where numerous patients with stab Neither of our patients with negative ferred one in the Canadian social wounds are admitted simultaneously (as results of laparotomy had serious com- environment. in gang wars), to avoid overload of plications. This is in contrast to the operating room facilities. So far in high morbidity and mortality often re- References Canada such incidents are infrequent. ported, as in the series of Maynard and 1. PRINTEN K), FREEARK RJ, SHOEMAKER WC: We realize that our series is small Oropeza6 at Harlem Hospital Center Conservative management of penetrating in comparison with the large American in New York. The cause for the high wounds. Arch Surg 96: 899, 1968 series, but the results indicate that our incidence of complications after nega- 2. STEICHEN FM: Penetrating wounds of the chest and abdomen. Curr Probi Surg, Aug approach is safe and effective. We tive laparotomy is obscure, but many 1967 could be criticized for using an inflex- of the reported problems were related 3. SHAFTAN GW: Indications for operation in ible approach but it seems to be justi- to iatrogenic injury during exploration. abdominal trauma. Am J Surg 99: 657, 1960 fied by our results. There appear to be A later report from that institution 4. CORNELL WP, EBERT PA, ZUIDEMA GD: X-ray obvious advantages to repairing the in- indicated that a policy of mandatory diagnosis of penetrating wounds of the ab- jured viscus early, before gross clinical laparotomy in most cases was still fol- domen. / Surg Res 5: 142, 1965 signs of peritonitis, sepsis or shock be- lowed.7 5. Roor HD, HAUsER CW, MCKINLEY CR, come evident. This is attested to by the In conclusion, we emphasize that the et al: Diagnostic peritoneal lavage. Surgery fact that the only serious postoperative appearance of a stab wound of the 57: 633, 1965 complication was the herniation of a abdomen may be deceptive and the 6. MAYNARD AL, OROPEZA G: Mandatory opera- tion for penetrating wounds of the abdomen. small-bowel loop into the peritoneal de- intra-abdominal damage not readily ap- Am .7 Surg 115: 307, 1968 fect left by the stab wound. We now parent. We warn all emergency room 7. FORDE KA, GANEPOLA GA: Is mandatory ex- close all peritoneal defects, no matter physicians of the danger of treating ploration for penetrating trauma extinct? The morbidity and mortality of negative explora- how small, with interrupted Dexon 1 the patient casually, and suggest to tion in a large municipal hospital. .7 Trauma (polyglycolic acid) sutures. surgeons that our approach is the pre- 14: 764, 1974

