494 POSTGRADUATE MEDICAL JOURNAL October 1951 Postgrad Med J: first published as 10.1136/pgmj.27.312.494 on 1 October 1951. Downloaded from infection is the precipitating factor. Intramuscular sidering the use of antibiotics in non-tuberculous penicillin, combined where indicated, with inhala- disease of the chest. tion therapy should be commenced at once if chest 2. Bacteriological investigation and sensitivity infection is felt to be a contributory factor in tests of organisms obtained are essential. cardiac breakdown. Meanwhile investigations 3. Blunderbuss therapy must not be used. should be started and modification of treatment 4. Newly discovered and comparativelyuntested may be made as indicated. The effective treat- antibiotics must not easily replace tried remedies. ment of the lung lesion associated with the correct 5. The wider aspects of aetiology such as social approach to the heart condition may lead to factors must be evaluated. dramatic improvement in what may otherwise 6. The important part that lung infection plays seem to be a hopeless problem. in heart failure has been touched upon. I should like to thank my colleagues, and many Conclusions others in the hospital for their constant cooperation I. Dogmatism must be avoided when con- and help with these problems. BIBLIOGRAPHY GUNNISON, J. B., COLEMAN, V. R., and JAWITZ, E. (I95oa), FATTI, L., FLOREY, M. E., JOULES, H., HUMPHREY, Proc. Soc. exp. Biol. N.Y., 75, 549; (I95ob), J. lab. Clin. J. H., and SAKULA, J. (1946), Lancet, i, 295. Med., 36, 900oo. DAVIES, D., and ASHER, R. A. J. (I951), Lancet, i, 924. LEHR, D. (195ob), Brit. med. J., ii, 6o0. Protected by copyright. THE CLINICAL ASSESSMENT OF DISPROPORTION' By WILLIAM HUNTER, M.D., F.R.C.O.G. Obstetrician, Princess Mary Maternity Hospital; Associate Surgeon, Royal Victoria Infirmary, Newcastle upon Tyne; Senior Obstetrician and Zynaecologist, North-West Durham Hospital Group

Attention has been devoted during recent years other findings, to decide upon the further manage- to radiological methods of assessment of the sizes ment of the case. The words of the pious i8th of the maternal and foetal head and much century German midwife, Justine Siegemundin- has been achieved. The greatest strides have been 'All I do depends on God's help and on the made in the estimation of the size of the pelvis, skilful motions of my hands '-have a particular http://pmj.bmj.com/ but progress has not been limited to actual measure- application to this type of case. ment of the bony structures. There is now a Some indication of possible difficulty at the better understanding of the architecture of the time of the confinement may be discovered during pelvis-of its variations in shape as well as in the course of the routine antenatal investigation size-and of the significance of these variations. of a case. The patient may be of small stature, she So much thought has, in fact, been directed into may have an obvious limp, occasionally due to these new channels that of the of the or she show comparatively many ankylosis hip, may gross de- on September 25, 2021 by guest. methods of clinical assessment previously in use formities of the long or spine and, for in- seem to have been forgotten or to have fallen stance, there may be obvious rachitic manifesta- largely into disuse. For this reason the time now tions. In giving the medical or surgical history seems opportune to re-consider some of the she may bring forward an account of fractures, clinical methods available for estimating the tumours or diseases of the pelvic bones or spine, relative sizes of the foetal head and the maternal or tumours of the pelvic organs. The previous pelvis. It is, after all, upon these methods that we obstetric history may suggest the possibility of re- must rely to select those cases which require fuller current complications arising in the approaching investigation and ultimately, in conjunction with confinement. There may have been a prolonged or complicated labour, a difficult delivery or Caesarean *A paper read at a meeting of the Newcastle and section, maternal trauma or a stillborn Northern Counties Medical Society in Newcastle upon or injured child, possibly of large size, on a pre- Tyne on Thursday, February i, 1951. vious occasion. In all such cases every effort October 1951 HUNTER: Clinical Assessment of Disproportion 495 Postgrad Med J: first published as 10.1136/pgmj.27.312.494 on 1 October 1951. Downloaded from should be made to elicit as much information as made by this method than by the alternative possible about the previous confinement. This ' pelvic grip ' with the hands laid on either side of applies especially to confirmation of the patient's the midline in the supra-pubic region with the story, and a report upon the efficiency of the fingers pointing towards the pubes and palpating uterine contractions and the immediate cause of the foetal head bimanually as it lies above the pelvic any difficulties which may have arisen. Further brim. This is as one would expect. It is much