1401
best social outcome. We do not, however, underestimate the
value of satisfaction with exercise and the possibility that it
had temporary benefits during the difficult early weeks after
the patients returned home.
Although rehabilitation results are unimpressive, the good
outcome in all three groups, including the controls, is
striking. It is evident in the social ratings, the low incidence of
severe psychological symptoms, and also in the exercise
testing-which confirms reports"that within a few weeks of
infarction many patients achieve normal work levels without
supervised training. Comparison of our normal treatment
group with our 1975-76 follow-up study5,7 suggests an
improvement in the psychological and social outcome over
the past 3 years. This is probably a continuation of longer-
term trends associated with early mobilisation and more
positive medical advice. Although over the past 15 years
interest in rehabilitation has greatly increased, the need for
routine programmes has decreased.
Although the good outcome in many patients is
encouraging, some reported undue distress and limitations,
both at three months and at eighteen months, which two
widely recommended types of treatment were relatively
ineffective in preventing. The small benefits of advice
suggest there are opportunities for simple improvements in
routine care, but we believe that the main priority for
rehabilitation is the selective management of problems
detected early in convalescence. The content of such
treatment remains uncertain. Making our programmes more
intensive and prolonged would have had little more effect on
the cautious, anxious patients, who are often poor attenders,
and for whom there is a need to devise more acceptable and
effective rehabilitation. Close coordination with medical
treatment is obviously essential. Physical training may well
be a useful component but there might be advantages in
changing the emphasis from standard procedures in the
hospital gymnasium to individual plans, discussed with the
whole family, for home-based exercise. Clearly, the general
practitioner would have a central role in giving routine
advice, detecting difficulties, and arranging extra help.
Our findings show that adequate evaluation of the
effectiveness of rehabilitation requires controlled trials and a
comprehensive range of outcome criteria. It is easy for
doctors to be misled by enthusiasm and even by exercise-test
results into assuming benefits for everyday activity,
satisfaction, and morale. Poor attendance of many of the
patients with problems makes it even more likely that
therapists will overstate the benefits of treatment. We believe
that many claims as to the value of rehabilitation reflect a lack
of adequate measures and the biases of the uncontrolled study
of enthusiastic patients.
Our measures have proved reliable and useful and could be
used in further evaluation of improved rehabilitation. The
first priority is more effective care of the minority of cautious
and anxious patients. However, where the resources are
available, it may also be useful to offer well-motivated
patients more ambitious training to improve physical fitness.
We thank Mrs A. Foster, Mrs B. Williamson, Miss M. Lightbody, Mr P.
Cooper, and Dr M. Irani for their contributions. This work was supported by a
grant from the British Heart Foundation.
Correspondence should be addressed to R. M., Department of Psychiatry,
WarnefordHospital, Oxford OX3 7JX.
REFERENCES
1. Working Party of the Royal College of Physicians and British Cardiac Society. Cardiac
rehabilitation. J Roy Coll Phys Lond 1975; 9: 281-346.
BATHING OR WASHING BABIES AFTER BIRTH?
ANNELIE HENNINGSSON BERTIL NYSTRÖM
RAGNAR TUNNELL
Departments of Gynaecology and Obstetrics, Clinical Microbiology,
and Paediatrics, Huddinge Hospital, S-141 86 Huddinge, Sweden
One group of healthy full-term newborn
Summary
babies was washed after birth and another
was bathed to remove vernix caseosa and clean the skin. Few
infections, none of them serious, occurred in either group.
Bacterial colonisation of the umbilical cord on the third day of
life was similar in both groups. The rectal temperature fell
further and more infants cried during washing than during
bathing. Thus bathing the baby after birth makes it calmer,
quieter, and more comfortable than washing and causes less
heat-loss. Clinical signs of infection and bacterial colonisation
rates are no higher after bathing than after washing.
INTRODUCTION
THE American Academy of Pediatrics’ recommends that
the skin of the newborn baby should be cleaned with cotton
sponges soaked with sterile water, or that a mild non-
medicated soap should be used with careful water rinsing.
Similar recommendations have been published in Britain2
and in Sweden.3 Leboyer,4 on the other hand, recommends
that the newborn baby should be bathed instead of washed to
avoid unnecessary crying.
The present study compares the effects of bathing and
washing on the clinical-infection rate, bacterial-colonisation
rate, body-temperature, and crying in healthy full-term
newborn babies.
SUBJECTS AND METHODS
The study was carried out in one maternity ward at Huddinge
Hospital, Sweden, during four autumn months in 1980. Additional
observations were made during three winter months in 1981.
Ward Routines
At delivery, mother and baby are given an identification number.
The umbilical cord of the baby is closed with a plastic clamp, which
is left until the infant is discharged from hospital. 2 h after delivery
mother and baby are transferred from the delivery unit to one of
three maternity wards, depending on which ward has unoccupied
beds.
A rooming-in system is used, with one or two mothers and their
babies per ward room. At night all babies are placed in a nursery.
2. Wenger NK. Research related to rehabilitation. Circulation 1979, 60: 1636-39.
3. International Society and Federation of Cardiology Scientific Councils. Secondary
prevention in survivors of myocardial infarction. Br MedJ 1981, 282: 894-96.
4. A.H.A. Council on Scientific Affairs. Physician supervised exercise programs on
rehabilitation of patients with coronary heart disease. JAMA 1981; 245: 1463-66.
5. Mayou RA. Psychological reactions to myocardial infarction. J Roy Coll Physns Lond
1979; 13: 103-05.
6. Bruce RA. Principles of exercise testing. In: Naughton JP, Hellerstein HK, eds.
Exercise testing and exercise training. New York: Academic Press, 1973.
7. Mayou RA, Williamson B, Foster A. Outcome two months after myocardial infarction
J Psychosom Res 1978; 22: 439-45.
8. Goldberg DP, Cooper B, Eastwood MR, Kedward HB, Shepherd M A standardized
psychiatric interview for use in community surveys Br JPrev Soc Med 1970, 24:
18-23.
9. Goldberg DP. Detection of psychiatric illness by questionnaire. London Oxford
University Press, 1972.
10. Norris RM, Cuaghy DE, Mercer CJ, Deeming LW, Scott PJ Coronary prognostic
index for predicting survival after recovery from acute myocardial infarction.
Lancet 1970; ii: 485-87.
11. DeBusk RF, Houston N, Haskell W, Fry G, Parker M. Exercise training soon after
myocardial infarction. Am J Cardiol 1979; 44: 1223-29.
 1402

