TEW: USE AND ABUSE OF 1031 averaged twenty-one months of complete dis- also, that he believes there must be an occasional ability before operation. The first case was thyro-cardiac in every medical community suffer- operated on in October, 1920. The cases oper- ing from cardiac decompensation, hopelessly dis- ated on since this report continue these ex- abled so far as medical treatment is concerned, tremely gratifying results. Dr. Hamilton, the but potentially curable by surgical treatment, cardiologist of our clinic, has repeatedly stated, once the underlying thyroidism is discovered.

THE USE AND ABUSE OF THE OBSTETRICAL FORCEPS* W. P. TEW, M.B., F.R.C.S. (Edin.) From the Department of and Gynecology, University of Western Ontario, London, Ont. SPEAKING in a general way, one may say dead or dying child and evidently often piece- that obstetrical forceps have rendered meal. It was not meant for the delivery of a greater assistance to womenkind during labour living child. The Arabians, in the tenth and than any other mechanical apparatus. At the eleventh centuries, made use of an instrument same time, this instrument has done more harm for delivering a dead or dying child. They to womenkind than any other mechanical device were destructive instruments with long teeth. used in obstetrical and gynaecological work, with The whalebone fillet was extensively used by the possible exception of the curette. When the the Japanese. The vectis was extensively used curette is in use, there is usually only one life in Holland in the seventeenth century. This at stake, while with the use of the obstetrical brings us up to the time of the use of the obstet- forceps there are two lives usually to be con- rical forceps proper by the Chamberlain family. sidered. The forceps devised by Peter Chamberlain and Parturition is a perfectly natural event when models of its later improvements were found in the conditions accompanying it are natural. In 1813 in a secret closet in the old Chamberlain normal cases, the attendance of midwives or home. The characteristic features of the Cham- obstetricians might be regarded in the light of berlain instrument were-its fenestrated blades, luxuries. There are times, however, when the the cephalic curve, and a gliding lock. Smellie, event no longer remains within physiological in England, in 1779, improved the Chamberlain limitations. It is this class of case which, no instrument by adding a pelvic curve, wooden doubt, prompted the physicians of ages past to handles, and a better lock. Levret, in Paris, mould an instrument for rendering assistance. modified the Chamberlain forceps in a somewhat The development of this instrument is interest- similar way. In 1783 Stein attached a dynamo- ing. I do not propose to go into the details of meter to the forceps in order that the exact its evolution here, but would like to remind you amount of pressure could be determined. Tar- of a few of its outstanding features. nier, in Paris, added the axis traction rods. The death of Rachel "in hard labour,'" as The development of the obstetrical forceps is spoken of in the Book of Genesis, antedates the briefly as follows: Smellie's modification, 1729; writings of Hippocrates by many centuries. Levret's modification, 1729; Tarnier's modifica- The Book of Exodus makes mention of the fact tion, 1875. that the Hebrew women were more easily de- This brief history of the development of the livered at than were the Egyptian obstetrical forceps will serve our purpose. We women. Hippocrates tells us of the use of the must now pass on and say something concern- crotchet, an instrument used for extracting a ing its use. As stated before, forceps have doubtless, a very definite field of usefulness. I *Delivered before the Sudbury Medical Society, June 19, 1925. would like to emphasize this particular part of 1032 THE CANADIAN MEDICAL ASSOCIATION JOURNAL the paper because we all know that, with injudi- most frequent I believe to be incomplete flexion cious use, the obstetrical forceps become most of the head. If this is the case and the flexion dangerous instruments. Now let us confront cannot be corrected, we simply must be prepared ourselves with the question: When should for- to give the patient extra time. These are good ceps be used? Before answering this question, cases for some forms of the so-called "twilight I wish to state that we will speak of their use sleep." The patient deserves our sympathy and here only in vertex cases, and that we will speak encouragement, but certainly not the premature of them as high, mid, and low forceps. The application of forceps. She says "she is tired application of "high" forceps signifies their out"; and no doubt she is mentally very tired. use before the bi-parietal diameter of the skull The true criteria of fatigue in the mother are has become engaged in the brim of the pelvis; elevations of temperature and pulse rate; and in of "mid" forceps means their use with the bi- the baby, heart rate over 170 or below 100. In parietal diameter of the feetal skull engaged in such cases the mother's temperature and pulse the brim of the pelvis; of "low" forceps, their should be taken hourly, and the feetal heart rate application after this same diameter has passed taken at least every two hours. the brim of the pelvis and the vertex or some The delivery of this type of case usually com- other part of the foetal skull is now on the pletes itself normally if plenty of time is pelvic floor or perineum. allowed. If, however, the head does not engage When should we use high forceps? This