[De-professionalization or 'para-professionalization'? The professional development of the midwife and her place in the obstetrics of the 19th century]

The present article deals with the standing and the tasks of midwives in 19th century Württemberg. After outlining the legal framework of obstetrics, special emphasis was given to the education and activities of contemporary midwives, and to their numbers. At the beginning of the 18th century, obstetrics was almost exclusively in the hands of women. After 1800, a growing number of barber-surgeons and physicians began to practise obstetrics. At the same time, vocational training and qualification of women-obstetricians increased considerably. Schools for midwives and lying-in hospitals were founded. In these schools a limited number of midwives were trained by physicians. Finally a hierarchy of different groups of obstetricians developed: first physicians, then barber-surgeons, midwives and folk healers. Although midwives were more or less excluded from operative obstetrics and high-risk-pregnancies, care and supervision of uncomplicated pregnancies, and of women in childbed remained their responsibility. It could be shown that in 19th century Württemberg more than 90 percent of pregnancies ran a safe course, and neither physicians nor barber-surgeons took a special interest in the care of normal births. Thus there was no dramatic transfer of obstetric care from the hands of the midwives to those of academically trained men. The high social status of the university-bred physicians separated them from most of the patients, as did the doctors' high fees. A certain indolence, and a remarkable sense of shame on the part of the pregnant women prevented much demand for academic obstetricians.

Transient epileptic foci associated with intracranial hemorrhage in patients with subdural and epidural electrode placement

We report two cases of transient epileptic foci in humans associated with placement of intracranial electrodes. The abnormalities consisted of restricted areas of active, almost continuous, rhythmic spiking, intermittently evolving into electrographic seizure activity, which resolved spontaneously within 3-4 days. The first occurred after placement of a subdural electrode grid and the second following insertion of epidural peg electrodes. Neuroimaging demonstrated a small subdural hematoma overlying the grid and a focal intraparenchymal hemorrhage underlying the affected epidural electrodes. The insertion of intracranial electrodes may be complicated by the induction of transient epileptic foci unrelated to a patient's typical epileptic generator.

Behavior problems among young children in low-income urban day care centers

The purposes of this study were to describe: (a) the frequency and correlates of behavior problems among a sample of 2- and 3-year-old children from low-income families as seen by their parents and day care teachers, (b) the degree to which parents and teachers agree about the children's behavior problems in their respective contexts, and (c) family characteristics that distinguish toddlers with behavior problems both at home and at day care from the rest of the sample. Parents of 133 toddlers from 10 Chicago day care centers completed measures of child behavior problems, child behavioral intensity, parenting self-efficacy, discipline strategies, and stress. Children's day care teachers also completed a measure of child behavior problems. Parent-reported behavior problems were associated with higher child behavioral intensity, greater parent stress, lower self-efficacy, and discipline strategies characterized by irritability, coercion, and inconsistency. Parent and teacher ratings on child behavior were correlated for boys' behavior problems only. Parents reported more child behavior problems than teachers. Approximately 8% of the children were rated as having behavior problems at home and at day care. Although most of the children are functioning well, many of these parents and toddlers are engaged in highly stressful and coercive relationships.

Behavior problems among young children in low-income urban day care centers

The purposes of this study were to describe: (a) the frequency and correlates of behavior problems among a sample of 2- and 3-year-old children from low-income families as seen by their parents and day care teachers, (b) the degree to which parents and teachers agree about the children's behavior problems in their respective contexts, and (c) family characteristics that distinguish toddlers with behavior problems both at home and at day care from the rest of the sample. Parents of 133 toddlers from 10 Chicago day care centers completed measures of child behavior problems, child behavioral intensity, parenting self-efficacy, discipline strategies, and stress. Children's day care teachers also completed a measure of child behavior problems. Parent-reported behavior problems were associated with higher child behavioral intensity, greater parent stress, lower self-efficacy, and discipline strategies characterized by irritability, coercion, and inconsistency. Parent and teacher ratings on child behavior were correlated for boys' behavior problems only. Parents reported more child behavior problems than teachers. Approximately 8% of the children were rated as having behavior problems at home and at day care. Although most of the children are functioning well, many of these parents and toddlers are engaged in highly stressful and coercive relationships.

