21 The family doctor and local health authority will be given details of all babies leaving hospital after a forceps delivery and asked to cooperate in following them up to school age ; the district nurse and health visitor will pay attention to the times of walking, sitting, standing, talking, &c. The family doctor will be requested to watch progress and note any inter- current illness, until finally the school medical officer is able to add his assessment. Neither the mothers nor children will be asked to report back to hospital as this might cause unnecessary anxiety. SUMMARY In a pilot survey of the immediate and late effects of forceps delivery two groups have been followed up : (a) difficult forceps deliveries in Glasgow, and, (b) all forceps deliveries in the Inverness area. The combined stillbirth and neonatal-death rate for the " difficult " cases is high (11-4%), but the late results in those infants who survived appear to be very satisfactory. The results suggest, not that the operation should be abandoned, but that suitable cases should be more carefullv selected. REFERENCES D’Esopo, D. A. (1949) Amer. J. Obstet. Gynec. 58, 1120. - (1950) Ibid, 59, 77. Roberts, H. (1939) J. Amer. med. Ass. 113, 280. Stewart, R. M. (1942) Proc. R. Soc. Med. 26, 25. Wetterdal, P. (1951) Nord. Med. 45, 1000. New Inventions ILIAC-CREST SUSPENSION IN THE TREATMENT OF SACRAL BEDSORES THE prevention of bedsores, though important, is not always easy. Into every hospital comes occasionally the senile overweight patient, often incontinent and often with some cerebrovascular complication which makes nursing extremely difficult. It is not uncommon for an incipient sacral bedsore to be treated by nursing the patient on alternate sides-a programme destined to produce two further trochanteric sores. As the nursing of these, often non-cooperative, patients on their faces is impossible, iliac-crest suspension offers the only chance of getting their sores healed. It is surprisingly comfortable and calls for no special care other than treatment of the shoulders for possible pressure necrosis. Kirschner wires cut out of the iliac crest in a few days. Crutchfield’s skull callipers are inadequate because they win not close completely. Tne oesu appliance can be made by any hospital engineering shop from Steinman’s nails. One 10-in. Steinman’s nail makes exactly two hooks, 3 in.long and 3/4 in. in diameter (fig. 1). These hooks are inserted through the region of the anterior superior iliac spine under direct vision, one being in- serted from within outwards, and the other from without inwards and at least 2 in. away from the first hook. The point of each hook will either lie in the substance of the ileum or, where the bone is thin, penetrate both cortices and lie innocuously against one table of the bone. . Two hooks on each side give support of enough strength to hold any patient for any length of time. The hooks should be inserted with the patient in bed. The " foot " end of an operating-table is placed under the patient’s buttocks, and the table is raised about 1 ft. Sufficient pillows are placed under the head and thorax to allow the trunk to remain horizontal. The pins are inserted and fixed by cord as shown in fig. 2. The table is now lowered and removed. The legs can be put in any desired degree of abduction, and if the patient is incontinent a receiver can be placed on the bed below the perineum. It has been my practice to remove the mattress and to place gamgee tissue on the wire mattress. Ward dressings can then be done from the side with a spot-lamp shining through the wire mattress without disturbing the patient. Fig. I-One of the hooks (half size). Fig. 2-Method of suspension. Warmth is achieved by having a large cage over the legs and by putting on sheets and blankets in three sections. It is to be emphasised that this appliance is intended only for those unfortunate senile patients in whom any chance of success would otherwise have to be foregone. It is a technique which may lead to a happy wheel-chair life at home instead of permanent confinement to a hospital bed. N. J. BLOCKEY M.B. Mane., M.CH.ORTH. Lpool, F.R.C.S. Manchester Royal Infirmary. Reviews of Books Guide to Obstetrics in General Practice WILLIAM C. W. NIXON, M.D. Lond., F.R.C.S., F.R.C.O.G., professor of obstetrics and gynaecology, University of London; ERIC B. HicESON, M.R.C.S., D.OBST., chairman, Wiltshire Local Obstetric Committee. New York and London : Staples Press. 1953. Pp. 301. 30s. Some readers of this book will wish that it had been more dogmatic, but others will approve the authors’ intention to stimulate thought and discussion. Naturally, much space is given to antenatal care : many practical observations are made on the preparation of the woman for her labour, and, following current trends, much stress is laid on the psychological aspect of management. A very good chapter, based on long experience, deals with the types of call a practitioner may receive from midwives. Nearly three-quarters of these come under one of the following five headings : ruptured perineum, delay in the first or second stage of labour, abortion, toxaemia, and antepartum or postpartum haemorrhage. Of these, ruptured perineum is dealt with thoroughly, but delay in the first stage gets rather more cursory treatment, and the practical aspect of delay in the second stage, with details of instrumental delivery, is dismissed quickly. Much information is given about the treatment of postpartum haemorrhage ; but in cases of ante- partum haemorrhage-the rare calamitous haemorrhage of placenta praevia-practitioners are advised to invoke the help of the flying squad. If no squad is at hand, treatment with scalp forceps is suggested ; for the modern view, it is stated, does not allow packing. The chapters on the care of the breasts and on breast-feeding are admirably written by Dr. Harold Waller, whose experience and results command attention even- perhaps especially-from those who do not share his opinions. Looked at as a whole this book is very readable and contains a wealth of information, as one would expect from the two chief authors. All general-practitioner obstetricians will be the richer for reading it ; but they must not expect always to get unequivocal instructions as to what to do, in even the commoner difficulties.
