8I*?lseiiij*UNSFUL-FORCEPS-UAS-fEBurn=-Is.-[Inaddition,in-132cases(23. - PDF document

8I*?lseiiij*UNSFUL-FORCEPS-UAS-fEBurn=-Is.-[Inaddition,in-132cases(23.6perceiit-.ofthe,totalseries)thepuerperiumwasniorbldaccordingtotheBritishMedicalAssociationstandard.Manyofthepatientsrecoveredsufficientlytoleavehospitalonlyafterexhaustingweeksoffever.Includingstillbirthsandneo-nataldeaths357oftheinfantswerelost-amoitalityof64-percent.Suchfiguresinidicateonlytooclearlvhowanxiousmustbetheprognosiswhereaninjudicioususeofforcepsresultsinfailure-toeffectdelivery.Thefullsigniificanceofsuchfailtirelies,however,notonlyintheimmediategraverisktolifewhichitinvolves,butalsointhefrequencywitlhwhichcrippliniginvalidismnmayfollowastheresultofinfection1orinjurysustained.Fewpatienitsescapedwithoutioreorlessseriouslacerationofthecervix,vagina,orpelvicfloor;sloughingoftlhev-aginaltissueswithfistulaformationoccurr-edinseveralcases.Further,itwillbealppreciatedthataprimaryrepairwasseldomfeasibleorsuccessful.Manypatientswereperforcedis-clargedonlytofacefurtlherweeksormonthsofillhealth.Sothattheextentofsubsequentdisabilitvmightbedetermineditwasdecidedtonmakeafollow-iupstuidyc-fsuchpatientsinthisseriesasweredeliveredintheEditi-burglhRoyalMaternityHospital.Inall,116patientswerecolmmunicatedwithandaskedtoreportatthehospitalforexamination.Ofthese,18didnotresponidorcouldinotbetraced.Theend-resultsof98cases,lhowvever,are.avail-able,anidmuaybesumiliarizedasfollows.In24cases,orroughlyone-fifthofthetotal,thelpatientstatedthath-erhealthhadnotinanywaysuiffered,andpelvicexaminationrevealednoabnornialityofiniportanie.TTheremainiing74,however,hadallsufferedvaryilgdlegreesofinconvenience,ordiscomfort,sometimesamounitinigtoseriousillhealth;in,almostalloftheseonefouindstigmataoftheordealthroughwhichtheyhadpassed.Lacerationiofthecervix,withorwithoutdownwarddis-placemieiitoftheuterus,wasthelesionimostcommnxonlvencounteredin,thisfollow-upinivestigation.Th.efrequencywithwlhielhsutchaninijuryvwasfoundisofspecialimPo1r-tance;in.thefirstplaceitemiphasizeshlow'collmmollvillunsuccessful-forcepscasesofall-typesfailureistheresult.ofanattemiptto.completedelivery-beforethecervixisfullydilated,andthereforebeforetihepatienithaslhadthebenefitoftlheseconidstage.oflabour.h'liecorollar-yislikeviseapparent.:iniury-tothecervixandtotheilupersupportingstructuresoftheuteruismu111stinevitablyoccurwhereforcepsareappliedbeforethecervixhlasfullyretractedoverthepresentingpart.Backwarddisplacementoftheuteruswaspresentinaconsiderablenijmberofcases.Inafewtheconiditionwasuniaccompaniiedbyanyotlherpelvicabnornmality.Inthenmajoiity,-however,itwasassociatedwithsuibinvolutioi,with(lownwarddisplacemiient,orwitlh.pelvicinfection;ofitselftheretroversionwasprobablyoflessimiiportanicethanweretheotherconditionsofwhiehitwasacomplication.Pelvicinfection,evidencedbychroniicsubinivolution.im1pairedmiiobilityoftheuterus,orbyenlargemiientanldabniormiialsein.sitivenessoftheuterinieappendages,wasfoundinapproximatelyone-thirdofthecasesexaminied.Ingreaterorlessdegreeitwasmiietwithinalilmosteverycaseinwhlichthepuerperi-uhadbeenifebrile.Thesepatientscomplainedofsymptomis-varyingfromminordis-comiforttomiioreorlessconstantanldacutemiserv.Inmost,suclhreliefasmiedicalmeasurescouldofferhadalready-beenafforded,andformanyitheordealofamajoroperationwastheonlyalternlativetoconitinluedillhealth.Twenty-foutrpatientsofthosewlhoreportedhladbeensubjectedtooperatioiifordisabilityresultinigdirectlyfromithetl)eofdystociaiunderconsidlerationIin10casesareparativel)rocedlurehadbeencaririedoutforinjurytocervixorpelvicfloor;in3casesanoperationiforvesico-vaginialfistulahadbeeniperformed;4patientshadbeenculrettedformeenorrhagia;in6caseshyisterectomiiyortheremoval,oftheuterineappendageshadbeencalledfor.Therehad,inaddition,beenoneoperationforextra-ulterinegestation.Themajorityoftheseptetosenljoyrseasonlably-goodhealth.In19patienltsofthlosewhorepsorted,subsequlentpreg-nlanlcyhadoccurred;in113casesthepzregnancyhadpLo-ceedednormallytosuccessfuldeliverytattersm;in15p-atientsabortionalhadoccurred,andinoinecasethiegestationhad.been.extrauterineintype.Fortherest,inwhioniafterareasonableintervalcon-ceptionlhadnotoccurred,manyadmliittedthatthroughapprehelnsianofitsdangerspregnancywasbeingavoided.Tlherewereotherswhosechiefconcernwasthatthleylhad,beendeniiedtheprivilegeofasecondchance,andforAwhomtlhesufferinganddangertolifewhichtheyhadbeencalledontofacelhadmiieantlessthanthedisappointmenitofanemuptycot.Suclh,inbrief,isarecordoftheconsequenceswhlielmayfollowill-timedormiisdirectedeffortstosuplplelinenitorsupplantNature'smetliods.Towhatextenttheuiisue-cessfulforcepscaseistheindirectoutcomeofiniadequate-undergraduatetraininig,ofinsufficientco-olreationbetweenmidwife,famllilydoctor,andconsultant,orofdefe&tivemiiuniicilplorpublichealtlhadministration,,isopentoquestion.OfthisbroaderaspectofetiologyProfessorFletchler.Sla-halsspoken.Moredirectlyitismanifest,thatmiianyofthesedisasterscouldhavebeenipreventedlbv.ante-niatalrecognitionofconitractionlofthepelvis,unlduesizeoftheclhild,orotherabnormality.Initsimnmediatecausationtheunsuaccessfulforcepsc.Lsewouldappeartobe,verylargely,theoutcomeofnaon-observaniceofonieofthreeelemu-entaryrulesinregardtoforcepsoperationi.First,thatforceps.shouldnotbeapplweflinthepr-eseniceofmiiarkeddisparityinrelationito-theheadandpelvis,anadriarelv,-ifever,wlheint4ieheadisstil1mnovableabovethepelvicbrimu.Thefrequenicywitlhwhielcitwasfouncdthatforcepsdeliveer-hadbeeniatteemptedwhiletheheiactdWasstilluniengagedwouldindicatethatt}hedifficultyaniddangerofthehiiglhfor-cepsoperationarenotsufficientlyappireciated.Secondly,thatforcepsshouldnlotbeap)pliedwitlioutaniexactknowledgeofthel)ositionwhichtheheadoccupiesin.thepelvis.Theinitialm-iistakeillunsuccessfulforcepscasesissofrequentlyonieofdiagnosisthatitw-ouldappear-necessarytore-emphasizethewisdomIiofthetimie-lhonouieddictuDm"clhloroformllanidthewhole1hanid?asaprellininiarvtofor-cepsapplication.ThethirFdessentialisthattthecervixslhouildbe(omlpletelyeffacedandretlacte(loverthepr-esentinlgpart.Onlsoelementaryaprovisotothesafeuseofforcepsoniewi-ouldlhesitatetoinsist,weieitn6tsofrequentlydisregarded.Toremuov-ethestigmiiawhichto-dayattachestotlepractioeofmidwiferybygivingeffecttostuchrecommenda-tionlsasvairioutscomnmitteesofinquiryhiavemademlavbeaniextravaganthope.Toinsistthatforcep.sslhoulldniotbeappliedsinl(essonIstrictobstotricaliudicationsmaybweacounselofperfectioln.Tosavemuanyliveswh-11iclhnIeednlothelostandtorelievethebuir(dellofmnucha'voidablesuffer-inigbyagreaterdlis1reti.onau(dcareintheus'eofforcepsahis,Illl+,is�1ids-reasonablycherish.UNSUCCESSFULFORCEPSCASES:-HowF.xRCANTHEYBEPEThVENTEDBYEFFICIENTANTE-NATALCARE?*BYJAMESHENDRY,M.A.,B.Sc.,M.B.,F.R.F.P.S.G.,Muirhea'dProfQssorofObstetricsandGynaecology,Glasgow'Univeiiity:VisitingPhysician,Glasg6wRoyalMaternityandWomienl'sHospital;Gynaecologist,GlasgowRoyalInfirmary..INthlisniewspaperage,isthereanycitizenwliohasiit.beenmadeawareof,theunsatisfactorystate-ofobstetric.practiweill-thiscoiintrv?Hardly.aweekpasseswitlhout.somerefereiceinthela-yprcss*toconferencesonmaternalmortality,-toquestionsinParliamiienitonithesamesubject,ortotheappointmentofdepartmentalco-1mmittees--forexample,"to,adviseuponitlheapplicationijtomaaternalmortalitiyandmiiorbidityofthemedeicalanldsuirgiealkniow-ledgreatpresentavailable."ObstetricsismadetoappeartheCinderellaamoingtheashes,whileh1ergorgeouslyarrayedsisters,MedicinieandSnrgery,gototheball.Occasioinallythedignlifiedwveeklyormonithllreviewsenterthlelists.NotmanvweeksagotheSpectator'seliampion;awell-equtiippedCruisader,arraignedtheGeneralMedical*ReadinadiscussionintheSectionofObstetricsandGynaeco1y(oftheAnnuialMeetingofthitbritishMedicalAssociation,Cardiff,1928.!