Respiratory muscle training in patients with moderate to severe myasthenia gravis

BACKGROUND

Myasthenia gravis (MG) is a specific autoimmune disease characterized by weakness and fatigue. MG may affect also the respiratory muscles causing symptoms that may vary from dyspnea on severe exertion to dyspnea at rest. This study was undertaken in order to determine the effects of respiratory muscle training on respiratory muscle performance, spirometry data and the grade of dyspnea in patients with moderate to severe generalized MG.

METHODS

Eighteen patients with MG were studied and divided into 2 groups: Group A included 10 patients (3 males and 7 females aged 29-68) with moderate MG, and Group B that included 8 patients (5 males and 3 females aged 21-74) with severe MG. Patients in Group A received both inspiratory and expiratory muscle training for 1/2 h/day, 6 times a week, for 3 months, while patients in Group B followed the same protocol but had inspiratory muscle training only.

RESULTS

Mean PImax increased significantly from 56.6 +/- 3.9 to 87.0 +/- 5.8 cm H2O (p < 0.001) in Group A, and from 28.9 +/- 5.9 to 45.5 +/- 6.7 cm H2O (p < 0.005) in Group B. The mean PEmax also increased significantly in patients in Group A, but remained unchanged in the patients in Group B. The respiratory muscle endurance also increased significantly, from 47.9 +/- 4.0 to 72.0 +/- 4.2%, p < 0.001, in patients of Group A, and from 26.0 +/- 2.9 to 43.4 +/- 3.8, p < 0.001, in patients in Group B. The improved respiratory muscle performance was associated with a significant increase in the FEV1 values, and in the FVC values, in patients of both groups. Mean dyspnea index score also increased significantly from 2.6 +/- 0.8 to 3.6 +/- 0.4 (p < 0.005) in Group A, and from 0.7 +/- 0.2 to 2.0 +/- 0.2 (p < 0.001) in Group B.

CONCLUSIONS

Specific inspiratory threshold loading training alone, or combined with specific expiratory training, markedly improved respiratory muscle strength and endurance in patients with MG. This improvement in respiratory muscle performance was associated with improved lung function and decreased dyspnea. Respiratory muscle training may prove useful as a complementary therapy with the aim of reducing dyspnea symptoms, delay the breathing crisis and the need for mechanical ventilation in patients with MG.

The long-term efficacy of a behavioral parent training intervention for families with 2-year-olds

The effectiveness of a behavioral parent training (BPT) intervention for improving maternal self-efficacy, maternal stress, and the quality of mother-toddler interactions has been demonstrated (Gross, Fogg, & Tucker, 1995). The 1-year follow-up of the 46 parents of toddlers (assigned to an intervention or comparison group) who participated in that study is reported. It was hypothesized that (a) BPT would lead to enduring positive changes in parenting self-efficacy, parenting stress, and parent-toddler interactions; and (b) the amount of parent participation in the intervention would be correlated with greater gains in parent-child outcomes at 1 year. All the families were retained and significant gains in maternal self-efficacy, maternal stress, and mother-child interactions were maintained. Minimal BPT effects were found for fathers. BPT dosage was related to reductions in mother critical statements and negative physical behaviors at 1-year postintervention. The findings are consistent with self-efficacy theory and support parenting self-efficacy as a target for BPT in families of young children.

Neuropsychological impairment from acute low-level exposure to carbon monoxide

OBJECTIVE

To investigate the effects of acute low-level exposure to carbon monoxide on higher cognitive functions in healthy humans.

DESIGN

An empirical study of the effects of low-level exposure to carbon monoxide on higher cognitive functions in young healthy volunteers and a matched nonexposed control group.

SETTING

A dormitory at the Hebrew University campus in Jerusalem, Israel.

PARTICIPANTS

Forty-five student volunteers who were exposed to carbon monoxide from residential kerosene stoves for 1.5 to 2.5 hours (air carbon monoxide concentrations of 17-100 ppm; mean +/- SD, 61 +/- 24 ppm) served as the experimental group and 47 nonexposed students served as the control group.

MAIN OUTCOME MEASURES

A battery of neuropsychological tests was administered to each participant including digit span, the revised Wechsler Memory Scale for verbal and figural memory, Trail-Making Test parts A and B, digit symbol, block design, and the Rey Auditory Verbal Learning Test.