Succesful of locked

ANDREW P. MILLER, MB, CH B, D (oBsT), RCOG

Interlocking of twin , usually prior to the expected date of delivery. and obstructing the descent of, the after- recognized in the second stage of la- Twin A was presenting by the breech; the coming head of twin A. bour, is rare, occurring only once in presentation of twin B was uncertain, Approximately 4 minutes had elapsed 90 000 deliveries. In 1958 Nissen1 re- although thought to be vertex. since delivery of the torso of twin A and At 10 pm she was examined vaginally convulsive respiratory efforts of the baby viewed the world literature and cate- for the first time. The membranes had had begun. It was considered that this twin gorized the various types of interlock- ruptured previously and a small quantity would be lost if speedy delivery was not ing. The following report describes a of was draining, the cervix accomplished, so, because of the mother's case of interlocking that fell into group was partially effaced and dilated 3 cm, unusually capacious pelvis, it was decided 1 of Nissen's classification, the com- and the breech was still above the ischial to attempt to extract the two heads monest type; baby A was in breech spines. simultaneously. With the assistance of a presentation and baby B in vertex, and It was confirmed that twin A was pre- powerful bearing-down effort by the B's head was compacted in the pelvis senting by the breech and it was clear mother, an excellent, sustained uterine that the was comparatively small. contraction and strong traction on the in advance of A's head. The case is of The beats of both fetal hearts were of pelvis of twin A, the twins delivered especial interest because it is rare for good quality and at normal rates. simultaneously, locked chin to chin and such interlocked twins to be delivered Since no difficulty was anticipated, la- partially enveloped in a single amniotic successfully per vaginam and for both bour was allowed to continue until full sac. Within a few minutes a single placenta babies to survive - only three out of dilatation, which occurred at 3 am Sept. was delivered spontaneously; bleeding was eight babies in Nissen's series survived. 10. Contractions were excellent, the minimal and the contracted down The relatively large size of the infants mother was stoical and enthusiastic, and satisfactorily. in this report is also worthy of note. the breech rapidly descended to the outlet Twin A, weighing 2115 g, was pallid in an apparently normal fashion. Follow- and "flat", with an Apgar score of only ing infiltration of the perineum with a 2 at birth, but was rapidly resuscitated. Case report local anesthetic, a generous right medio- Twin B weighed 2500 g and was in ex- lateral episiotomy was made. The legs of cellent condition, cried immediately and A 20-year-old woman gave birth in twin A were then brought down easily; had an Apgar score of 9 at birth. Both February 1975 to her first child, a boy the torso was allowed to hang for 1 or 2 twins subsequently did well, and mother weighing 4000 g. It was a spontaneous minutes and it then became obvious that, and twins were discharged home on the vertex delivery and was accomplished with although delivery almost to the scapulae 6th day with breast-feeding established. such ease that it was realized her pelvis had been accomplished, no further descent Following delivery, radiographic pel- was unusually large. was occurring. vimetry was performed and the diameters On Sept. 9, 1976, in her second preg- In the process of bringing down the were reported as follows: anteroposterior nancy, she was admitted in labour 29 days arms of twin A it was discovered that (AP) of inlet, 14 cm; transverse of inlet, there existed, to the right and posterior, 14 cm; AP of midpelvis, 15 cm; inter- Reprint requests to: Dr. A.P. Miller, Nanaimo Regional General Hospital. 1200 Dufferin Cres., a mass (subsequently identified as the spinous, 12 cm; posterior sagittal of inlet. Nanaimo, BC V9S 2B7 head of twin B) positioned in advance of, 9 cm; and intertuberous, 12 cm. 158 CMA JOURNAL/JULY 23, 1977/VOL. 117 6. PETERS L: Interlocking or collision of twins Discussion twin A the outcome is uniformly fa- - dystocia - low Caesarean delivery. Calil vourable.4'6'7 West Med 46: 403, 1937 7. MURPHY DV: The case of locked twins. There are several considerations in Perhaps earlier diagnosis of pending Lancet 1: 1300, 1921 the etiology of interlocking of twins. interlocking could be made if radio- The most important factors are the age graphy were done on admission of the and parity of the mother and the size mother in all cases of twinning, espe- of the twins. Some 77% of mothers cially when the presentation is vertex BOOKS are under 30 years of age and 72% in one twin and breech in the other, continued from page 1S6 of interlocked twins occur in primi- then repeated in 2 or 3 hours after gravidas.1 Larger twins tend to lock SIGNIFICANCE OF MEDICAL MICROBIOLOGY IN good labour or rupture of the mem- THE CARE OF PATIENTS. Victor brian. 261 pp. above the pelvic inlet and small twins branes. If the second radiograph Charts. The Williams & Wilkins Company, Balti- more; Burns & MacEachern Limited, Don Mills. lock after descent into the pelvis.2 showed interlocking or pending inter- 1977. $26.35. ISBN 683-05164-4 In the reported cases of interlocking locking, cesarean section could be con- SOCIAL AND HEALTH ASPECTS OF SEXUALLY twins in which twin A's presentation sidered. TRANSMITTED DISEASES. Principles of Control was breech and twin B's, vertex, the Measures. Study based on the Technical Discus- For his encouragement and assistance in sions Held During the Twenty-Eighth World Health first twin was frequently decapitated Assembly, 1975. Public Health Papers No. 65. to effect delivery of the second; thus, the preparation of this communication I 56 pp. World Health Organization, Geneva, 1977. acknowledge my debt of gratitude to Dr. $3.20, paperbound. ISBN 92-4-130065-5 the mortality for first twins has been Roland Radcliffe, department of high.3 If cesarean section is done with- A STEP-BY-STEP LEARNING GUIDE FOR OLDER and gynecology, Nanaimo Regional Gen- RETARDED CHILDREN. Vicki M. Johnson and out prior attempted vaginal delivery the eral Hospital. Roberta A. Weiner. 214 pp. illust. Syracuse Uni- versity Press, Syracuse; Burns & MacEachern fetal outcome is much better than if Limited. Don Mills, 1977. $12.25, paperbound. vaginal delivery is attempted and fails; References ISBN 00-8156-2167-1, clothbound; ISBN 0-8156- Fox and colleagues4 reported no deaths 2181-7, paperbound when cesarean section was done ini- 1. NissaN ED: Twins: collision, impaction, STEREOSCOPIC ATLAS OF MACULAR DISEASES. compaction, and interlocking. Obstet Gynecol Diagnosis and Treatment. 2nd ed. J. Donald M. tially and 33% mortality when cesa- 11: 514, 1958 Gass. 411 pp. illust. The CV. Mosby Company, 2. COHEN M, Koin. SO, ROsENThAL AH: Fetal Saint Louis, 1977. $68.25. ISBN 0-8016-1754-5 rean section was done after vaginal interlocking complicating twin gestation. Am delivery had failed. It has been stated J Obstet Gynecol 91: 407, 1965 3. KIMBAL AP, RAND PR: Maneuver for simul- THE TOTAL CARE OF SPINAL CORD INJURIES, that interlocking occurs only in the taneous delivery of chin-to-chin locked twins. Edited by Donald S. Pierce and Vernon H. Nickel. second stage of labour, so that pro- Am I Obstet Gynecol 59: 1167, 1950 339 pp. lilust. Little, Brown and Company, Boston; 4. Fox RL, NATHANSON HG, TEJANI N, et al: J.B. Lippincott Company of Canada Ltd., Toronto. phylactic measures such as cesarean Interlocking twins. Experience with four cases 1977. $24.75. ISBN 0-316-70740-6 and suggested management. Obstet Gynecol section cannot reduce the mortality of 46: 53, 1975 WORLD REVIEW OF NUTRITION AND DIETETICS. this situation.5 If cesarean 5. SWANN RO: Interlocking and collision in Vol. 26. Human and Veterinary Nutrition. Edited section can multiple . Am I Obstet Gynecol by Geoffrey H. Bourne. 274 pp. IlIust. S. Karger be performed prior to the descent of 73: 907, 1957 AG, Basel, 1977. $64. ISBN 3-8055-2392-0