- 186AuG.-4,1928]UJNSUCCESSFULFORCEPSCASES.Councilfortheinadequateteachingofmedicalstudents,arraignedthestreptococcusasthecauseofpuerperalfever,andthentarraigned"thebusydoctor,theperturbedfather,andthewearymother"for"meddlesomemidwifery"whichintroducedthestreptococcus.Hispleawasfortheextensioniofante-natalsupervisionandtreatment.Interestinthissubjecthaspermeatedeveryhomeintheland.AtaveryimportantmeetingintheWestminsterCentralHall,London,onFebruary28th,1g28,attendedbyrepresentativesfromcountynursingassociations,infantwelfarecentres,andmaternityandchildwelfarecomn-mittees,amessagewasreadfromourgraciousQueenMarythatshe"viewedwitlhgraveconicernthecontinuedhighrateofmaternalmortality,andfeltthataveryrealendeavourshouldbemadetoremovethisreproachfromthenationallife.TheQueentruststhismaybeachievedthroughtheeducationofmothersthemselvesintheneedforante-natalcare,throughinquiryintotheimmiiediatecausesofmortalityinchildbirth,andthroughawiderprovisionoffirst-classmedicalandmidwiferyservice."Themembersofthemedicalprofessionineedbeundernomisa)pprehensionastowhomthelpublicarebeingencouragedtoholdresponsibleforthehighmaternalmortalityandmorbidityates.AtthatCenttralHallmeeting,attendednotonlybytherepresentativesIhavereferredto,butalsobySirGeorgeNewmanandDameJanetCampbelloftheMinistryofHealth,LadySelbornei.sreportedtohavecrystallizedthefeelingofmanypresentinherstatementthat"thereisdangerinthedoctor."Thisisalmosttheidenticalphraseusedbythatfamousmidwives'championoftheeighteenthcentury,Mrs.Niliell,inherdiatribesagainstthe"men-midwives"ofthattime,amonigwhomweretheillustriousSmellieandWilliamHunter.Inthepresentdiscussionwearenotconcernedwitlhanyconsiderationastohoworbywhomobstetricpracticeshouldbeconducted.Wearesimplyanalysingaseriesofactualcasesinwhichinistrumentalinterferenicowasun-successful.Dr.Millerhasdealtwiththeactualrecords.Myspecialdutyistoconsiderhowfarthesecasesofunsuccessfulilnstrumentalinterventionicouldhavebeenpreventedbymoreefficientante-niatalcare.CONTRACTEDPELVIS.Dr.Miller'sfiguresshowthatinmorethanione-tliirdofthecasestherowasdisproportionibetweenthepresentingpartandthepelvis.Inonlyaverysmallnutnmberwasthisduetounusualsizeofthechild.Itis,ofcourse,wellknownthattheincideniceofcontractedpelvisvariesindifferentdistrlicts;whiletheaverageinallthreesetsoffiguresisabout33percenit.,theincidenceintheGlasgowseriesisactually50percent.,anidanunusuallylargenumberofthesearcoftheflatrachIitictype.Averylargenuinberofthesecasescouldboidentifiedearlyinpregnanicy.NeedIrieferheretothefactthatmanyofthesewomiienlhaveverystrikingevidenceofskeletaldeformity-lamelv,stuntedgrowtlh,spinalcurva-ture,sword-bladetibiae,etc.?Ishouldliketomentionspeciallytherelationshipbetweenkyphoticspinaldeformityandcontractedpelvicoutlet,andbetweenlameness,wheretheweightofthebodyhasbeenfromclhildhoodborneonionethigh,andunilateralpelvicdeformity.Idonotdisputethefactthatgrossdeformitynmayaccompanyaroomypelvis,butskeletal-irregularityshouldbeadangersign'al.Whileexternalpelvimetry-thatis,themeasurementoftheinterspinous,intercriftal,andexternalconjugatediameters--onlygivesanestimiateoftheinsidepelvicdiameters,irregularitiesintheformeremphasizetheneces-sityforinternalexaminiationi.Theforilmofthepelvicoutletshouldalwaysbeexamine'd.Asharpsubpubicangle,witlhthedistancebetweentheischialtuberositiesreduced,indicatescontractionattheoutlet;withoutsuchanexam-inationthisabnormalitymightescapenoticeuntillateinlabour,becauseinsuchacasetheheadoftenpasseseasilythroughthebrimandcisonlyarrestedlowintlhepelvis.An-examinationiofthediagonalconijugatodiameterslhouldalwaysbeattempted.Therearemanywomen"inwhomanattemptatthismeasurementpervaginammayvbeextremelydifficultintheearlynionths;anattemptduringtheseventhoreighthmonth,however,isusuallysuccessfulowingtotheincreasingsoftnessoftheparts.Wheretheexaminationisstilldifficultthen,acertainamountofassistanceisgotbyaskingthepatientto"beardown"duringtheexamination,thusrelaxingtheperinealmuscles.Ihaveheardbothstudentsandpractitionersassertthattheyweregreatlyhandicappedbyshortfingers,,butIsubmitrespectfullythattherearefewfingerstooshorttomeasurethediagonalconjugateinthecasewhichislikelytocausedifficulty.Inthe-seriesofcaseswhichIhaveinvestigatedIfoundtheestimatedtrueconjugatetobe3-1inchesin19cases;3inchesin14cases;23inchesin9cases,and21inchesin2cases.Infourofthemcraniotomywasextremelydifficultowingtothesmallsizeofthepelvis.Inalloftheminternalpelvimetryshouldhavebeenfairlyeasv.Aiiestimationofthediagonalconjugateisnotacom-pleteexaminationoftheinteriorofthepelvis.Theexamin-ingfingersshouldalwayssweeproundthepelvicbrim;inthiswaymanycasesofasymmetricaldeformitywillbeidentified.Inparticular,thegenerallycontractedpelvis,;wherethetrueconjugatediametermaybenormalwhilethetransversediameterismarkedlydiminished,canbeidentified.Ishallreferlatertothefactthatsuchanexaminationshouldalsoidentifyfibromyomataorovariancystslikelytogiverisetogravedifficultyinlabour.Towardstheendofpregnancythereareothermethodgofidentifyingcasesofcontractedpelvis.Apendulousabdomeneinaprimigravidashouldalwaysarousesuspicion.Again,inaprimigravidatheheadshoulddescendintothepelviccavityduringthelastmonth.Whilethenon-descentmaybeduetofaultypresentation,neoplasm,orevenplacentapraevia,itisveryoftenduetocontractedpelvis.Inforty-sixcasesoffailedforcepsinprimigravidaeinmyseries,theheadwasstillfreeabovethebriminltwentycaseswhenthepatientwasadmittedtohospital.Again,atthisstagethebestofallpelvimeters-namely,'thefoetalhead-isavailable.Themostconvenientwayofusingthispelvimeter,inmyexperience,isthemodificationofMuller'smethod,solongadvocatedbyProfessorMunrdKerr.Ifthereistheslightestdoubtaboutanycase,Ishouldrecommelidmoststronglythatanexaminationbythismethodbomadeunderananaestheticwithinthelastmontlh.Ishouldliketopointoutherethlatwhilediagramsmayshowthefingersinthepelviswitlhtheradialborderstowardsthefoetalhead,itwasneverin-tendedthatthecompleteexaminationshouldbemadeinthisposition.Noonewouldevermakesuchanexamina-tionexceptwiththepalmarsurfacesofthefingers.Itisnotonlytherelationshipoftheheadtothetrueconjugatewhichshouldbeexamined,buttheengagementofthewholesurfaceofthepresentingparttoeachpointofthepelvicbrim.Thereisanessentialdifferenceintheexaminationandprognosisofacaseofgenerallycontractedpelvisascom-paredwithaflatrachiticpelvis.Inthelattertheamountofspaceavailableinthelateralbaysoneaclhsideofthepromontoryisofgreatimportance.Inafavourablecasetheheadengagestransverselyandmakesitswaythroughthebrimbythedescentoftheoccipitalendthroughonebay.Inagenerallycontractedpelvis,however,thetotalareaofthebrimissmallandtheheadcanlonlypassthroughinextremeflexion.Thisextremeflexionmakestractionwithforcepsdifficult,asonlyaninsecureholdis,obtained.Onewouldhardlythinkitnecessarytomentionthefactthatthehistoryofproviouslaboursinacaseofcontractedpelvisismostvaluable.InspiteofthisIhaveinvestigatedsevencasesoffailedforcepsinwhichtheonlypreviouspregnancyhadterminatedinadifficultinstrumentalstill-birth,twoinwhichbothpreviouspregnancieshadtermin-atedininstrumentalstillbirths,andonewhereonepreviouslabourhadterminatedinacraniotomyandtheotherinaninstrumentalstillbirth.Therewasstillanothercasewithahistoryoffivepreviousdifficultinstrumentallabourswitltwostillbirths.Indiscussingthevalueofante-natalexaminationincontractedpelvisIhavenotmadeanymentionofx-rayexaminationofthepelvis.Absolutemeasurementbyxraysisnotofgreatvalueexceptinextremecases,andIMEDICLTJOUINA&--.IA