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BRITISH CONGRESS OF OBSTETRICS

AND GYNÆCOLOGY.THE DUBLIN MEETING.

THIS Congress was held at Dublin from April 24thto 26th under the presidency of Dr. GIBBONFITZGIBBON. On the first day a discussion on the

MANAGEMENT OF CASES OF PELVIC DISPROPORTION

was opened with a paper on Diagnosis by Prof.111--,RO KERR (Glasgow). He pointed out that it wasvery difficult by any method to arrive at exactmeasurements of the pelvic inlet, whereas deformitiesof the outlet could be exactly determined. Theselection of treatment for deformity of the pelvis atthe inlet depended on exact estimation of the relativesize of the head to the pelvis, but for the outlettreatment should be based on exact measurement ofthe outlet. It was important to recognise minordeformities, since failure to do so often resulted inunsuitable treatment; indeed, he believed that thelargest proportion of disasters occurred in this group.The practical question was : Will the head pass ?Among the factors which influenced spontaneousdelivery were : (a) previous obstetric history, (b) irregu-laritv in the pelvic brim, (c) size of the foetal head,(d) degree of ossification, (e) variety of biparietalobliquity, and (f) strength of uterine contractions.

Prof. FLETCHER SHAW (Manchester) read a paperon the Immediate Results to Mother and Child ofLabour with Contracted Pelvis. One of the mostdifficult tasks confronting an obstetrician, he said,was to decide what method of delivery to recommendto a woman with a moderately contracted pelvis. Itwas impossible to lay down hard-and-fast rules;nothing but experience and careful observation wouldallow of a correct decision. Analysing a series of290 cases of contracted pelvis delivered in St. Mary’sHospitals, Manchester, in a period of nine months, helaid stress on the fact that among the 242 cases whichwere admitted from the antenatal department thematernal mortality was nil, the foetal mortality being5-7 per cent. The other 48 had been admitted asemergencies, and in these the maternal mortality was10-4 and the foetal mortality 56-2 per cent. Betterproof of the importance of antenatal examination andsubsequent treatment by experts could hardly beadduced. Prof. Shaw went on to describe the methodsof delivery in detail, emphasising the importance of atrial labour in an institution under expert supervision.A history of previous stillbirths, he said, inclined himto advise Caesarean section. This operation at termwas preferable to induction before the thirty-sixthweek. but he considered that medicinal inductionafter the thirty-eighth week could do no harm to thechild and many cases so treated terminated naturally,which otherwise would have required Csesarean section.He believed that none of the staff of St. Mary’sHospitals had found any marked advantage fromsection through the lower uterine segment. In his

opinion one of the greatest blots upon modernobstetrical practice was the fact that the increasednumber of Caesarean sections had not diminished thenumber of craniotomies. In concluding, Prof. Shawemphasised the importance of antenatal supervisioncarried out by a skilled obstetrician who would attendthe patient in her confinement and be responsible forthe delivery.

Dr. JAMES Young (Edinburgh) read a paper on theFactors Underlying Maternal Mortality in the OperativeTreatanent of Obstructed Labour. There was con-siderable variation, he said, in the published mortalityfigures of different hospitals in respect of the operativetreatment of both clean and emergency cases of pelvicdisproportion. He quoted figures from the reportsof nine well-known hospitals totalling 1043 Caesareansections with a mortality of 3-6 per cent. However, onregrouping certain hospitals the maternal death-ratewas shown to vary from 0-7 per cent. to 4-3 per cent.

for similar cases. There was evidence that thesevariations were determined not so much by the type-of operation selected and by the operative technique-employed as by the success attending the efforts toprevent, on the one hand, contagion of the clean bythe emergency case, and on the other hand, contagiontransmitted from one emergency case to another. Ingeneral this risk of contagion sprang from the inade--quacy of the machinery of segregation and this in turnmight be dependent upon the difficulty of organising-a satisfactory system because of the architecturalunsuitability of the buildings. He outlined the generalprinciples followed by the Edinburgh school forthe treatment of labour with obstruction due to-

