealand expeditionary force occupied the former german island of western samoa; in sept. nauru surrendered to a vessel of the australian navy; and in sept.-oct. the japanese occupied the german caroline and mariana is- jands. german vessels of war were at large in the pacific at this time, and on sept. 7 1914, a landing party from the “nurnberg ” wrecked the pacific ‘ all red ” cable station on fanning i.; but communication was restored by the operator. moving eastward across the ocean, the german vessels bom- barded papeete, capital of the french island of tahiti, on sept. 22. later, the south pacific was outside the range of naval operations, and the remoteness of. some of the islands was exemplified when lord jellicoe on h.m.s. “ new zealand ” found in oct. 1919 three europeans confined on christmas i., and ignorant of the cessation of the war. apart from the occupation of samoa and the carolines, certain changes in government took place during the period of the war. the commonwealth govt. of australia took over the administration of norfolk i. in 1914, and the executive council was made in 1915 to consist of six elected members and _ six members appointed by the administrator. the gilbert and kllice is., previously a british protectorate, became a colony in 1916. ocean, fanning and washington islands were included jater in that year, and ocean i. became the seat of government. christmas i. was included in roto. the wallis and horne islands, previously a f'rench protectorate, were declarcd a colony in rgt7. this annexation had been proclaimed four years earlier, but opposition was fomented in fotuna (iforne is.) by oceanography roman catholic missionaries; and even in uvea (wallis), where the native chiefs had asked for annexation, french law could be only gradually introduced. the so-called four-power treaty signed on dec. 31 1921 by great britain, the united states, france and japan at the washington conference, defined the mandated territories and the respective sovereigntics in oceania (japanese in the carolire and marshall groups; australian in the former german new guinea and islands east of it; british over nauru) and specified those areas in which no further fortification should take place. japanese proceedings in the carolines under military admi=is- tration had previously evoked a good deal of criticism, especially in australia, partly on account of their secrecy and partly 01 strategic grounds. the civil administratioi was established under the mandate in april 1922. a substantial influx of japanese immigrants has taken place. an administrative system which, it was honed in some quar- ters, might be modified in course of the settlements after the war, but was not, was the anglo-french condomizium over the new hebrides. opinion has been frecly expressed in australia that the system is cumbrous and makes against progress, ard that the french interest should be abolished by purchase or ex- change, and the islands brought within the british sphere, under the imperial govt. or that of the commonwealth. population.—the populations, according to recent census figures or estimates, of the principal groups covered by this notice are as follows:— caroline, mariana, marshall and pelew is. (japanese), 52,222 including 3,671 japanese (1920). cook is., niue and other oceanic isi:ands belonging to new zca- land, 13,209 (1921). easter i. (chile), est. 300 (1922). fiji (british), 157,266 (1921), including 3,878 whites and 60,634 indians. gilbert and ellice is, (british), 29,897 (1921). marquesas is. (french), under 3,000 (1923). nauru (british), 2,166 (1922), including 110 whites and 900 labourers recruited from other islands, and chinese. new caledonia (french) 47,505 (1921), inclucing 16,794 whites and 3,618 asiatics. noumea, the capital, had 9,614 inhabitants, in- cluding 6,238 free whites and a penal clement of 600. new hebrides (anglo-french condominium), 55,000-60,000 natives: 275 british, 709 french, indo-chinese coolies and other immigrants, 1,032 (1923). tuamotu (paumotu) archipelago (french—the first 1s the proper form of the name), 3,715 (1924). ; samoa (new zealand), 37,299 (1924): (american), 8,194 (1922). society is. (french, including tahiti), 7,145 (1924). tonga (british protectorate), 24,935 (1921). tubuai is. (french), about 3,000. wallis is. (french), about 4,500. the decrease of native povulation continues in most of the islands; from whatever cause, the islands under french control, especially the socicty, tuamotu and neighbouring groups, appear to be specially affected. the french administrations have been criticised for lack of care for the wellbeing of the natives: in new caledonia they are said ‘to make little effort