information should be obtained whenever possible easier to judge the size of a ball or an orange by from the doctor in attendance at the time of this holding it in one hand than by rolling it between complicated labour. the fingers of the two hands. A general examination is necessary in all cases Next the flexed foetal head is depressed down- in early pregnancy, and abdominal palpation wards and backwards into the by the should be carried out repeatedly, especially during examining hand to gain some impression of the the last six weeks of pregnancy, the bladder and ease with which it can be fitted into the pelvis. It rectum being empty. The height of the uterus is important that the sagittal suture should be may be checked by sinking the edge of the left directed into the axis of the brim and not tilted hand into the abdominal wall above the fundus. to front or back. It is sometimes recommended The presentation, position, attitude and, to a lesser that the head should be fitted into the brim with extent, the size of the foetus can usually be deter- the patient sitting. This, however, by tilting the mined with a reasonable degree of accuracy by pelvic brim may give fallacious and over-optimistic Pawlik's grip followed by the fundal and umbilical impressions. In fitting the head into the pelvic grips carried out in the standard textbook manner. brim, not only is the amount of descent noticed but As a supplementary method of examination, the degree of over-riding of the pubes by the skull ballotting the foetus by rocking the hand with the is estimated by the fingers of the right hand. finger and thumb outstretched, as in Pawlik's grip, There should normally be a step-up from the Protected by copyright. in different parts of the may be helpful foetal head on to the pubes and not vice versa, especially for identifying the foetal back and, when when the head is pressed back against the spine. carried out with the left hand, for locating the It is frequently stated that the foetal head foetal head when it lies in the uterine fundus. It is engages in the pelvic brim in the primigravida unhelpful to feel for the foetal parts by a rotatory between the 34th and 36th weeks and in the multi- movement of the finger-tips on the uterine wall. gravida shortly before the onset of labour. While This tends to rub up a contraction of the uterus and it is true that lightening, and so engagement of the so to mask the underlying foetal parts. It there- head, usually occurs earlier in the primigravida fore makes identification still more difficult. In than in the multigravida, it is not unusual, even applying Pawlik's grip and the umbilical and under normal conditions, to find the head high at fundal grips the method of ballottement should be the 36th week or even later in either case. If the used. Pawlik's grip should be carried out by a head has not competely engaged in the pelvic side to side rocking movement of the hand and cavity by the 36th week of pregnancy at latest, in wrist from the forearm, tapping the foetal head either a primigravida or a multigravida, a vaginal http://pmj.bmj.com/ alternately with the thumb and the fingers rather examination is essential. If the head is engaging, than by firmly grasping the foetal head as it lies in that is if part of the head has entered the pelvic the lower uterine segment, a procedure which cavity although the greatest engaging diameter tends to cause unnecessary pain. The estimation has not yet passed the brim, the examination may of the size of the foetus is largely based upon the be deferred for a further two weeks. If at the assessment of the size of the foetal head, but a 38th week the head is not completely engaged, estimate of the relative bulk of foetal sub- examination must then be carried out. rough vaginal on September 25, 2021 by guest. stance and liquor amnii, the height of the breech Repeated abdominal and, when necessary, vaginal in the uterus considered together with the degree examinations will minimize the risk of any case of of engagement of the head and the apparent size disproportion being overlooked and will make the ofthe various foetal parts provide valuable auxiliary ultimate findings more reliable. information. The appraisal of the high foetal head It is often recommended that the external pelvic is, however, of first importance. A general im- measurements should be taken as routine after the pression of its size can be obtained from Pawlik's abdomen has been palpated. I personally think grip after the head has been flexed. This head that if these measurements are taken and the inter- flexion is effected by pressing on the foetal breech spinous and inter-cristal diameters and the ex- at the uterine fundus with the left hand to arch ternal conjugate are found to be normal one tends the child's back towards the uterine wall and at to be lulled into a false sense of security and to the same time tilting the head with the right hand. assume that the pelvis is normal. Yet it is not A better assessment of the size of the