Kathleen Vaughan

THE SHAPE OF THE PELVIC BRIM AS THE DETERMINING FACTOR IN CHILDBIRTH.

The gastritic changes concurrent with gastric ulcer and carcinoma are of great interest, and it has even been suggested that their study may enable us to foretell the later onset of ulcer and carcinoma. This, perhaps, is unduly optimistic, at any rate as far as carcinoma is concerned, but the study of the relief pattern may shed some light on the factors at work. Another interesting field of s-tudy is provided by the cases of gastritis following gastro-j ejunostomy. PEPTIC ULCER In the skeleton meal, as in the full meal, the direct evidence is given by the actual niche. There are both advantages and disadvantages in the former procedure; it is sometimes difficult to fill the niche when the main cavity of the stoinach is empty. On the other hand, in ulcer of the cardia, and in ulcer of the corpus away from the sky-line of the lesser curvature, as well as in pyloric and pre-pyloric ulcer, the filling and visualization of the niche is often very much ea-sier in the skeleton meal. The conditions of the mucosa around the ulcer can also be studied. Barclay has emphasized the fact that the apparent size of an ulcer depends on the heaping up of the mucosa around it; so the decrease in size of a niche under treatment can be misleading. The presence of radial striae in the mucosa converging on the site of an ulcer is another valuable sign. Duodenal ulcer can often be diagnosed by the skeleton meal, but the best method is that described by Akerlund, .Attinger, and Berg. This is, to fill the duodenal cap completely by pressure on the stomach and on the descending duodenum. The cap is then examined at all possible angles for contour deformities, and then completely emptied by compression or manipulation and examined again for any residue in a niche. The skeleton meal is especially well adapted for the diagnosis of jejunal and gastro-jejunal ulcer, and also for the differentiation between ulcer and diverticulum. Fig. 2a shows a small ulcer niche on the lesser curvature,

The Squatting Position in Labour

transferred from her shoulders to those of the doctor, and all her incentive to try to recognize these warning signs is taken from her. I am at one with Dr. Oxley that the midwife should have the fullest recourse to the doctor, and that she should refer any case in which she has the least doubt to him, not only once or twice, but as many times as may be necessary. It would lead to more satisfactory results if greater insistence were put on midwives doing their own antenatal work and keeping a full and complete record which shows both negative and positive observations. The medical health authorities of this city are endeavouring to increase the efficiency of the local midwives by postcertificate instruction; the view is taken that not only should midwives be able to conduct normal labour, but they should be able to recognize the abnormal, both in pregnancy and in labour, and that any case in which they have the least doubt should be referred to the patients own doctor. The C.M.B. course of instruction and examination is now turning out very efficient midwives who, in the main, should be quite capable of doing their own ante-natal work up to the point at which the co-operation of the doctor is necessary.-I am, etc.,