Patients and Design of Study TABLE I-NO. AND RATE OF INFANTS COLONISED IN UMBILICAL CORD
ON THIRD DAY OF LIFE
In the maternity ward where the study was carried out all full-
term healthy newborn babies were divided into two groups-those
with even identification numbers (group I) and those with odd
identification numbers (group n). Premature or sick babies who
were transferred to the special neonatal ward and subsequently to
the maternity ward were not included in the study.
On admission to the ward all babies in group i were bathed in a
bathtub filled with lukewarm water. To simulate conditions at home
the water temperature was not exactly measured. The baby’s whole
body was immersed in the water and its skin cleaned by hand. Non-
medicated soap was applied to the skin-folds with a face-flannel.
After the bath a quick shower, with lukewarm water was given.
Immediately afterwards the baby was wrapped in a big towel and
dried. All babies in group 11 were washed with a face-flannel and a
non-medicated soap, and no shower was given. Immediately after
washing the baby was wrapped in a big towel and dried. Before
discharge 5 or 6 days after delivery the bathing or washing
procedure, as appropriate, was demonstrated to the parents, who
were instructed to use the method demonstrated to them at home. started after specimens for culture were taken. The baby
Otherwise the daily care of the babies in the hospital did not differ quickly recovered. In two babies in group I (bathed) minor
between the two groups. No routine daily whole-body bathing or local staphylococcal skin infections developed (in one case
washing was performed. Babies whose skin became soiled were after discharge from hospital). Topical treatment was given
washed under running water.
and they recovered promptly.
The bath tub was cleaned with a detergent after each baby.5
232 babies were included in the study during the first period. 118 14 of 118 infants in group I and 18 of 114 infants in group II
of these were bathed (group i) and 114 were washed (group II). developed a moist and smeary umbilical cord. None of these
was regarded as an infection and none required antibiotic
During the second period of the study, in the winter of 1981, an
additional 165 babies were observed for clinical signs of infection. treatment. Separation of the cord before discharge from
80 of these were bathed and 85 were washed. hospital occurred in 7 babies in group I and 6 in group II.
One case of sudden infant death occurred 30 days after
Clinical Signs of Infection discharge from the hospital. This infant belonged to group II.
During the hospital stay of 5 or 6 days all babies were observed for
clinical signs of infection. After discharge from hospital parents of Bacterial Colonisation
newborn babies attend child-welfare centres. The staff of these The numbers and rates of infants with bacterial
centres were asked to report to us any clinical signs of infection in
colonisation of the umbilical cord on the third day of life are
any of the babies included in the study. Also, parents were
encouraged to report signs of infection in their babies. All infants given in table I.
with severe infection within the region are referred to the paediatric Of the 205 infants studied 203 were colonised with, on
clinic of Huddinge Hospital for hospital care. average, two strains. Staphylococcus aureus was the most
common species (isolated from 58% of the infants), followed