head can be unusual to find these measurements within normal 496 POSTGRADUATE MEDICAL JOURNAL October I951 Postgrad Med J: first published as 10.1136/pgmj.27.312.494 on 1 October 1951. Downloaded from limits in cases of pelvic contraction. On the other drawn up and widely separated, is necessary in a hand, if the measurements are subnormal the con- high proportion of all primigravidae and multi- sequences are not likely to be so serious as a more gravidae. It is essential in all cases in which the detailed examination will almost certainly be greatest diameter of the foetal head has not passed carried out. The , however, will not through the pelvic brim before the 36th or at necessarily be found to be deformed. As, in my latest the 38th week of pregnancy. This applies opinion, these measurements are unreliable in whether or not the patient has had previous con- indicating the presence or absence of pelvic de- finements. Rather than take any chance of error formity and may prove misleading, I do not take when not absolutely certain of the diagnosis after them during the course of routine examination of abdominal palpation, it would be safer to examine the ante-natal case. every patient vaginally. The cause of the high The is reasonably accessible, the head may be a tonic condition of a well-developed chief difficulties in the way of assessment of its muscular or an atonic condition of the size being due to the thickness of the superficial uterine or abdominal muscles. It may be due to covering tissues. The width of the subpubic deflexion of the head or posterior position of the angle is of considerable importance and the angle occiput, to the large size of the foetal head as- between the pubic rami should, therefore, be sociated with a big foetus or foetal abnormality, carefully investigated. It is normally slightly more to tumours in the pelvis or placenta praevia, or or less than a right angle. If it is more acute it is to tumours, fractures or deformities of the pelvic probable that the ischial tuberosities are closer bones. together than usual and that transverse contraction The most important of these conditions which of the bony outlet is present. Apart from the risk may keep the head high are, from a practical point of arrest of the foetal head during the second stage of view, occipito-posterior position often with in- of labour this narrowing of the sub-pubic angle complete head flexion, a large foetus, pelvic con-Protected by copyright. may so limit the available space in the anterior seg- traction or a relatively large foetus with a relatively ment of the pelvic outlet that the greater part of small pelvis. Internal pelvic examination is also the head must be born behind the ischial necessary whenever a malpresentation has been tuberosities through the posterior part of the out- found or there is a history of previous complicated let. This is liable to cause extensive and even or unsatisfactory confinement. A history of a complete laceration of the and to inflict previous normal confinement does not mean-that a considerable damage upon the pelvic floor. The subsequent labour will necessarily be uncom- length of the inter-ischial diameter between the plicated. The foetus may be larger, the presenta- medial borders of the ischial tuberosities may be tion and position may be different, the uterine measured by a pelvimeter or by the clenched fist. action may be less satisfactory and it is even Reliable measurement by the pelvimeter is fre- possible that the pelvis may be smaller. If uterine quently difficult owing to the thickness of the sub- fibroids are palpable through the abdominal wall cutaneous fat in this region, and the measurement examination is to exclude the

vaginal necessary http://pmj.bmj.com/ of this diameter, normally about 4 in., indicates presence of pelvic fibroids which might obstruct only its approximate length. As a rough guide to labour, these tumours frequently being multiple. the space available between the ischial tuberosities Vaginal examination should be carried out at or the introduction of the knuckles of the right hand after the 36th week of pregnancy, when its purpose at the interphalangeal joints into the inter-ischial is to estimate the sizes of the pelvis and foetal space, at the level of the anus, can be tried. If the head and the relative proportion between the two. pelvic outlet is normal, four knuckles should At this time the soft tissues are relaxed and readily pass between the ischial tuberosities, reasonably accurate estimations are possible with on September 25, 2021 by guest. although this measurement is also approximate in minimal discomfort to the patient. If the estima- view of the inconstant thickness of the sub- tion is made during the early months of pregnancy, cutaneous fat. Some obselvers stress the im- owing to the inelasticity of the soft tissues, the size portance of the measurement of the posterior of the pelvis tends to be under-estimated. On sagittal diameter taken from the mid-point of the introducing the