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RUPTURE OF THE PREGNANT UTERUS
736 UNMARRIED PARENTHOOD Sin,—Now that we have completed the circuit of the course, may I revive the matter which initiated the correspondence ?’? Dr. Hamilton (March 30) makes the critical point of it : every child has the right to be conceived in love, born in happiness, and nurtured in security. A great deal of human coition takes place, and will quite certainly continue to take place, in circumstances which, within marriage or outside it, do not fulfil these conditions. It is possible to ensure that in a proportion of these cases, at least, coition will not be followed by conception. It seems to me that if we are
really concerned with the rights of the child, we should attempt to ensure that this is so. If we are not concerned very much about the rights of the child, but very greatly concerned to preserve a particular doctrine of conduct, we shall wish to limit the availability of contraceptive knowledge so that we can continue to appeal to the rights of the child when appeals to the beauty of holiness wear thin. It seems to me that while we may well hold our own conclusions upon the doctrine of conduct, we ought not to let our zeal for it increase the number of unwanted children among those who find our doctrine unconvincing ; by withholding contraceptive knowledge in the interests of sacramental marriage, we shall certainly not stop human beings from coition in a very wide range of contexts. By providing it, we might even make more of these contexts sacramental, instead of psychologically and morally negative. ALEX COMFORT. RUPTURE OF THE PREGNANT UTERUS was most interested in the 3 cases of ruptured uterus reported by Mr. Higgins (March 23). His opinion that a change may be appearing in the commoner causes
SiR,-I
predisposing to uterine rupture is one which I have held myself for some time. The tragic aetiology of the accident in the past has often been the neglected transverse lie, the unrecognised hydrocephalic, or the unsuspected pelvic contraction in the multipara-abnormalities which are more frequently recognised now and appropriately dealt with before there is any danger. There has always been, however, a group of patients-previously a small group but now relatively much larger-in which no major fault had been present to explain why the uterus ruptured. In this group a weakness of the uterine muscle may have arisen from a cervical tear, or following difficult manual removal of an adherent placenta, or, as Mr. Higgins suggests, following traumatic curettage. Such a weakened area might give way during a labour only slightly more difficult than usual, perhaps due to no more than a large child or a degree of extension of the head, two abnormalities which were illustrated by Mr. Higgins’s first case. As a further illustration of the changing actiology of uterine rupture, I would like to quote some figures Between 1951 and 1955, in previously reported.] Sheffield, 8 cases of uterine rupture were seen in the Jessop Hospital for Women and the City General Hospital. In only 1 was the rupture due to a neglected transverse lie ; in 1 it was due to an attempt to deliver the impacted shoulders of a baby weighing 111/2 lb. ; in
1, to
a
previous Fothergill colporrhaphy ;
in
1
to
a
pregnancy in a rudimentary uterine horn ; in 1 to previous fundal perforation during curettage ; and in 3 the rupture was unexplained in multiparous patients. I think that the importance of tlie changing etiology lies in the need for us to think of the possible diagnosis of rupture of the uterus under different circumstances than in’the past. When signs of shock appear in a patient with obstructed labour due t,o lie or gross
disproportion,
the
diagnosis
of
rupture
of the uterus
1. Dewhurst, C. J. J. Obst. Gynœc., Brit. Emp. 1956,
63,
can
125.
usually be made without difficulty. When, however, collapse occurs without any apparent reason in a seemingly normal labour-or even in pregnancy, as in 2 of Mr. Higgins’s cases-the suspicion of uterine rupture may not so easily arise in our minds ; the absence of the common aetiological agents of the past may delay the correct diagnosis in favour of, say, accidental hmmorrhage or adrenal haemorrhage, with the result that operation may not be performed in time. I think Mr. Higgins’s paper has given us valuable additional information on the present-day aetiology of this serious accident. of Obstetrics and Gynæcology Jessop Hospital for Women,
Department
Sheffield.