is and delivery must be carried out by the obstetri- a most vital question, and one that requires our cian, I would seriously consider internal ver- best attention. We cannot look upon this sion in preference to high forceps, if the cir- lightly. I will give you evidence to this effect cumstances of the case would permit of such. later in my paper. I do not question for one The indications for use of mid forceps are minute but that each one of you here can quote much the same as those just given for the use personal experiences which will corroborate my of high forceps. The dangers of the one are conclusions regarding the use of high forceps. almost as great as those of the other. I there- Now let us discuss the real indications for the fore strongly advise against their use, except use of high forceps. We may at first name in cases where there is imminent danger either several apparent ones, yet on second thought to the mother or baby. we have certain alternative procedures which The indications for the use of low forceps are answer the purpose more satisfactorily. Briefly, more readily thought of and accepted. They I would say that the indications for the use of are as follows: (1) Vertex delayed unduly on high forceps are, certain grave dangers to either the perineum; especially in elderly primipara; the mhother or child, e.g., serious cardtac com- (2) uterine inertia-and here pituitrin often plications of the labouring mother, or a failing gives good results. foetal heart, as in a case of prolapsed cord. If such a grave situation presents itself, we must Now let us consider what some of the dangers bear in mind the primary requisites permitting are attending the use of forceps. To begin with, the application of high forceps, namely, (1) A we must remember that even the application of bony pelvis which is within normal limits; (2) low forceps is not free from certain dangers, a fcetal head which is not too large to pass, and both to mother and child, yet the dangers I is in proper position for extraction; (3) pro- wish to speak of here are mostly met with in longed labour, i.e., prolonged second stage; (4) cases where either high or mid forceps have there should be no tumours, either bony or soft, to be used. obstructing the passage; (5) the must 1.-Dangers to the mother: (a) lacerations be sufficiently dilated; (6) a living child is not of cervix-may be due to unskilful application an essential. to the outside of cervical lips; (b) extensive A considerable number of forceps cases come vaginal and perineal tears; (c) fractured under the heading of prolonged labour. We coccyx; (d) separation of symphysis pubis; (e) must be careful with this particular question. damage to sacroiliac joint; (f) sepsis. If the second stage is unduly prolonged, there 2.-Dangers to the child-and "herein lies a is usually a very definite reason. One of the long tale of woes." Injuries to the child may TEW: USE AND ABUSE OF OBSTETRICAL FORCEPS 1033 he considered under the following two head- However, the essentials of treatment are-care- ings: ful nursing, repeated spinal punctures, which A.-Injuries to soft structures: sometimes help, and lastly, the removal of a 1.-Cerebral trauma-directly or indirectly: localized hematoma, and the elevation of deep (a) cerebral cedema; (b) cerebral haemorrhage; depressed fractures. (c) trauma to brain substances from fractures The meninges surrounding the brain and large or indentations of skull bones. venous channels really act in some respects as 2.-Facial injuries-One of the common in- ligaments. They are able to withstand a cer- juries being facial paralysis, which usually is tain degree of stretching, but beyond this they but temporary. will certainly tear, and in tearing the enclosed B.-Damage to bones: blood vessels are often torn also. The tentorium (a) Indentations; (b) fractures. cerebelli is the common site of such tearing. This very vital question of the causation of The degree of laceration and amount of hemor- foetal death has been recently receiving consid- rhage of course varies quite considerably. erable attention in practically every civilized It seems that even in the most skilled hands, country in the world. Dr. Eardley Holland, of we find a very high percentage of intracranial London, England, has reported his findings in injuries when forceps are used. This particu- 300 post mortem examinations of fretuses that larly applies to the use of high and mid forceps. were viable but were born dead or died within The use of low forceps is not accompanied with a few days after . His work was evidently nearly so much danger, yet the use of low for- thoroughly carried out and his conclusions as ceps is not free from danger by any means. a to the causes of death were as follows: fact, we at times find at autopsy cerebral oedema Complications of labour. 51 per cent. or haemorrhage in what was thought to be a Syphilis ...... 16 normal confinement. There is very evident dan- Toxwemias of . 10 ger in all breech extractions. The meninges are Chronic renal and other very liable to tear with the delivery of the after maternal diseases ...... 2 coming head. How are we to assist in discour- Diseases of placenta ...... 6 aging the use of the obstetrical forceps except Faetal deformities ...... 5 in cases where we are certain that a very just Cause of death unknown .... 