fingers into the vagina, after inter-ischial line to the tip of the , but I assessing the sub-pubic angle and pelvic outlet, the feel that in cases of doubt there are more satis- walls of the pelvic cavity are palpated and an im- factory methods for confirming the clinical findings pression of normality, roominess or of restricted than by taking such an arbitrary measurement, space may be gained. The degree of separation of even if it is considered in conjunction with the the pubes may be assessed by grasping the sym- transverse diameter. physis between the index finger in the vagina and Vaginal examination of the pelvis, carried out the thumb over the mons veneris. The ischial with the patient lying on her back with her knees spines may then be palpated and if they are unduly October 1951 HUNTER: Clinical Assessment of Disproportion 497 Postgrad Med J: first published as 10.1136/pgmj.27.312.494 on 1 October 1951. Downloaded from prominent the fact should be noted, especially in casionally unreliable readings may result not only cases of occipito-posterior position. At the same from faulty technique but also from tilting of the time the size of the sciatic notch should be checked pelvic bones, in particular of the sacrum when the as, if this is unduly small, the pelvis may be de- joints are more than usually flexible and the patient formed. Any change from the normal gradual is put into unnatural positions for radiography. curve of the sacrum either in the direction of Although it provides an extremely valuable aid to straightening or excessive angulation should not be diagnosis, it is uneconomic to use this method in all overlooked. Excessive mobility of the sacrum cases and it does not obviate the necessity for a should be noted and the pliability of the sacro- careful clinical assessment. coccygeal joint confirmed. Attention should now be directed to the assess- Measurement of the diagonal conjugate from ment of the size and pliability of the foetal head. the lower border of the symphysis to the The previous diagnosis of the position of the head promontory of the sacrum is now carried out. The in relation to the four quadrants of the pelvis and index and second fingers of the right hand are to the intermediate positions is confirmed by passed into the vagina and advanced towards the palpation of the accessible sutures and fontanelles sacral promontory. If a steady pressure is main- of the vault. An impression of the degree of tained on the perineum with the flexed free fingers, flexion, the size, the extent of ossification and the in all but the most unco-operative patient it should pliability of the foetal head is then gained by be possible to reach the promontory with the tip bimanual palpation together with determination of of the middle finger in a normal but not unusually the width of the accessible sutures and fontanelles. large pelvis. The middle finger is pressed steadily The possibility of hydrocephalus must be kept in against the promontory and the position of the mind when the head is large and the sutures broad, lower border of the symphysis pubis or the sub- and the increased risk of intra-cranial injury in pubic ligament is marked, as it lies near to the cases of the small poorly ossified skull of the pre- Protected by copyright. metacarpo-phalangeal joint of the right index mature baby must not be forgotten. The greater finger, with the nail of the left index finger. The the arc of the palpable segment of the vault or right hand is now withdrawn and the distance dome of the skull the larger is the head likely to from this point to the tip of the middle finger is prove. measured with a rule or pelvimeter to obtain the The head is then flexed and depressed into the diagonal conjugate. If, with the patient recumbent pelvic brim by the abdominal hand as the degree the pubes are horizontal or parallel with the bed, of descent, and therefore the degree of proportion, 3 in. and if vertical i in. is deducted to give the is assessed by the fingers in the vagina. At this true conjugate. This is probably the most im- stage the more acute the angle between the anterior portant single diameter of the pelvis. parietal and the back of the pubes the more If the promontory is found to be of the 'over- favourable is the outlook. The thumb of the right hanging' type projecting well forward over the hand brought over the pubes can now be used to pelvic brim the true measured in the estimate the of of the foetal head conjugate degree overriding http://pmj.bmj.com/ manner described tends to be over-estimated. over the pubes and to confirm the abdominal Not less than i in. must, therefore, be deducted in findings. It is important, in fitting the head into such cases. It is important that a false pro- the brim, that it should not be tilted to direct the montory formed at the junction of the bodies of sagittal suture forwards or backwards. Tilting the first and second sacral vertebrae should not be forwards tends to give the impression of a less mistaken for the true promontory