disproportion.Dr. J. D. BARRIS (London) gave a contribution on

the Results of Disproportion as Treated by Induction..Beginning with an outline of the history and originof induction he showed how with the increasing-safety of the Csesarean operation it was encroachingmore and more upon the time-honoured method ofinduction. The most difficult problem, he thought,.was that of correctly estimating the time at which toinduce. The best test of disproportion was the amountof moulding of the foetal head, but this could only beascertained after labour was completed. Before-labour the sole known factor was the disproportion ;-it was only during labour that factors previouslyunknown came into play, such as the moulding anddegree of flexion of the foetal head and the characterof the second stage. A floating head even in aprimigravida in the later weeks of pregnancy did notof itself indicate disproportion, although it called for-investigation. Dr. Barris thought that induction fordisproportion had stood the test of time. It was easyto carry out, the labour was usually uncomplicated,.it had a remarkably low maternal mortality, itavoided the risk of a difficult labour or Caesareansection, and the foetal mortality was not unduly high-in suitable cases. Its use, however, should be limitedLto cases of moderate or slight disproportion after thethirty-sixth week, in which the vertex was presenting..Having regard to our social conditions it remained the-best method for such cases.

Dr. BETHEL SOLOMONS (Dublin) read a joint paperwith Dr. WENTwORTH TAYLOR (Dublin) on theDiagnosis of Disproportion, Antenatal and Intranatal,.with a View to Treatment. It dealt with the materialover a period of two years at the Rotunda Hospital,and 294 cases were considered. Among the questions.discussed were : Does difficult labour depend on smallexternal measurements ? Is the outlet measurementof value ? Should the Skutsch pelvimeter be used,.and will X ray pelvimetry replace this method A modification of the external Müller procedure wassuggested and illustrated. The Kerr-Muller procedure-must be carried out as a routine, and treatment wouldlargely depend on the result of this examination,successful results being only obtainable after experi-ence. In trial labour the details of making a rectal’examination were important. The fact that a womanhad been delivered of one or two infants normallydid not exclude possible difficulty in subsequentconfinements. Disproportion might be caused byfactors other than the relation of the head to thepelvis; incoordinate uterine action was a typical-’example. Examples of this abnormality were givenand the question was discussed. At the conclusion ofthe paper a summary of the varieties of contractedpelvis encountered in the investigation was given.A paper by Prof. R. W. JoHNSTONE (Edinburgh)

was devoted to Induction of Premature Labour inDisproportion. He did not agree with those who saidthat the foetal head did not grow appreciably in thelast four weeks of pregnancy, and pointed out thatossification of the bones of the vault of the skull wenton rapidly during this period, the head becoming:progressively less malleable. During the five years-1923-27 premature labour was induced on account ofpelvic contraction in the Royal Maternity Hospital,Edinburgh, in 104 cases ; a follow-up of these showeda combined foetal and neonatal mortality of 6-7 per’

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cent. Out of 72 babies traced a year after delivery4-4 per cent. were alive, which compared favourablywith the 90-5 per cent. who might be expected to bealive at the end of the first year according to thefigures of the Registrar-General for Scotland. Thespeaker also quoted favourable figures for the secondand third years of life. His figures did not bear outthe statement that the earlier the induction the greaterthe foetal mortality. In conclusion, he comparedCaesarean section at term with premature induction oflabour, pointing out that with induction there was nomaternal mortality and no uterine scar ; the puerperalperiod was normal, and the fertility of the women, inhis opinion, was better than after Caesarean sections.He thought that induction was suitable for those casesof disproportion where there was just an element ofdoubt whether a full-sized child would pass throughthe pelvis (especially in a primipara), for the informa-tion so gained would be of great value in subsequentlabours. Secondly, it seemed to be indicated for awoman who, in a previous labour, had been deliverednaturally of a stillborn child of average or over averagesize, or in whom a test labour on a previous occasionhad failed and necessitated a high forceps operation.Cases of slight contraction of the outlet also camewithin this category of suitability.

Discussion.Prof. OSBORN POLAK (New York) said that in

America they had to deal chiefly - with generallycontracted and high assimilation pelves ; rachitic,simple, flat and scoliotic pelves were, he said, rela-tively rare. Induction of premature labour hadreceived a good trial in America and was beingabandoned. He thought that in cases of dispropor-tion one thorough examination of the patient shouldbe made under anaesthesia. He advised the use ofoxygen in order to avoid asphyxia neonatorum forthose patients that had been given morphia. After25 years’ experience of the upper incision and11 years of the lower segment one for Caesarean section,he had come to the conclusion that the latter was ’’

superior. In suspect cases he allowed the placentato be extruded by the vagina in order to avoid con-taminating the peritoneum.

Mr. EARDLEY HOLLAND (London) said that itrequired much experience to know when to interferein a trial labour, and therefore it was dangerous toadopt this as a general method. Nevertheless in safehands trial labour was superior to induction. Hethought that most of the antenatal work in Englandwas mere eyewash, and laid stress on the necessity forthose who would actually be responsible for thedeliveries to supervise the antenatal period.

