Canad. Med. Ass. J.

July 2, 1966, vol. 95

phe does occur, a prearranged plan must be put into

action for the immediate procurement and administration of massive blood transfusion. (5) Laparotomy
must be performed immediately regardless of the vital
signs. (6) If the condition of the patient is grave,
surgery may be temporarily halted after bilateral clamping of the infundibulo-pelvic ligaments and the uterine
vessels, or the clamping of the edges of the uterine
laceration. Massive blood transfusion is carried out
through several portals until the blood pressure and
other vital signs improve. This improvement occurs
rapidly once the bleeding has been controlled; surgery
can then be completed.
Editorial Subcommittee of the
Committee on Maternal Welfare,
The Canadian Medical Association.

To the Editor:
In the Discussion of the article on cephalopelvic
disproportion in the issue of May 21 (Canad. Med. Ass.
J., 94: 1126, 1966), I read the following statement:
"The rupture of a classical Cesarean section scar
seldom occurs during labour but characteristically takes
place in the seventh or eighth month of pregnancy
when the uterus is accommodating itself to the rapidly
growing fetus."
I have been practising for 30 years and never heard
this before. I have agonized over whether to deliver
patients per vaginam after previous Cesarean sections
and heard arguments for and against it. In the absence
of other indications there was always the thought that
one was exposing the patient to the unnecessary risk of
rupture of the previous scar.
The statement quoted would indicate that this danger was very slight and would not need to be considered unless the uterus was known to be infected
at the time of the previous surgery.
I would appreciate some discussion on this problem.
R. HAYWARD, M.D.
Box 48,
Little Current, Ont.
To the Editor:
In reply to Dr. R. Hayward's query, the statement
was made that in the majority of women, scars of
previous classical Cesarean section rupture before the
onset of labour, because the Editorial Subcommittee
of the Committee on Maternal Welfare of the C.M.A.
believe that this fact is not generally appreciated by
all physicians giving obstetrical care. Some authorities
contend that, regardless of the type of previous Cesarean section, the dictum "once a section, always a
section" should be followed, while others teach that
a repeat Cesarean section is not necessary in the
management of non-recurring obstetrical complication
if the fetal head is well engaged at the onset of labour,
if there is no disproportion, if labour is progressing
normally, and if good facilities are available for the
immediate care of a patient with rupture of the uterine
scar. Such facilities include blood for immediate massive
transfusion and the immediate availability of adequate
personnel and facilities for the anesthesia and
laparotomy.
Editorial Subcommittee of the Committee
on Maternal Welfare, C.M.A.

LETTERS TO THE JOURNAL 35

THE PHYSICIAN AND THE ENGINEER

To the Editor:
Dr. Driessen in his letter (Canad. Med. Ass. J., 94:
918 [April 23], 1966) discussing an editorial has drawn
attention to an area of great importance.
The engineering profession is becoming increasingly
aware that equipment and systems to be used by man
must be designed for man. This need was shown
dramatically during the last war. At the Institute of
Bio-Medical Electronics, University of Toronto, we
have been teaching a course on Human Factors
Engineering to postgraduate engineering students in
co-operation with the Department of Industrial Engineering, and a course has also been given for several
years at the University of Waterloo to final-year engineering students.
The medical profession has been far slower to
realize the medical importance of designing equipment and systems so that men are not pushed beyond
their physiological and psychological limits. Improper
design is a cause of both mortality and morbidity and
is a proper area of investigation for preventive and
industrial medicine. Yet with certain notable exceptions, few industrial physicians have taken any interest
in the product of the industry in which they are involved, or the machines used to produce the product.
They regard their responsibilities as restricted to the
health care of the workers.
We are moving into an age of more and more complex systems and equipment, whose powers to destroy
grow at much the same rate as their powers to benefit.
The modern automobile typifies this. Moreover, it is a
paradox of modern engineering that, in making life
easier for most of us, it lays heavier and heavier
burdens on a few of us. It is far easier to travel to
Vancouver today than it was 50 years ago; but a few
minutes in a busy air traffic control centre, or on the
flight deck of an airliner landing in bad weather, are
sufficient to show who is carrying the burden. Men
such as air traffic controllers, airline pilots, surgeons
and others are often asked to solve difficult problems,
control very complex equipment and make vital decisions in a very short time under considerable environmental and mental pressure.
It is the responsibility of both medicine and engineering to ensure that the equipment and systems that
men have to handle are designed to suit human physiological and psychological capabilities. This applies both
to the design of machines within a factory and the
design of the products of those machines. The etiology
and prevention of a disaster is as much a medical
problem as the surgical treatment of the victims.
In attacking these problems they need the assistance
and perhaps direction of basic sciences, psychology,
physiology, and physics. Nevertheless, the fact that
medicine and engineering are the professions through
which scientific knowledge is applied to improve the
well-being of man means that it is these professions
that are responsible for taking action.
The bacteriologist can show the etiology of infectious diseases and how they are spread; the physician is the man who must stop them from spreading.
E. LLEWELLYN THOMAS, M.D., P.Eng.
Institute of Bio-Medical Electronics,
University of Toronto,
Toronto 5, Ont.