RESULTS

Venous blood carboxyhemoglobin (Hbco) levels in participants of the study group ranged from 0.01 to 0.11 (mean +/- SD, 0.04 +/- 0.03) and correlated with air carbon monoxide concentrations (r = 0.39; P = .01). The experimental group scored significantly lower than controls on the following tests: digit span forward (P = .02), short-term (P = .008) and long-term semantic memory (P = .008), digit symbol (P = .004), block design (P = .009), recall of figural memory (P = .02), and Trail-Making part A (P = .04). No significant differences were found between the experimental and control groups in other tests.

CONCLUSIONS

The lower scores on neuropsychological tests indicate dysfunctions in memory, new learning ability, attention and concentration, tracking skills, visuomotor skills, abstract thinking, and visuospatial planing and processing. These dysfunctions correspond with previous reports of carbon monoxide neurotoxic effects in patients with moderate carbon monoxide poisoning. Low-level exposure to carbon monoxide results in impairment of higher cognitive functions. Neuropsychological testing appears to be sensitive in the detection of subtle neurologic dysfunctions resulting from carbon monoxide poisoning.

[Therapeutic thrombocytapheresis--effect on hemorheologic parameters]

Common features of all myeloproliferative diseases (CMPE) are a markedly increased number of platelets and restrictions in the subjective feeling of the patients, comprising symptoms like nausea, headache, sensory deficits and transient paresis. Meanwhile, it has been shown that platelet pheresis (mTD) does not only reduce platelet counts sufficiently but also results in an impressive relief of the subjective complaints. To test the part that rheological mechanisms play hereby, relevant rheological parameters in the blood of 22 CMPE patients and of 8 healthy platelet donors as controls were analyzed before and after treatment with an AS-104 cell separator. Concerning the viscosity of whole blood und the filterability of erythrocytes, there was seen neither a difference between the patients and the controls, nor before and after mTD. As a result of treatment of patients, the moderately raised plasma viscosity was normalized, whereas the aggregation of erythrocytes was significantly lowered. It is concluded that there is an influence of hemorheological conditions on the patient's subjective feeling. These would originate in neurological dysfunctions caused by CMPE-induced restrictions in cortical microcirculation. The erythrocyte aggregation, lowered by mTD, would cause an improvement of microcirculatory fluidity and would, in consequence, abolish the neurological symptoms.

[Gottlieb Burckhardt's (1836-1907) contribution to psychosurgery: medicohistorical and ethical aspects]

Psychosurgery is defined as the practice of destroying or removing healthy brain tissue in order to change behaviour. Although the neurologist Egas Moniz (1874-1955) is occasionally said to be the founder of psychosurgery, the first psychosurgical operations were performed by Gottlieb Burckhardt, a Swiss psychiatrist who practised in the late 19th century. In 1891 he reported the results of topectomies on six patients suffering from different psychiatric diseases. The aim of the present article is to illuminate the life of Burckhardt as well as his contribution to psychosurgery. Special attention is paid to the ethical aspects of his operative interventions. First of all, we have to make allowance for the fact that the therapeutic chances in 19th century psychiatry were quite poor. Therefore, Burckhardts topectomies might have been seen as a new and hopeful way of therapy. But by analysing Burckhardt's case reports, it becomes clear that he did not intend to cure his patients but only to ameliorate their disturbing behaviour and their non-compliance. Burckhardt himself tried to justify the immense risk of his operations by referring to the necessity of progress in medicine. Although Burckhardt spoke of promising improvements, his positive appraisal can hardly be maintained. For this and other reasons, his contemporary colleagues mainly declined his methods and reports.

[Contribution of Gottlieb Burckhardt (1836-1907) to psychosurgery from the medical history and ethical viewpoint]

Psychosurgery is defined as the practice of destroying or removing healthy brain tissue in order to change behaviour. Although the neurologist Egas Moniz (1874-1955) is occasionally said to be the founder of psychosurgery, the first psychosurgical operations were performed by Gottlieb Burckhardt, a Swiss psychiatrist who practised in the late 19th century. In 1891 he reported the results of topectomies on six patients suffering from different psychiatric diseases. The aim of the present article is to illuminate the life of Burckhardt as well as his contribution to psychosurgery. Special attention is paid to the ethical aspects of his operative interventions. First of all, we have to make allowance for the fact that the therapeutic chances in 19th-century psychiatry were quite poor. Therefore, Burckhardts topectomies might have been seen as a new and hopeful way of therapy. But by analysing Burckhardt's case reports, it becomes clear that he did not intend to cure his patients but only to ameliorate their disturbing behaviour and their non-compliance. Burckhardt himself tried to justify the immense risk of his operations by referring to the necessity of progress in medicine. Although Burckhardt spoke of promising improvements, his positive appraisal can hardly be maintained. For this and other reasons, his contemporary colleagues mainly declined his methods and reports.