C. J. DEWHURST.
OBSTETRIC FLYING-SQUADS
SiR,—Mr. Telfer Gray (March 30) should realise that mission hospital provides only a of a vast problem. I did not visit the Bolobo area, and have no information of the Bayanza or the Wadia whom, I suspect, he served. My safari was to visit personally the authorities upon the subject of my research and the tribal villages of the people over a wide area of the Belgian Congo and Central and East Africa. We do not form our own opinions from a six months’ investigation, but we acquire and profit by the expert knowledge of local witnesses. My statement, that postpartum haemorrhage is almost entirely absent in uncomplicated labour among unurbanised tribal Africans (March 23), is amply justified by the evidence that I have upon this subject and the status of those who generously gave their time to help me in this investigation. If Mr. Gray could study these original documents he would appreciate the limitation of his experience and withdraw his uncalled-for imputation that I imagine Africa to be an obstetric Utopia. seven
years in
one
parochial picture
GRANTLY DICK-READ. AN ADJUSTABLE SPLINT FOR FRACTURES INTO THE KNEE-JOINT
interested to see a modification of my Nir. Tupman (March 23). Several similar alterations have already been suggested by other users of this method. When this form of traction and splintage was originally devised and published, it was my deliberate intention to keep the apparatus as simple as possible so that it might be readily assembled from existing materials. I have, moreover, continued to use this method unmodified to my satisfaction since that time, although I agree that there are certain slight disadvantages in the maintenance, to which Mr. Tupman refers. Like him, I have found the method particularly valuable in the treatment of injuries in the neighbourhood of the knee-joint, and indeed I know of no other method by which bony union can be quickly obtained with good alignment while preserving an. excellent range of knee
Sm,-I
was
splint by
movement. I am hoping shortly to publish my own modification of the splint which resembles in some ways Mr. Tupman’s, but over which it has certain advantages-namely,
retention of the simple ’’ rigging " and incorporation of a hinge at the knee which adjusts itself to the alteration in the axis of the knee during movement. I still prefer to use skeletal traction through a Steinmann pin in the upper end of the tibia, but I agree that strapping traction is a perfectly satisfactory alternative. I firmly believe, however, that modifications of the splint are of themselves of little importance compared to the underlying principle involved in its use-namely, early of muscle action, which promotes rapid bony union and retains a supple and powerful lower limb. GEOFFREY R. FISK.
really concerned with the rights of the child, we should attempt to ensure that this is so. If we are not concerned very much about the rights of the child, but very greatly concerned to preserve a particular doctrine of conduct, we shall wish to limit the availability of contraceptive knowledge so that we can continue to appeal to the rights of the child when appeals to the beauty of holiness wear thin. It seems to me that while we may well hold our own conclusions upon the doctrine of conduct, we ought not to let our zeal for it increase the number of unwanted children among those who find our doctrine unconvincing ; by withholding contraceptive knowledge in the interests of sacramental marriage, we shall certainly not stop human beings from coition in a very wide range of contexts. By providing it, we might even make more of these contexts sacramental, instead of psychologically and morally negative. ALEX COMFORT. RUPTURE OF THE PREGNANT UTERUS was most interested in the 3 cases of ruptured uterus reported by Mr. Higgins (March 23). His opinion that a change may be appearing in the commoner causes
SiR,-I
predisposing to uterine rupture is one which I have held myself for some time. The tragic aetiology of the accident in the past has often been the neglected transverse lie, the unrecognised hydrocephalic, or the unsuspected pelvic contraction in the multipara-abnormalities which are more frequently recognised now and appropriately dealt with before there is any danger. There has always been, however, a group of patients-previously a small group but now relatively much larger-in which no major fault had been present to explain why the uterus ruptured. In this group a weakness of the uterine muscle may have arisen from a cervical tear, or following difficult manual removal of an adherent placenta, or, as Mr. Higgins suggests, following traumatic curettage. Such a weakened area might give way during a labour only slightly more difficult than usual, perhaps due to no more than a large child or a degree of extension of the head, two abnormalities which were illustrated by Mr. Higgins’s first case. As a further illustration of the changing actiology of uterine rupture, I would like to quote some figures Between 1951 and 1955, in previously reported.] Sheffield, 8 cases of uterine rupture were seen in the Jessop Hospital for Women and the City General Hospital. In only 1 was the rupture due to a neglected transverse lie ; in 1 it was due to an attempt to deliver the impacted shoulders of a baby weighing 111/2 lb. ; in
1, to
a
previous Fothergill colporrhaphy ;
in
1
to
a
pregnancy in a rudimentary uterine horn ; in 1 to previous fundal perforation during curettage ; and in 3 the rupture was unexplained in multiparous patients. I think that the importance of tlie changing etiology lies in the need for us to think of the possible diagnosis of rupture of the uterus under different circumstances than in’the past. When signs of shock appear in a patient with obstructed labour due t,o lie or gross
disproportion,
the
diagnosis
of
rupture
of the uterus
1. Dewhurst, C. J. J. Obst. Gynœc., Brit. Emp. 1956,
63,
can
125.