Transcript
21
The family doctor and local health authority will begiven details of all babies leaving hospital after a forcepsdelivery and asked to cooperate in following them upto school age ; the district nurse and health visitorwill pay attention to the times of walking, sitting,standing, talking, &c. The family doctor will be
requested to watch progress and note any inter-current illness, until finally the school medical officeris able to add his assessment. Neither the mothers norchildren will be asked to report back to hospital as thismight cause unnecessary anxiety.
SUMMARY
In a pilot survey of the immediate and late effects offorceps delivery two groups have been followed up :(a) difficult forceps deliveries in Glasgow, and, (b) all
forceps deliveries in the Inverness area.The combined stillbirth and neonatal-death rate for the
" difficult " cases is high (11-4%), but the late results inthose infants who survived appear to be very satisfactory.The results suggest, not that the operation should be
abandoned, but that suitable cases should be morecarefullv selected.
REFERENCES
D’Esopo, D. A. (1949) Amer. J. Obstet. Gynec. 58, 1120.- (1950) Ibid, 59, 77.
Roberts, H. (1939) J. Amer. med. Ass. 113, 280.Stewart, R. M. (1942) Proc. R. Soc. Med. 26, 25.Wetterdal, P. (1951) Nord. Med. 45, 1000.
New Inventions
ILIAC-CREST SUSPENSIONIN THE TREATMENT OF SACRAL BEDSORES
THE prevention of bedsores, though important, is notalways easy. Into every hospital comes occasionally thesenile overweight patient, often incontinent and oftenwith some cerebrovascular complication which makesnursing extremely difficult. It is not uncommon for anincipient sacral bedsore to be treated by nursing thepatient on alternate sides-a programme destined toproduce two further trochanteric sores. As the nursingof these, often non-cooperative, patients on their facesis impossible, iliac-crest suspension offers the only chanceof getting their sores healed. It is surprisingly comfortableand calls for no special care other than treatment of theshoulders for possible pressure necrosis.
Kirschner wires cut out of the iliac crest in a few days.Crutchfield’s skull callipers are inadequate because they
win not close completely. Tne oesu
appliance can be made by any hospitalengineering shop from Steinman’s nails.One 10-in. Steinman’s nail makes exactlytwo hooks, 3 in.long and 3/4 in. in diameter(fig. 1). These hooks are inserted throughthe region of the anterior superior iliacspine under direct vision, one being in-serted from within outwards, and theother from without inwards and at least2 in. away from the first hook. Thepoint of each hook will either lie in thesubstance of the ileum or, where the boneis thin, penetrate both cortices and lieinnocuously against one table of the bone.
. Two hooks on each side give support
of enough strength to hold any patientfor any length of time. The hooks
should be inserted with the patient in bed. The " foot "end of an operating-table is placed under the patient’sbuttocks, and the table is raised about 1 ft. Sufficientpillows are placed under the head and thorax to allowthe trunk to remain horizontal. The pins are insertedand fixed by cord as shown in fig. 2. The table isnow lowered and removed. The legs can be put inany desired degree of abduction, and if the patient isincontinent a receiver can be placed on the bed belowthe perineum.
It has been my practice to remove the mattress and toplace gamgee tissue on the wire mattress. Ward dressingscan then be done from the side with a spot-lamp shiningthrough the wire mattress without disturbing the patient.
Fig. I-One of thehooks (half size).
Fig. 2-Method of suspension.
Warmth is achieved by having a large cage over thelegs and by putting on sheets and blankets in threesections.
It is to be emphasised that this appliance is intendedonly for those unfortunate senile patients in whom anychance of success would otherwise have to be foregone.It is a technique which may lead to a happy wheel-chairlife at home instead of permanent confinement to ahospital bed.