CONCOURS NOTICE Bourses de voyage de I'OMS WHO Fellowships 1978 1978 Chaque ann6e, l'Organisation mondiale de Ia The World Health Organization allocates each Sant6 alloue au Canada un certain nombre de year a small number of fellowships to Canadian bourses de voyage en vue d'encourager des Health Workers. Awards will cover per diem programmes d'6tude en pays .trangers d'une maintenance and transportation. The fellowships dur.e d'environ deux . trois mois. are used to provide short programs of study Sont admissibles au concours, les citoyens abroad of approximately 2 to 3 months' duration. canadiens qui travaillent . titre professionnel Canadian citizens engaged in a professional dans le domaine de Ia sant& soit dans le sec- capacity in operational or educational aspects teur enseignement ou dispensation des soins. of health care are eligible to apply. Ineligible Ne sont pas admissibles: les travailleurs en are workers in pure research, undergraduate recherche pure, les .tudiants d'un cours de and graduate students and applicants more than diplOme universitaire ou sup.rieur et les per- 55 years of age. sonnes .g.es de plus de 55 ans. Applicants will be rated and chosen by a Les candidats seront choisis par un comit6 de selection committee on the basis of their educa- s6lection suivant leur 6ducation et experience, tion and experience, the field of activity they le champ d'action o.i us oeuvrent, le sujet qu'ils propose to study and the intended use of the se proposent d'.tudier, et Ia mani.re de mettre knowledge gained during their fellowship upon . profit les connaissances acquises. La d6cision return to this country. Final acceptance will finale rel.ve de I'OMS. remain the responsibility of WHO. Les projets de demande devront .tre soumis Projects should be submitted for October 31, pour le 31 octobre 1977. 1977. Pri&e d'adresser toute demande Requests for information should be de renseignements .: directed to: SERVICES INTERNATIONAUX D'HYGIENE INTERNATIONAL HEALTH SERVICES Immeuble Brooke Claxton Brooke Claxton Building Parc Tunney Tunney's Pasture Ottawa, Canada KIA 0K9 Ottawa, Canada KIA 0K9

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