AuG.CGESSFU4,BCEPS1923J(MJO187thereexaminationofthediagonalconjugateisrelativ-elyeasy.Inborderlinecasesthefoetalheadisthetruepelvimeter,andeven.itsposition.at.thebrimbeforetheonsetoflabourdoesnotgiveanyindicationastohowitwillmouldoralteritspositionandrelationshipundertheinfluenceofuterinecontractions.MunroKerr'smethodofpelvimetrygivesafarmorereliableprognosis.-InthegenerallycontractedpelvisIbelievethatthereisafieldforx-rayexamination.InarecentpublicationProfessorMartiusofGottingenhas-recommendedapro-jectionmethodofpelviimetryforsuchcases.1TllepatientisplacedinapositionresemblingFowler'sposition,soastobringthepelvicbrimparalleltothetable.-Usingafixedfocallength,andknowingtheheightofthepelvicbrimabovethephotographicplate,itispossibletocalcu-latetheactualareaofthepelvicbrim.ProfessorMartiusbelievesthatanormal-sizedfoetuscannotcomethroughsuchapelv-iswhentheareaofthebrimislessthan70or80squarecentimetres.InallthisreferencetocontractedpelvisIhaveclaimedthatitispossibletoforetelldifficultv.Casessuitableforinductionoflabourmiiaybeidentifiedfromthethirty-sixthweekonwards.Whenapatientwithaknowndeformityisallowedtogoon'totermitisadvisabletohavethepatientadmittedtohospitalattheonsetoflabour,oratanyratetohaveherregardedfromthebeginningoflabourasoneinwhomevenCaesareansectionmiaybecomenecessary.Theresultofthelabourwilldependnoto'nlyonthedegreeofdisproportion,butalsoolnthemouldabilityoftheheadandthestrengthoftheuterinecontractions.Iftheuseofforcepsisdecidedon,amostcarefulre-examiiniationofthepatientshouldbemadeaftershehasbeenanaesthetizedifnecessary,withthehandinthevagina.Inthiswaythepositioncanbeaccuratelydia-gnosed.Ifthereseemslikelytobegreatdifficultyitisbettertostopwiththisexaminationratherthantoendangerthemotheranddamagethechildbyviolenteffortsatdelivery.IhavemyselfhadthemortificationofperformingCaesareansectionina"failedforcepscase,anddeliveringachildwithafracturedskullandbothcheeksverybadlytornbytheforceps.Insuchcasesthenumberofvaginalexaminationsshouldbekepttoaminimum.Rectalexaminationcanbecome,withpractice,justassatisfactoryandcertainlylessdangerous.WehaveallbeenwarnedhowmuchgraverbecomestheprognosisinaCaesa-reansectioncasewitheachyaginalexamination.Inborderlinecasesofcontractedpelvismyownpre-ferenceistoallowthepatientagoodlonglabour,andthen,ifprogressisnotsatisfactory,toperformtheloweruterinesegmentCaesareansection.Thelongerthepatienthasbeeninlabour,withinlimits,theeasieristheoperation.OCCIPITO-POSTERIORPOSITIONS.Dr.Miller'sanalysisshowsthatoccipito-posteriorposi-tionswerepresentonlyslightlylessfrequentlyintheseriesof"failedforceps."Incomparativelyfewoftheseeaseshadtheabnormalpositionoftheocciputbeenrecog-nizedbeforetheapplication6fforeeps,andinvei'ryfewhadanyattemptbeenmadetocorrectthepositionbeforeusingthem.Insomeitwouldappearthatthetractionnmerelyacceintuatedthemalpresentation.Carefulante-natalexamination'canuisuallyidentifyoccipito-posteriorpositions.Therearesomecasesinwhichaparticularlythickorspeciallysenisitiveabdominalwalldoesmakesuchane'xaminationdifficult.Theeasewithwhichlimbsarepalpatedinfrontandtheeasvidenti-ficationofthefoctalchinareusefulguides.Wherepalpationisdifficu-ltacoupleofx-rayphotographs,frontalandlateral,shouldgiveacompletediagnosis.Thereissomedifferenceofopinionastowhetheroccipito-posteriorpositionscanbecorrectedbeforetheonsetofhbour.Whilemanyhospitalworkerslhavereporteddis-appointingresultsinthisdirection,Dr.Haultain,twoyearsago,publishedaseriesofcasesinwhichhesecured'permanentcorrectionbytheuseofpadsandabinderin87percent.oftheprimigravidae,andin83percent.of'themultiparae.2Dr.IHaultainstressedtheenthe-impor-tanceofcarryingoutthiscorrectioninthelastmonthofpregnancy,anidparticularlyincaseswheretheheadremainedfreeabovethebrim.ThesuccessesoriginallyreportedbyDr.Buist,andbymanywhohavefollowedhim,shouldha,vegainedmorewidespreademploymeintofthis'methodofcorrection.Evenwherenoattempthasbeenmadetocorrectanoccipito-posteriorposltionbeforetheonsetoflabour,wemustrememberthatcertainly60per.cent.,ifnotquitethe80percent.referredtoinmosttextbooks,dorotatespontaneously.Theiniiportantpointistorecognizetheassociationofthismalpositionwithaprotractedlabour.Whentheabnormalpositionhasnotbeenrecognizedbefore,itshouldnieverescapenoticewhenthepatientisexaminedbeforetheapplicationofforceps.Evenaveryfirmandextensivec?putsuccedaneumshouldnotobscurethediagnosis.Whenforcepsareappliedwhiletheheadisstillintheoccipito-posterior.position,especiallywhenitishighinthepelvis,theycertainlydoslipeasily.Associatedwiththispositionofthevertex,asalsoincasesofcontractedpelvis'thereisoftenslowdilatationofthecervix.In50pernceniofmyseriesofcasesinwhichforcepshadbeenunsucqessfullyappliedin-occipito-posteriorpoSitionlSthecervixwasstillincompletelydilatedwhenthepatientwasadmittedtohospital.OTHERABNORMALPRESENTATIONS.Faceanidbrowpresentationsdonotoccuru'ntiltheonset,oflabour,exceptunderinostuniusualcircuimstances.Whilewsuchabno'rmalitiescannot,therd.eore,beidentifiedduringpregnancy,tlheconditionslikely,togiv,erisetothemmayb1~e.OfthesethemostimportantarebonydeformityWfhethevis'anbdbliquity,-oftheaxisoftheuterus.'WlKileboth'can'beidentified,thelattercanoftenbeeffectivelytreatedbytheuseofabinder.UJnusualsizeofthefoetusandhydramnios'calntothbeidentifiedbeforelabourcomeson,butsuchothercausesasanmenccphaly,meningocele,andcoDngenitalgoitrecanhalrdlybediagnosedinadvance.Transverseandobliquepresentationsshouldbeidentifiedbeforetheonsetoflabour.Theymaybe'correctedinthecaseswherealaxabdomiinalwallisresponsible.Wherethecauseisacontractedpelvis,amalformeduterusoraneoplasm,theearly)recgniitioinofthecausewillallowarrangementsforpropertreatmenttobemade.Whilebreechpre-entationshardlycomewithinthescopeofthispaper,therearetwocasesintheserieswhereforcepswereu.nsuccessfullyappliedtoanundiagnosedbreech.Atthatstagecarefulexaminationshouldhavemadeadiagnosiseasy.Inbreechpresentations,especiallyinprimigravidae,theimportantpointistohaveversionperformedbeforetheonsetoflabour.Thispresumestimelydiagnosisbypalpation,whiclhmaybediffioult.Incasesofthistypexrayexaminationismostlelpful,notonlyinarrivingatadiagnosis,butalsoinin'dicatingin.whichdirectionthefoetusshouldbeturned.TLTMOURS.Uterineandovariantumoursappearonlytwiceinourseriesofcases.Thleycanalmostalwaysbeidentifiedbeforetheonsetoflabour,andinfactareusuallynoticedatthefirstpelvicexamination.'lheneversuchadiagnosishasbeenmadethepatientslhouldbeinsomeinstitutionattheon,setoflabour,sothatmajorsurgicalinterferencemaybecarriedoutwithoutdelay,shoulditbecomenecessary.FOETALABNORMALITIES.Ineightcasesoftheseriesthedifficultywasduetohydrocephalus.Amongallfoetalabnormalitiesthisisprobablytheonemosteasilydiagnosedbeforetheonsetoflabour.Thieoutlineofthelargesoftheadcangenerallybeidentified,exceptwhereitisobscuredbyhydramnios.Whenithasbeenrecognized,perforation,after'aboutathree-fingerdilatationofthecervixisreached,maypreventanexhaustinglabour.Generalfoetaldropsyisgenerallyassociatedwithsomeotherabnormality,suchasanabnormalpresentation;andtheover-distensionoftheuterusshoulddeterminethepatient'stransferencetohospital.Foetalmonstersoftenescapenoticeuntil.theactualappearanceofdystocia1asthepresentingpartmaybeofIAUG.4,192,8."ITftT"mMBDICALJOUBWAL187 188AG.u..