N. J. BLOCKEYM.B. Mane.,
M.CH.ORTH. Lpool, F.R.C.S.Manchester Royal Infirmary.
Reviews of Books
Guide to Obstetrics in General PracticeWILLIAM C. W. NIXON, M.D. Lond., F.R.C.S., F.R.C.O.G.,professor of obstetrics and gynaecology, University ofLondon; ERIC B. HicESON, M.R.C.S., D.OBST., chairman,Wiltshire Local Obstetric Committee. New York andLondon : Staples Press. 1953. Pp. 301. 30s.
Some readers of this book will wish that it had beenmore dogmatic, but others will approve the authors’intention to stimulate thought and discussion. Naturally,much space is given to antenatal care : many practicalobservations are made on the preparation of the womanfor her labour, and, following current trends, muchstress is laid on the psychological aspect of management.A very good chapter, based on long experience, dealswith the types of call a practitioner may receive frommidwives. Nearly three-quarters of these come underone of the following five headings : ruptured perineum, -
delay in the first or second stage of labour, abortion,toxaemia, and antepartum or postpartum haemorrhage.Of these, ruptured perineum is dealt with thoroughly,but delay in the first stage gets rather more cursorytreatment, and the practical aspect of delay in the secondstage, with details of instrumental delivery, is dismissedquickly. Much information is given about the treatmentof postpartum haemorrhage ; but in cases of ante-partum haemorrhage-the rare calamitous haemorrhageof placenta praevia-practitioners are advised to invokethe help of the flying squad. If no squad is at hand,treatment with scalp forceps is suggested ; for themodern view, it is stated, does not allow packing. Thechapters on the care of the breasts and on breast-feedingare admirably written by Dr. Harold Waller, whoseexperience and results command attention even-
perhaps especially-from those who do not share hisopinions.Looked at as a whole this book is very readable and
contains a wealth of information, as one would expectfrom the two chief authors. All general-practitionerobstetricians will be the richer for reading it ; but theymust not expect always to get unequivocal instructionsas to what to do, in even the commoner difficulties.
22
And if it is not the essentially practical handbook whichmany will seek, it is also not the review of the literaturewhich it often tries to be. The mixture is unusual,and will please some more than others.
Treatment of Respiratory Emergencies IncludingBulbar PoliomyelitisTHOMAS C. GALLOWAY, M.D., professor emeritus ofotolaryngology, Northwestern University Medical School.Springfield, Ill. : Charles C. Thomas. Oxford : BlackwellScientific Publications. 1953. Pp. 94. 21s. 6d.
IN a short but stimulating volume Dr. Gallowaywrites as an otolaryngologist who has made a wide studyof respiratory emergencies. In dealing with mechanicsof respiratory obstruction he is particularly interested inacute tracheobronchitis and the pathological changesresulting from this infection. He advocates tracheotomyif there is impending asphyxia, cyanosis, or exhaustion,and he follows this with postural drainage and irrigationwith warm sodium bicarbonate solution. The latterpromotes vigorous coughing and is said to liquefy viscoussputum. He wisely stresses the danger of anoxia, parti-cularly of the type which may be present without obviousclinical signs. The danger of permanent changes in thecerebral cortex as the result of a seemingly short periodof anoxia is not always recognised, particularly if thereis an added toxic condition, such as poliomyelitis.
Dr. Galloway’s main subject is acute bulbar polio-myelitis, in which he thinks that the chief danger lies inobstruction of the air-passages by secretions. The basisof treatment should be postural drainage, continuousaspiration, and tracheotomy. Tracheotomy should beperformed before the clinical condition has deteriorated,and it may be necessary to supplement treatment with arespirator. When there is a tracheotomy opening it actsas a by-pass and prevents secretions being sucked intothe trachea from the pharynx. Inhaled secretions maysoon produce spasm and precipitate catastrophe withlittle warning. The value of postural drainage is discussedin some detail, showing the value of the prone positionor head-down tilt in the supine posture in keeping thelungs clear.