usually be made without difficulty. When, however, collapse occurs without any apparent reason in a seemingly normal labour-or even in pregnancy, as in 2 of Mr. Higgins’s cases-the suspicion of uterine rupture may not so easily arise in our minds ; the absence of the common aetiological agents of the past may delay the correct diagnosis in favour of, say, accidental hmmorrhage or adrenal haemorrhage, with the result that operation may not be performed in time. I think Mr. Higgins’s paper has given us valuable additional information on the present-day aetiology of this serious accident. of Obstetrics and Gynæcology Jessop Hospital for Women,
Department
Sheffield.
C. J. DEWHURST.
OBSTETRIC FLYING-SQUADS
SiR,—Mr. Telfer Gray (March 30) should realise that mission hospital provides only a of a vast problem. I did not visit the Bolobo area, and have no information of the Bayanza or the Wadia whom, I suspect, he served. My safari was to visit personally the authorities upon the subject of my research and the tribal villages of the people over a wide area of the Belgian Congo and Central and East Africa. We do not form our own opinions from a six months’ investigation, but we acquire and profit by the expert knowledge of local witnesses. My statement, that postpartum haemorrhage is almost entirely absent in uncomplicated labour among unurbanised tribal Africans (March 23), is amply justified by the evidence that I have upon this subject and the status of those who generously gave their time to help me in this investigation. If Mr. Gray could study these original documents he would appreciate the limitation of his experience and withdraw his uncalled-for imputation that I imagine Africa to be an obstetric Utopia. seven
years in
one
parochial picture
GRANTLY DICK-READ. AN ADJUSTABLE SPLINT FOR FRACTURES INTO THE KNEE-JOINT
interested to see a modification of my Nir. Tupman (March 23). Several similar alterations have already been suggested by other users of this method. When this form of traction and splintage was originally devised and published, it was my deliberate intention to keep the apparatus as simple as possible so that it might be readily assembled from existing materials. I have, moreover, continued to use this method unmodified to my satisfaction since that time, although I agree that there are certain slight disadvantages in the maintenance, to which Mr. Tupman refers. Like him, I have found the method particularly valuable in the treatment of injuries in the neighbourhood of the knee-joint, and indeed I know of no other method by which bony union can be quickly obtained with good alignment while preserving an. excellent range of knee
Sm,-I
was
splint by
movement. I am hoping shortly to publish my own modification of the splint which resembles in some ways Mr. Tupman’s, but over which it has certain advantages-namely,
retention of the simple ’’ rigging " and incorporation of a hinge at the knee which adjusts itself to the alteration in the axis of the knee during movement. I still prefer to use skeletal traction through a Steinmann pin in the upper end of the tibia, but I agree that strapping traction is a perfectly satisfactory alternative. I firmly believe, however, that modifications of the splint are of themselves of little importance compared to the underlying principle involved in its use-namely, early of muscle action, which promotes rapid bony union and retains a supple and powerful lower limb. GEOFFREY R. FISK.