-928]tNSUCCESSULFORCEPS-CASES.O[TIRERN9SFULFORCEPtMEDIC2.joulalNAL-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~normalpropor-tionsandinnormal-position.Thedifficultyofdiagnosinganencephalyandcongenitalgoitrehasalreadybeenreferredto.CASESOFINCOMPLETEDILATATIONOFTHECERVIX.Indiscussingoccipito-posteriorpositioinsIreferredtotheslowdilatationof.thecervixinsuchcases.Inmyseriesof68casesofcontractedpelvisinwhichforcepshadbeenunsuccessfullyapplied,thecervixwasstillincom-pletelydilatedin33ofthecaseswhenthepatientwasadmittedtohospital.Intwoofthisgroupthedilatationwasofsuchsliglhtdegreethatitwmadifficulttoimaginehowforcepscouldeverhave,beenappliedtothefoetalhead.Inallthesecasestherewasadefinitecauseforthedelayedlabourandtheslowdilatationofthecervix,butin151ofallthecasesreviewedbyDr.Millertherewasnoevidenceofanyabnormalitv;yetforcepshadbeenappliedbeforethecervixwasfullydilated.Inthe34caseswhichIcontributedtothisgrouponemotherdiedfromruptureoftheuterus,fivehadamorbidpuerperium,buttheremainderhadanuneventfulrecovery.Thereareprob-ablymailyofthesewomenwlhowillstillrequiretreatmentingynlaecologicalwards,becausetractionthroughanundilatedcervixcausesnotonlytearingofthlecervix,butalsoforceddescentofthecervixwithsubsequentuterineprolapse.However,itiswheinweconsidertheresultstothechildthatthepictureisblackest.Ofthe34children15werestillborn,andseveralofthesurvivorsshowedextensivebruisingatbirtlh.Ithinkwemustagreethattheapplicationofforcepsbeforecompletedilatationofthecervixisamostdangerousprocedure;yetweseehowoftenitappearstohavebeenpractised.Efficientante-natalcareshouldidentifythecaseswherelabourislikelytobeprotractedanddilatationslow,butitisonlyeffectiveteachinigwhichcanpreventthetooearlyapplicationofforcepsinnormalcases.FrommyexperienceasateaclherIknowtllatonquestioningstude'ntstllereishardlyonewhodoesnotremembertostatethattlhocervixmustbefullydilatedbeforeforcepsareapplied.ThepointonwhichIthinkteachersandtextbooksdonotlaysufficientemplhasisisthatmanualdilatationofthecervixisseldomjustified,and,evenwhenitisattempted,isveryoftenincomplete.Ilhaveevenbeeninformedbyayounggraduate,negotiatingfortheadmissionofhis"failedforceps"casetohospital,thathehadfirstusedgentletractionwiththeforcepstosecuredilatationofthecervix.Thepatienteventuallydeliveredherselfspontaneously.CONCLUSION.Inestimatinghowfartlhecasesof"failedforceps"couldhavebeenpreventedbyefficientante-natalcare,Ihavetriedtoshowthatalmostalloftherealabnor-mualitiescouldhavebeenidenitifiedduringthecourseofpregnancy,andparticulairlyinthelastmonth.Thereisonlyaverysmallgroupoffoetalabnormalitiesofthedevelopmentaltypewhichcannotbedetectedbeforetheonsetoflabour.Ante-natalsupervision,however,cannotpreventthetooearlyapplicationofforcepsinnormalcases.Whenabnormalitieshavebeendetectedtheymayeitherbecorrectedbeforetheonsetoflabour,asinoccipito-posterior,breech,andtransversepresentations,orsenttoahospitalorsimilarinstitutioniwhereappropriatetreat-mentcanbecarriedoutinthemostfavourablecircum-stancesatthecorrectstageinlabour.Itmaybeaskedwhethertheante-natalsupervisiontowllichIhavereferredcanbeefficientlycarriedoutbythefE.milyphysician.Inmaiiycasesitcan,buttheeremustalwaysbeaconsiderableproportionofcasesinwhichaccuratediagnosisofpelvicdisproportionorabnormalpresentationisdifficult,evenforthehospitalphysicianwitlhspecialtraininig.Hemayrequirethehielpofxraystoestablishihisdiagnosis.Itwouldappear,therefore,thabanefficientobstetricservicewouldrequlirewell-equippedconsultative.ante-natalcentrestowhichthecasespresentingdifficultiestothefamilyphysicianlcanlbereferred.