You have never heard of obstetrical forceps? Well, forceps are used to assist in a vaginal delivery, and often is the last step before the decision is made to perform cesarian delivery. Forceps have been in use for over one hundred years, are named after the obstetrician who developed each particular kind, and are still used today in special circumstances. This story tells of a time when obstetrical forceps were used in my general surgery practice. To date, and after thorough review of the surgical literature, there is no record that this instrument had ever been used outside the practice of Obstetrics.
Let me introduce myself. I am Dr. Roland Fleck, and I am a graduate of the University of Innsbruck Medical School in Austria. Although I am an Austrian native, a portion of my training was also at the University of Paris, France. In 1957, 6 months after my graduation, I came to the United States on an immigration visa to do my internship at Providence Medical Center in Portland, Oregon. I then proceeded into residency and specialty training at University of Wisconsin, Madison in General Surgery and Urology.
The first job after my training was at the MacIntosh County Memorial Hospital, Ashley, ND. The 26 bed hospital had lost their only doctor, and was about to close. My one year contract turned into 15 years, 8 of which I served as the only physician in a county of 5000 people. I practiced the whole spectrum of medicine, including general surgery, urology and Ob/Gyn. It was so remote that I even delivered two of my own kids. It was a busy part of my life and I LOVED it. Often I refer to this section of my life as my “Albert Schweitzer” experience. When a blizzard ripped through the region, you were cut off from the world, no matter what support you needed. You had to be very self-sufficient, and rely on your own resources.
In 1977, an opportunity opened for an extra year of urology training at the Mayo Clinic in Rochester, MN. After years of medical isolation, it felt good to be in an ivory tower again. At the end of that year of fellowship, the plan was to start a new urology practice in Walla Walla, Washington. Our moving company was delayed by two weeks, and the family preferred to spend the time waiting at a cooler spot, Jackson Hole, Wyoming. Dr. Horst Zincke, a cancer specialist at the Mayo Clinic, had a friend in Jackson Hole, Dr. Bill Mott, an orthopedic surgeon. They had interned together in Iowa and when Horst heard we were going to be in Jackson Hole for two weeks, he wanted us to “say hello” to Bill.
We called on Dr .Mott and relayed the greetings. Soon the conversation turned to my future plans. “Well, we would really need you here,” was Dr. Mott’s comment. “Dr. Ralph Hopkins has been our visiting urologist here in Jackson, coming 150 miles from Riverton two days each month. The death of one of his partners made it no longer possible for him to come to Jackson. We need to replace him. You could take his place,” said Bill. It would be quite a jump to increase from a twice monthly satellite clinic to a full-time, practice. However, a chance to come to Jackson made all obstacles seem insignificant. What a chance to live in a place, most like my beloved native Tyrol, Austria! Within hours, a call went to the moving company– “We still need you to move us, but we will be moving to Jackson Hole, WY, instead!”
Outlying clinics in Driggs, Afton, and Kemmerer, along with reverting back to my roots as a general surgeon expanded into a full practice. love of aviation and my trusty 231 Mooney shortened the 170- mile commute to Kemmerer from 2 1/2 hours to 45 minutes. It suddenly did not seem so far, and it enlarged the practice territory, to include practically all of western Wyoming.
At one clinic visit in Kemmerer, in 1983, a patient in his mid-sixties presented with increasing abdominal girth and constipation. Let’s name him “Lyle.” Examination disclosed that he had a massive tumor, filling his entire pelvis, which not only obstructed the large bowel, but the urinary tract as well. He clearly needed immediate relief, and this was well before the era of laparoscopes and robots. A colostomy was created on the left side of the abdomen and a urostomy on the right. These procedures did provide some comfort to what would probably be a brief survival for Lyle. Any idea to resect the tumor seemed impossible. The tumor was solid and filled the entire pelvis from bone to bone. Not even the tip of an index finger could be squeezed to separate the tumor from the bone. Lyle coped reasonably well with his two new stomas, and follow-up visits showed him to make good progress. After half a year, Lyle wondered aloud, “if the tumor could be radiated to shrink it.” Lyle had a zest for life, and wanted to make the best of his remaining time. He did go through with a full course of radiotherapy.
After another 6 months Lyle inquired how much the tumor had diminished in size as a result of his radiation treatments. A CT scan of the pelvis was ordered and showed that the tumor mass indeed had shrunk enough, that I thought one could do repeat surgery and place a finger between the tumor and the pelvis wall to try and find a cleavage plane. Lyle wanted to give it a try. He was reopened, and this time an index finger could be forced between the tumor and the bony pelvis. It was a hard and delicate maneuver to separate the tumor from the pelvic wall, without disrupting the iliac vessels feeding blood to the lower extremities. Eventually the tumor could be freed around its whole circumference. Now came the last step, to get the tumor out of the pelvis. A finger could be inserted on each side, but the tumor always slipped away and could not be budged. A whole hand would be needed on each side of the tumor mass, but there was no way to even think of getting a hand in when barely an index finger had room. A corkscrew-type instrument was a fleeting thought, which theoretically could pull out the pelvic mass like a cork from a bottle, but seemed impractical. Besides, how big a corkscrew would be needed to remove a tumor two sizes bigger than a baby’s head?
A baby’s head? Now, that was a thought. Why not use Simpson obstetrical forceps, which in obstetrics are used to assist a fetal head through the birth canal? Never heard of it, but WHY NOT try it? “Get me a Simpson from OB,” I shouted excitedly. “What in hell does Fleck want to do with a pair of Simpsons? He doesn’t have OB privileges,” I overheard the OB nurse say through a few doors of the old hospital, which today houses the professional offices. Never mind, just get me the Simpsons,” was the short answer.
It had been a few years since I had last used forceps, as I had delivered babies in my North Dakota practice for 15 years, but the technique was like riding a bike—once you know how to do it, you know how to do it! First one blade had to be rotated in, then the next one, eventually approximating the handles of the forceps blades. It took a little bit of wiggling before I could close the handles. Pulling on the closed Simpson forceps was the same technique as in OB, just in the opposite direction. Up, instead of down. Everybody held his breath. The tumor actually moved a little bit from side to side. Now it was essential that the tumor would not slip out of the blades. The handles had to be solidly approximated and not allowed to slip. Upward traction was applied to the monstrous tumor mass. With a huge sucking sound the tumor actually emerged from the pelvis. Hurrah! The Simpsons had saved the day!
Now that the tumor was moved out of the way, both hands could be inserted into the pelvis and the lower segment could be separated and the tumor removed. Lyle got nine extra precious years. The pathologist diagnosed the tumor as a mucinous adenocarcinoma of the rectum, with invasion of the entire pelvis. The tumor showed no propensity to metastasize, and Lyle had a few more good years. The nuisance of his prior surgery was taken in stride.
This was the first time Simpson obstetrical forceps were used in General Surgery–anywhere. And it happened right here in Jackson, at the St. John’s Hospital.
Roland Fleck, M.D.
1962 – 1977 , McIntosh County Memorial Hospital – Ashely, ND
1978 – 1978, Mayo Clinic – Rochester, MN
1978 – 2007, St. John’s Medical Center – Jackson, WY
2007, Mbeya Referral Hospital – Mbeya, Tanzania
2009 – 2014, Caribou Memorial Hospital – Soda Springs, ID