to put native labour to use, and indeed their control is rot wholly effective. there was a small native rising there in 1917. japanese, tonkinese and javanese labour is imported. the fijians and the gilbert and ellice islanders also diminish in numbers. in the latter colony the govt. enforces the prohibition of alcohol; but it is still urged that the adoption of european clothing, as the natives become better educated, weakens their resistance to pulmonary diseases. and not orly here, but in many parts of oceania, an influenza epidemic in 1918 caused many deaths—4,o00, for example, in tahiti, and 1,000 in tonga. nevertheless, there are exceptions to these unhappy con- ditions. thus american samoa was free of the epidemic, and the native population is estimated to have increased over 40 yo during 22 years of american control. native education has in some instances become a matter more of government concern and less exclusively in missionary hands. thus down to 1916 education in fiji was almost entirely a missionary organisation ; but the govt. then passed an act rendering all schools which comply with certain conditions eligible for state aid. the 1097 gilbert and ellice govt. introduced a new system in 1920, and the new zealand administrations have taken similar action. among immigrant asiatic peoples, apart from the japanese, the most important group is that of the indians in fiji. in- dentured indian labour was stopped in 1916, though free labourers could still be admitted. under indenture the gereral condition of the indians was good, though isolated abuses gave rise to private philanthropic interference from australia. but many indians in fiji have entered into trade and become well-to-do, and having (on the whole) benefited by residerce in the colony proceeded to strikes and sedcitions, the unrest in india having been reflected in tiji and fomented by imported agitators. stern measures by the covt. have been effective. trade.—copra, phosphates and fruits are the chief articles of export from oceania. some of the islands are leased to coconut companies, and in many the industry flourishes, evt not in all. the cost of importing labour and collecting the produce proves too heavy in some instances, as for example christmas i., which has changed owners!:ip more than once, and in 1923 employed only two frenchmen and 18 tahitiars under a british company. some of the copra-yielcing islands ave liable to occasional hurricanes which may almost wreck the industry—there was one such in niue in 1915; but as a practical method of celebrating the end of the war 15,000 nuts were planted there. drought also may be a deterrent of the corra industry. thus in the cilbert is. in r915—8 there was a shortage of rainfall, with only 14 in. in the driest year; the normal ranges from 80 to 140 in. annually. the fruit-growing industry of the cook is. is believed capable of great expansion. fiji exports principally sugar and molasses, copra, bananas and trocas sl ell. rubber is grown, but the industry could not withstand the low prices of 1920-1. an interesting attempt to acclimatise the mocora palm is contemplated in niue, with a view to makirg tanama hats from the fibre; the natives are skilled weavers of pandanus hats, but the trade has declined. nauru is the chief producer of phosphates (sce naurv). the excellent quality of the nickel ard chrome ores of new caledonia has attracted attention, but there is no great develcp- ment owing to difficulty in obtaining labour, and o1 ly compar ies established under french law are permitted. makatea in the tuamotu group has become a phosphate ground of some im- portance, and is administered separately from the rest of the group. but the trade of the eastern trench islands generally is somewhat stagnant, and the development of tahiti as a holiday resort from america (an attractive consideration beirg the absence of prohibition) has been seriously discussed. (s.e archaeology: oceania; guam; fiji.) bibliograpiy.—f. coffee, forty years on the pacific, (1920); a. bullard, the a, b, c’s of disarmament and the pacific problems (1921); t. r. saint-johnston, the islanders of the pacific (1921); f. o’brien, atolls of the sun (1922); n.n. golooin, the problem of the pacific in the twentieth century (1922); g. regelsperger, l’oceanie francaise (1922); w. ii. r. rivers, essays on the le- population of afelanesia (1922); g. m. crivelli and p. lorwet, l'’australie et le pacifique (1923); c. n. de c, parry, wanderings in the pacific (1924); 1. cohen, journal of a jewish traveller, (1925); rk. w. williamson, zhe social and potitical systems of central polynesia (1926). (o.... r11.)",
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