Bacteriology by enterococci (44%), Staph. epidermidis (42%), Escherichia

coli (28%), and group-B streptococci (11%). No group-A
During the first study period, in the autumn of 1980, specimens
from the umbilical cord were taken for culture from all babies in the streptococci were isolated. No statistically significant
differences were found between group I and II either for
study on the third day after birth. Specimens for culture were also
taken at any sign of infection. Routine methods were used for colonisation totally or for colonisation with any single species.
specimen collection and transportation as well as for culture, From the 117 infants colonised with Staph. aureus 124
sensitivity testing, and staphylococcal phage-typing. All coagulase- strains were isolated (table II). Some infants were thus
positive staphylococci were phage-typed. Strains of Entero- colonised with more than one Staph. aureus strain. Phage
bacteriaceae were identified by the API 20-system.
TABLE II-STAPHYLOCOCCAL COLONISATION IN UMBILICAL CORD ON
THIRD DAY OF LIFE
Body-temperature and Crying
During the first study period the rectal temperature of the babies
was measured before and 2-5 min after bathing or washing.
Crying during and after bathing or washing was recorded during
the first study period.

RESULTS

Signs of Infection and Other Clinical Complications

No serious infection occurred in any child. One baby in
group 11 (washed) had a gonococcal conjunctivitis despite
silver-nitrate prophylaxis. The baby was promptly treated
and recovered without complications. One baby in group II
had fever and feeding problems on the 8th day of life and was
transferred to the neonatal ward. The symptoms were
interpreted as signs of infection. Cultures of blood and
cerebrospinal fluid were negative. Antibiotic treatment was