Prof. LUDWIG ADLER (Vienna) said that most ofthe confinements in his country were conducted inhospitals or nursing homes, but the methods weresimilar to those described by Kerr and Polak. He usedpituitrin combined with thymus gland extract inorder to induce labour.Dame LouisE McILROY (London) thought that the

age of the patient was more important than contractionof the pelvis and referred to work done in order todetermine the amount of " give " in the pelvic liga-ments. She did not think that radiographic examina-tion helped much in cases of disproportion.

Prof. JAMES HENDRY (Glasgow) found that thefcetal heart-rate was valuable in estimating thedegree of pressure on the foetal head. He reviewed25 cases of major pelvic contractions that had beenunder his care. He did not agree that a trial labourwas justifiable in a multipara who had had vigorousinterference in a previous labour, for he had seencases where the uterus had not stood the strain.-Dr. J. S. FAIRBAIRN (London) believed in prematureinduction of labour even in a primipara. He thoughtit preferable to err rather on the side of prematurity.-Dr. T. G. STEVENS (London) also deprecated thegeneral adoption of trial labour for disproportion. Headvocated premature induction. He thought that thegeneral maternal mortality from Caesarean sectionswas probably in the neighbourhood of 10 per cent. as

many cases were never reported. He did not thinkthat the placental site was infected before the placentawas extruded, but that the infection subsequentlyascended from the vagina. He therefore did not seewhy the placenta should not be brought out throughthe abdominal incision. The high forceps operationshould never be done ; forceps should only be appliedwhen the head could be seen on separation of thelabia.

Dr. W. R. MACKENZIE (Belfast) did not agree withthose who said that X rays were of no use in measuringthe pelvis.-Dr. F. H. LACEY (Manchester) referredto a paper he had read in 1918 on 75 cases of inductionat the thirty-seventh and thirty-eighth weeks ofpregnancy with no maternal mortality and morbidity,and 95 per cent. of the children surviving.-Dr. A. L.MuDALiAR said that cases of immature pelvis werenot uncommon in India, where many primipara wereonly 13 to 16 years of age. He did not induce in thesecases except just before term ; he thought the pelvisstretched considerably. The speaker described histechnique for symphysiotomy, which he had carriedout successfully in 34 cases during the last 15 years.-Prof. MILES PHILLIPS (Sheffield) hoped that inductionwould be generally approved by the Congress, andreferred to sluggish uterus as an indication forCsesarean section during a trial labour.-Mr. R. H.PABAMOBB (Rugby) said that pubiotomy was theonly resort when the child was alive and the patienthad been in labour some considerable time with a gooddeal of interference.Many of the speakers emphasised the fact that

antenatal clinics should only be conducted by skilledobstetricians who would supervise the deliveries.

The Chairman for the afternoon session. Dr. HAIGFERGUSON, referred to three points that had arisenfrom the papers and discussion : (1) Antenatal carewas not the be all and end all, and those conductingthe antenatal supervision should follow up the casesand be responsible for the conduct of labour.(2) Forceps should be applied only when the head waslow down. (3) Nature induced prematurely in nearlyall primigravidas, for the head sank down in the latterweeks of pregnancy. By giving quinine and castor oilwith a small dose of pituitrin the head would passdown into the pelvis and stay there.

FIFTH INTERNATIONAL CONGRESS OF

MILITARY MEDICINE AND PHARMACY.

(LONDON, MAY 6TH-11TH.)

THE International Congress of Military Medicineand Pharmacy, which meets in London for the firsttime, is being attended by some 750 delegates repre-senting 40 nations.

I INAUGURAL MEETING.’ The inaugural meeting was opened on Mondayafternoon by Sir LAMING WORTHINGTON-EVANS,Secretary of State for War. Before this meeting thePermanent Committee of the Congress held theirsession and the delegates paid a visit to WestminsterAbbey where General Lanne, representing France,and General Rouppert, representing Poland, headeda procession to the tomb of the Unknown Warrior,upon which they laid wreaths bearing the colours ofall the countries represented. The opening ceremonyin the Great Hall of the British Medical AssociationHouse was brilliant with the uniforms of manyforeign armies, in contrast with which the Servicedress of our army officers appeared dull, althoughdisplay of naval uniforms did not lack distinction.Among those present at the opening ceremony

were Lieutenant-General Sir Matthew Fell, Director-General Army Medical Services, President of theCongress, Surgeon Vice-Admiral A. Gaskell, MedicalDirector-General of the Navy, Air Vice-Marshal