11 reason for their use is confronting us? It seems He concludes by saying that the complications to me that we can easily assist, if we approach of labour fall to the doctor. The value of pre- each case methodically, and if we decide to use natal care of our obstetrical patients is well forceps only after all controllable factors of the known and need not be further stressed. The case have been carefully considered, and there most urgent reform now required is the im- still remains at least one very good justification proved training of the doctor and medical stu- for resorting to forceps delivery. dent. Faetal mortality is not likely to fall appre- Proper pre-natal care of the patient means ciably until the standard of midwifery is raised. that we know the size of the pelvis, and the Holland's report is most interesting; it points relative size of the head to the pelvic brim. If out to us very clearly wherein we should be able the patient is a primipara we should know to assist in lowering the fretal mortality in this whether or not the head is engaging properly country. He calls particular attention to the a few weeks before term. We should know fact that intracranial damage from the use or whether or not the mother is a comparatively abuse of forceps plays a most important role in healthy individual. The only point remaining raising the mortality rate. Next to forceps de- is that if during labour it is decided to use for- livery in danger to foetus comes breech extrac- ceps, one must be able to apply the forceps tions. properly, and learn to use the proper amount of The clinical manifestations of cerebral trauma traction. are usually very evident in the majority of cases. There is usually certain muscular twitching, Summary especially of the eyes, accompanied by a pecu- 1.-Forceps have a place in obstetrics, but it liar whining cry. Once the damage is done. is up to the doctor to keep them in their proper one is nearly helpless concerning treatment. place. 1034 THE CANADIAN MEDICAL ASSOCIATION JOURNAL 2.-NVith pre-natal care and sound obstetrical part of this very important work, we will find judgment and management during labour, the that the books of the future on obstetrics will use of the obstetrical forceps will be appreciably contain more voluminous chapters on the abuse of the obstetrical forceps. diminished, and the foetal mortality should pro- than on the use portionately decrease. BIBLIOGRAPHY HOLLAND, EARDLEY, Reports on Public Health, 1922, 3.-If we, as doctors, fail to carry out our vol. vii, p. 125.

URINARY RETENTION* GORDON S. FOULDS, M.B., M.S. Toronto FOR normal urination, the urethra must be then so turned that the head is pushed back to patent and there must be relaxation of the the meatus and manipulated out. sphincter accompanied by contraction of the Congenital valve formation at the bladder bladder. Therefore retention may be due either neck is not a common occurrence but is one to obstruction in the passages, or to interference which should not be overlooked. Children suf- with the normal detrusor action. In each case fering from this form of obstruction give a his- the exact cause of the retention should be dis- tory of difficult urination since birth. A dis- covered before treatment is commenced. The tended bladder may be felt on abdominal palpa- conditions giving rise to retention are best con- tion. In such cases the condition of retention sidered according to the age of the patient. with overflow is seen. If careful physical exam- In childhood, urinary obstruction may be due ination of the abdomen is omitted these small to phimosis, atresia of the meatus, impacted patients are frequently treated for ordinary calculus or foreign body, or congenital valv,e enuresis of childhood until the cause of the con- formation. The first two of these conditions dition is discovered. A small catheter will pass need no comment. Impacted calculi, though easily as the valve only obstructs the outflow. they may occur at any age, are relatively more A suprapubic cystotomy should be done and the common in children. The stone most frequently valve destroyed. lodges just within the meatus where it can be During young adult life, retention is most fre- felt on palpation; when in doubt a probe or quently due to the complications of gonorrheea small sound may be passed into the urethra and or to trauma. During a recent or recurring the click felt. A simple meatotomy will fre- acute gonorrhoeal posterior urethritis, urination quently suffice to make its passage possible. becomes painful and congestion of the mucous The other common location for impacted stone membrane and spasm of the sphincters ensue. is in the prostatic urethra. It may be dis- The history is usually sufficient to reveal the lodged and pushed back into the bladder by the nature of the difficulty. In less severe cases, a passage of a bougie. The nature of foreign hot sitz bath, which may be supplemented by bodies passed into the urethra is extremely the insertion of a belladonna and opium rectal varied. The history is usually the important fac- suppository, will usually give relief. When tor in discovering the nature of the obstructing these measures fail, a well lubricated rubber. object. One of the commonest articles is the catheter may be passed. When the bladder has ordinary large-headed pin; the head has been been emptied with a catheter it should be irri- pushed into the urethra till the point has disap- gated with 1/6000 potassium permanganate peared. The point should be driven through solution. the under surface of the urethra and skin and Peri-urethral abscess is easily discovered on careful examination of the penis. Acute pros- *Read before the Ontario Medical Association, Toronto, May 7th, 1925. tatic abscess gives rise to characteristic pain.