types 52 or 52/80 (25%) and 95 (21%) were the most common
types isolated. No single phage type was isolated significantly
more often in one group than in the other.
Body-temperature
The rectal temperature fell during cleaning in 40 of 98
(41%) infants in group I (bathed) and in 66 of 88 (75%) in
group II (washed). This difference is statistically highly
significant (p<0 001). In 23 of 98 (23%) infants in group I the
rectal temperature after cleaning was between 35’7&deg;C and
36 -4&deg;C, compared with 34 of 88 (39%) of infants in group II.
This difference is statistically significant (0 -05>p>0. 0 1).
Crying
During cleaning 55 of 118 infants (47%) in group I cried,
compared with 97 of 114 (85%) infants in group II. This
difference is highly statistically significant (p<0 001). After
cleaning 46 (39%) infants in group I cried, compared with 39
(34%) in group II. This difference is not statistically
significant.
DISCUSSION
Dry skin-care of newborn babies is generally recom-
mended.l-3 However, vernix caseosa must be removed from
skin-folds to avoid irritation. Also, the skin must often be
cleaned to remove blood or meconium-stained amniotic fluid
after birth. Thus some sort of wet procedure to clean the skin
after birth is unavoidable.
Bathing has been looked on as inappropriate or dangerous
until the umbilical cord has fallen off and the umbilicus
healed. To our knowledge this opinion has not been
documented. A baby will often cry when the skin is cleaned
by vigorous rubbing.
The results of this study confirm the clinical impression
that cleaning the baby with a towel makes the baby
uncomfortable and increases heat-loss, probably through
evaporation. During bathing babies were calmer, quieter,
and more comfortable than during washing, and they lost less
heat.
-
No ill-effects (as indicated by clinical signs of infection,
other complications from the umbilical cord, or bacterial
colonisation rates) were seen after bathing. In this study the
umbilical cord was closed with a plastic clamp, which was left
until the baby was discharged from hospital. If other methods
for clamping the cord are used, our results have to be
confirmed.
After the study was completed the ward staff chose to
continue bathing the babies as routine skin-cleaning
procedure because of the more positive reactions from the
babies.
We thank the nursing staff of the maternity ward for their help and Ms
Evamari Fallgren for technical assistance.
Requests for reprints should be addressed to R. T., Department of
Paediatrics, Huddinge Hospital, S-141 86 Huddinge, Sweden.
REFERENCES
1. American Academy of Pediatrics’ Committee on Fetus and Newborn: Skin care of
newborns Pediatrics 1974; 54: 682-83.
2. Emmerson AM, Jenner EA, eds. Infection control manual. Camden and Islington Area
Health Authority (T), Islington District, 1978.
3. Lagercrantz R, Nystr&ouml;m B. In: Gentz J, et al, eds. Perinatalmedicin. Stockholm: AWE/
Gebers, 1978.
4. Leboyer F. Pour une naissance sans violence. Paris: du Seuil, 1974.
5. Nystr&ouml;m B. The disinfection of baths and shower trolleys m hospitals. J Hosp Infect
1981; 2: 93-95.
1403
Occupational Health
MESOTHELIOMA IN A FACTORY USING
AMOSITE AND CHRYSOTILE ASBESTOS
E. D. ACHESON C. BENNETT
M. J. GARDNER P. D. WINTER
M.R.C. Environment Epidemiology Unit,
Southampton General Hospital
Summary 5 deaths have been certified as due to
mesothelioma (4 pleural and 1 peritoneal) in
men who worked at a London factory where insulation board
has been manufactured since 1946 from a mixture of amosite
and chrysotile asbestos. It seems reasonable to relate 4 of
these cases to work at the factory. Amosite has been the fibre
predominantly in use and seems likely to be the cause of the
tumours.
INTRODUCTION
AMOSITE
(the fibrous form of cummingtonite-grunnerite)
is amphibole asbestos which has been used in the United
an
Kingdom principally in the manufacture of insulation board
and of asbestos cement for pressure piping.’ Less is known
about the effects of amosite dust in man than of the effects of
chrysotile or crocidolite because populations exposed
exclusively to amosite are rare. This paper reports the
occurrence of mesothelioma of the pleura and peritoneum in
workers in a factory in London which has used amosite and
small quantities of chrysotile, but not crocidolite, in the
manufacture of insulation board. The question whether the
control limit - for amosite should be lower than that for
chrysotile is currently under discussion following the report
of the Advisory Committee on Asbestos.2
THE FACTORY
The present company took over the site from a flint brick-
works in 1945, but brickmaking continued on part of the
location until 1974. Amosite has been used in the
manufacture of insulation board from 1947 and since 1973
has been the only type of asbestos in use. Very short chrysotile
fibre (grade 6 or 7) was also used during the period 1946-73
but, except for a short period in 1946-47, amosite has been
the predominant fibre. The amount of chrysotile added
varied from nil to about 3% according to market conditions.
Crocidolite was used on an experimental basis for five short
trials each of less than one day’s duration in March, April,
May, and October, 1962, and in July, 1964. The experimen-
tal product was never manufactured on a commercial basis.
The proportion of asbestos in the insulation board varied
from 20 to 40%. Lime (25%), silica (as diatomite or ground
quartz) (25%), and cement (20%) were also used. Until a
change in the process in 1964 some of the men in the area
where the raw materials were handled were exposed to silica
as well as asbestos dust. For a short period in the 1950s low-
density insulation block was manufactured from amosite. As
a subsidiary operation vermiculite was exfoliated in a small
area of the factory for use off site. It was not incorporated in
the insulation board.
In the early years dust was controlled by centralised
exhaust systems for each building which were ineffective by
today’s standards. The first major improvement was the