[Origin and development of autopsy in Württemberg reflected by contemporary sources]

The present study deals with the introduction and the development of coroner's inquest in Württemberg. It could be shown that the contemporary discussion about the incidence of apparent death became an important reason for the establishment of necropsy in 1824. In spite of legal backing the institution of necropsy remained disputed until the end of the Kingdom of Württemberg in 1918. Above all, the differing qualification of the coroners gave rise to criticism. Although the legislator provided a general qualification in surgery, most the coroners did not boast a special expert knowledge. During the time in view, the participation of barber surgeons in necroscopy was decreasing; the percentage of physicians also remained very low. In 1911, only 119 out of 1814 coroners were physicians-on the other side 641 representatives of post-mortem examination worked as small-holders or day-labourers, and another 33 persons even earned their daily living by grave-digging. With regard to this, it is evident that the coroners in Württemberg formed a most heterogeneous group-both in social and in professional respect.

The effects of cardiac surgery on early and late pulmonary functions

BACKGROUND

Impaired pulmonary functions are common in cardiac patients. Early and late effects of cardiac surgery on pulmonary function tests (PFTs) are presented.

METHODS

Fifty patients undergoing cardiac surgery (coronary artery bypass grafting [CABG, 74%], valve replacement or valvuloplasty [20%] and combined procedures [6%]) were studied. Anginal and cardiac failure symptoms severity, and smoking history, were evaluated preoperatively. PFTs were studied and compared pre-, and 3 weeks and 3.5 months postoperatively.

RESULTS

Pre- and postoperative PFTs were inversely related to severity of preoperative symptoms. Forced vital capacity (FVC) dropped from 98% of predicted preoperatively, to 63% (P < 0.00001) and 75% (P < 0.00001) 3 weeks and 3.5 months postoperatively, respectively. Expiratory volume in the first 1 s of forced expiration (FEV1.0) decreased from 95% to 61% (P < 0.00001) and 70% (P < 0.00001), respectively. Forced expiratory flow at 50% of vital capacity (FEF50) decreased from 85% to 56% (P < 0.00001) and 59% (P < 0.00001). Forced expiratory flow at 75% of vital capacity (FEF75) decreased from 77% to 47% and 47% (P < 0.00001). Peak expiratory flow rate (PEFR) declined from 101% to 66% (P < 0.00001) and 86% (P < 0.003). Maximal voluntary ventilation declined from 103% to 68% (P < 0.00001) and 77% (P < 0.00001). Only FVC (P < 0.0003), FEV1.0 (P < 0.02) and PEFR (P < 0.0001) partially recovered postoperatively. Smoking history did not affect perioperative PFTs. Pre-, but not postoperative FVC, FEV1.0, FEF50 and FEF75 were worse in valve than in CABG patients.

CONCLUSIONS

Pulmonary functions deteriorate significantly for at least 3.5 months after cardiac surgery. Preoperative cardiac ischaemic and failure symptoms are inversely related to perioperative PFTs.

Biomechanical evaluation of polylactide absorbable screws used for syndesmosis injury repair

Simulated syndesmosis injuries were created in 12 fresh-frozen, below-knee cadaver specimens. Six specimens were repaired with a 4.5 mm stainless steel screw, and six were repaired with a 4.5 mm polylactide screw. Three specimens of each group were tested in load to failure by axially loading with 1400 N and externally rotating to 90 degrees. Three specimens in each group underwent fatigue testing by axially loading with 700 N and applying 2.5 N-m of torque for 57,700 cycles. Radiographs and computed tomography scans were evaluated. None of the screws broke or failed. Similar load to failure was noted in polylactide and control groups. Fatigue testing revealed no significant change in stiffness. No significant screw damage was evident on radiographic or computed tomography evaluation. The data suggest that a polylactide screw has sufficient fatigue and failure strength to allow for healing of this injury in a clinical situation.