at the lumbo- favourable, and backwards of a more favourable sacral junction. This mistake is unlikely to be outlook than is really justified. The head should, made if the sacral curve is followed well forwards therefore, be pressed down at right angles to the on September 25, 2021 by guest. by the examining fingers. If, passing from the pelvic brim in the axis of the pelvis, the normal sacral promontory, the tips of the fingers can reach tilt of the pelvic brim being kept in mind. Bi- and follow round the pelvic brim on either side it manual assessment is a valuable method of is almost certain that the brim is reduced in size. examination in all cases of possible disproportion. When any evidence of pelvic contraction is de- During labour it can be carried out with an even tected or suspected it is advisable to employ greater measure of accuracy and the state of the radiological to give a more detailed foetal membranes, the amount of descent during picture of the pelvic architecture and to provide uterine contractions, the size of the caput suc- useful estimations ofthe more important diameters, cedaneum and the degree of moulding can all be some of which are not readily accessible to clinical taken into consideration. Progress has been made assessment. This method is not infallible and, in with radiological cephalometry, but in general it the hands of inexperienced radiographers and has not yet attained the accuracy and reliability of radiologists, may give misleading figures. Oc- pelvimetry. In centres in which this method of Postgrad Med J: first published as 10.1136/pgmj.27.312.494 on 1 October 1951. Downloaded from 498 POSTGRADUATE MEDICAL JOURNAL October 1951 examination has been developed and given special measurement of the diagonal conjugate. The size attention very good results have been claimed. It of the foetal head can be judged by abdominal, is a method of examination which is likely to vaginal and bimanual vagino-abdominal examina- become increasingly useful in the future. tion. The relative sizes of the head and pelvis can The clinical assessment of disproportion there- then be estimated by direct fitting of the head into fore depends upon a careful examination of the the pelvic brim during bimanual palpation. The maternal pelvis and of the foetal head followed by importance of frequently repeated examinations fitting the head into the pelvis. The size of the cannot be overstressed. Radiology provides a pelvis can be estimated with a reasonable degree of valuable auxiliary method of assessment in ex- accuracy by palpation of its outlet and cavity and perienced and careful hands.

CHLORAMPHENICOL IN NON-TUBERCULOUS URINARY INFECTIONS

By R. MARCUS, M.D., CH.M., F.R.C.S. Protected by copyright. Department of Surgery, University of Liverpool.

Chloramphenicol (D-threo-i paranitrophenyl-2- cently been reviewed by Wells and Marcus (I949) dichloroacetamide-i, 3 propanediol) is a pure and will not be described in this communication. crystalline substance obtained from cultures of the streptomyces venezuelae (Ehrlich et al., 1948). Synopsis of Cases Treated Synthesis is relatively simple. It is administered Sensitivity tests showed streptomycin and in capsules containing 250 mgm. as it has a bitter penicillin resistant strains of organisms in all taste and is not very soluble in water. When it is cases. necessary to administer it parenterally, propylene http://pmj.bmj.com/ glycol is used as the vehicle. It is relatively stable Case I in that it retains Ioo per cent. of its activity at a W.H., aet. 76. Cystitis and epididymo- pH of o.4 to 9.56 and is unaffected by boiling in orchitis due to indwelling catheter and tidal distilled water for a number of hours (Gottlieb drainage after abdomino-perineal excision of et al., I948). rectum. Chloramphenicol is excreted by the kidneys in 30.11.50. Urine-moderate number of pus greater concentration than that found in the blood. cells and B.

coli. Sensitive to on September 25, 2021 by guest. After i g. a peak is reached in the blood and urine 32 units/ml. at two at which time the concentration is chloramphenicol. Chloramphenicol, 750 mgm., hours, six-hourly. Total dosage, 9 gm. about 33 times greater in the urine than in the 6.12.50. Urine-n.a.d. sterile. Epididymo- blood (Ley, et al., I948). orchitis improving. With the help of the Medical Research Council 9.12.50. Urine-sterile. Epididymo-orchitis I7 cases of non-tuberculous urinary infection have resolved. been treated with chloramphenicol and the results Urine-sterile. studied. No case was accepted for treatment 18.4.51. unless there had been a thorough and prolonged Remarks. Rapid and permanent sterilization of course of treatment with urinary antiseptics and the genito-urinary tract. penicillin. Penicillin and streptomycin were ad- ministered when the tests showed the organisms Case 2 were sensitive to these antibiotics. The dosage, 142067 F.B., aet. 73. Suppurative pyelo- mode of action and value of these agents has re- nephritis after catheterization for chronic re-