~Again,workofthiskindisfartooresponsibleanddifficultformidwives,andIbelievethlatamidwifeshouldnotbeauthorizedtoundertakethecareofanypregnantwomanwithoutprovisionbeingmadofor.thepatienttobeexaminedcarefullybyamedicalpractitionerbeforelabourisdue.REFERENCES.1Zeit.f.Geburtsh.undGynatkol.,1927,xci,3,p.504.2ProceedingsEdinburghObetetricalSociety,1926,p.133.UNSUCCESSFULFORCEPSCASES.*BYWILLIAMFLETCHERSHAW,M.D.,CH.B.,ProfessorofClinicalObstetricsandGynaecology,UniversityofManchester;HonoraryGynaecologicalSurgeon,ManchesteroyalInfirmary.INtlhelastfewyearsmoreandmoreattentionhasbeenfocuseduponmaternitypractice;meetingsofvariousbodiesoutsidetheprofessionhavediscussedthesubject,oftenwithgreatignoranceofthefacts,andnecessarily,fromthecompositionofthesemeetiings,theblamefortliepresenthighmortalityinchildbirthhasbeenthrownupontLomembersofourprofession.Inthegreatmajorityofinstancesthesechargesareaninljustice,anidaslightknowledgeofthefactswouldpreventthemfronibeingnmade;butinsomedirectionsobstetricpracticeleavesmuchtobedesired,anditbehovesus,asapyofession,totakestockofourmethodsandseeifitisnotpossiblotoraisethestandard.Itisforthisreason1onlythatwehave-broughtforwardthissubjectfordiscussiolbeforeameetiligcomnposedlargelyofgeneralpractitioners.Wehavestatedourviewsasmembersofthestaffsofmaternityhospitals,andwehopethatgeneralpriactitioneiswillfullvstatetheirviews,andthatthediscussionwiilbearfruit.Insimilardiscussionsinthepastithasoftenibeenstatedthattheconsultantspeaksonlyfromhisexpe-rienceofhospitalwork,and-compareshisownresultsinidealcircumstanceswiththoseofmenwhohavetoconducttheircasesincircumstancesfarfromideal.Thefactisoverlookedthatfewconsultinigobstetriciansreachthestaffoftheirhospitalwithoutanextensiveexperienceofmater-nityworkintheverypoorquartersoftheircities,andthereforearefullyalivetoallthesedisadvantages.Oneadvantage,andoneonly,hadwe'overthegeneralpracti-tioner-weweredoingobstetricalworkonly,andhadnoanxietyaboutothercasesbeingneglectedwhenwewereengagedforalongperiodoveronematernitycase.Ifthisisafactorinbadmidwifery,andIfeelsureitisoneoftImomostimportant,itisbettertofacethefactsandseeifa,remedycanniiotbefound.Theaspectofmaternityworkweareconsideringto-dayisoneofthegreatestblotsonourobstetricalescutcheon1.ThefiguresgivenibyDr.MilleroccurredintImepracticeofthreelargematernityhospitals,butthesehospitalswerechosenatrandom,andthereisnodoubtthatequallyco,nvincingfigurescouldbeproducedfrom.everyothermaternitylhospitalinthecountry.Thefactsarethere-andcareincontrovertible.Dr.Millerhasshownthetypesofcaseswhichresultinforcepsfailure,andhasanalysedthlecausesaniddiscussedthediagnosisandtreatmelit.Hehasalsodetailedtheappallingresultstomother.alndchild,resultswhichcouldhavebeenavoidedwithalittlemorecareandknowledge.Oneofthemoststrikinigfiguresinthisseriesisthelaigenumberofcraniotomiesperformed.InthelasttwentyyearsthenumberofCaesareanisectionsperformiedine-cliobstetricalunithasenormouslyincreased,andthefirstthoughtonseeingthesefiguresisthatmanyofthesechildrencouldhavebeensavedbythisoperation.Incon-sideringthisalternativetreatmentwemustrememberinthefirstplacethatthemajorityofthechildrenweredeadorbadlydamagedwhenthepatientwasadm1ittedtohospital,butasmallnumberwerealiveandweredeliberatelysacrificedtosavethemother.Caesareansectionperfornmedupona"cleanpatientisn1owasafeoperationwithaverylowrmortality,butCaesareansectionperformeduponapatientafterattempts*ReadinadiscussionintheSectionofObstetricsandGynaecolozgyoftheAnnualMeetingoftheBritishMedicalAssociation,Cardiff,1928.