In concluding chapters further indications for tracheo-tomy are discussed, but here, as in bulbar poliomyelitis,there is little mention of the possibilities of endotrachealaspiration or bronchoscopy. The whole subject is ofparticular interest at the present time when the treatmentof bulbar and spinal poliomyelitis is so much underdiscussion; and even if the reader may not agree with allDr. Galloway’s statements, he will certainly be stimulatedby his arguments and the way they are put forward.Notes on Mental Deficiency
J. F. Lyorrs, L.R,.c.P., D.P.M., medical superintendent;W. A. HEATON-WARD, M.B., D.P.M., deputy medical
THERE is a need for a booklet on mental deficiencyintended to give a concise outline for practicalpurposes," but somehow these notes have missed theirtarget. Perhaps the aim was not sufficiently clear,and the result has been over-simplification, combinedwith references to rarities, which will satisfy neither themedical nor the non-medical reader. On the clinicalside the acknowledged indebtedness to Tredgold’stextbook is very obvious, but the briefness of the notesdistorts the balance so that the reader inexperiencedin the subject will not distinguish the possible from theprobable. The most serious criticism is that there hasbeen a failure to fuse for the reader the clinical, anatomical,and ætiological classifications of mental deficiency ;and labels are too easily and freely attached to defectives.Those being introduced to work among them should beencouraged to see them as individuals, with their ownconstitution and experiences. Today, when much isbeing done to integrate the feebleminded into communitylife, the emphasis should be on training, occupation,and employment. Of the fifteen photographs, seven
deal with mongol abnormalities, four with misshapenskulls, and one with the rash of adenoma sebaceum,while three show a naked boy with Frohlich’s syndrome.This choice of illustrations will confirm in the susceptiblereader the impression that most defectives are physically
abnormal, ugly, and unpleasant. A more sympatheticvisual approach, showing the benefits of special educationand training, would encourage the student to helpthose whose mental ability is limited.Precis de genetique medicale
MAURICE LAMY, professor of medical genetics, ParisMedical Faculty, physician, Sick Children’s Hospital,Paris. Paris : Doin. 1952. Pp. 256. Fr. 1400.
THE author of a textbook as short as this must limithimself either to an account of the mechanism of hereditywith illustrations from human pathology or to an outlineof the way a number of different conditions are inherited.Professor Lamy has taken the first course. The bookis an introduction to human heredity rather than a bookin which the inquirer can look for a succinct accountof what is known of the part played by genetic factorsin causing a particular condition in which he is interested.As an introduction it is very good, though the beginnerwill be troubled by the numerous misprints : themathematical expositions are especially lucid and aresupplemented by a final chapter on elementary medicalstatistics. Professor Lamy has had the courage, too,to write a chapter on the practical application of humangenetics. Here he is obviously restricted by the repres-sive French attitude to family planning. He does notconsider positive eugenics at all, and considers negativeeugenics only in the sense that he advises people whoknow that their children would have a serious risk ofdeveloping genetically determined disease not to marryrather than to attempt deliberate limitation of familysize.
X-ray Sieve Therapy in Cancer -
BENJAMIN JOLLES, M.D., D.M.R., consultant radiotherapist,General Hospital, Northampton. London : H. K. Lewis.1953. Pp. 192. 25s.
Dr. Jolles is at pains throughout to emphasise theimportance of the connective tissue in malignant growths,not only in the way in which it influences their spread butalso in its response to radiation. He begins by surveyingpublished work on the properties and reactions of con-nective tissue ; but though he covers a great deal ofground, the precise significance of many of the facts is notmade clear, and this part is somewhat difficult reading.In the second part of the book he reports his studies ofthe protective action of normal tissue surrounding anirradiated area. By some careful work on the reactionof skin to X rays he has shown how critically the effect isdependent on the area of skin irradiated. A very muchlarger dose of X rays can be tolerated when the area ofskin is very small, for then the normal tissues surroundingthe irradiated area are exerting their maximum reparativeeffect. He takes advantage of this by giving irradiationthrough a chessboard sieve made of lead. In this waythe skin to be irradiated is divided into small squares,half of which are shielded. After half the treatment hasbeen given an alternative sieve is used to treat thecovered areas. By this means a considerably higher skindose can be given with less reaction. The tumourresolution obtained in some of the advanced cases is veryencouraging. He emphasises that accuracy of placingof the grids is highly important : no doubt necrotic ulcersmay develop if the tiny areas irradiated are allowed tobecome confluent.The place of grid therapy has yet to be determined, but
this book places it on a firmer theoretical basis, and givesa hint of its possibilities.
Textbook of Gynecology (4th ed. Baltimore : Williams& Wilkins. London : Bailliere, Tindall, & Cox. 1953. Pp. 800.68s. 6d.).-This truly magnificent work by Emil Novak andEdmund K. Novak, of Johns Hopkins Hospital, Baltimore,has been produced to meet the needs of the medical studentand practitioner ; but, in addition, it is outstanding as abook on gynaecological pathology. If a knowledge and under-standing of pathology is necessary for the interpretation ofsymptoms and signs and the dispensation of treatment, theauthors have provided an admirable basis for the practice ofthis part of medicine. Emil Novak has made a life study ofpathology, and his love of his subject is evident throughout.There are over 500 illustrations, many in colour, and nearlyevery one demonstrates some important point.
