of Rhodes. Spurious works Andronicus.

The American journal of obstetrics and diseases of women and children online

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third attack these were accompanied by symptoms of subacute
perforation. Laparotomy revealed a large indurated ulcer just
to the left of the pylorus on the lesser curvature firmly adherent
to the liver. A posterior gastroenterostomy was performed
with a short loop. Recovery was practically uneventfid, and he
has remained in good health for nine months.

Latent Chorea. — ^In discussing this affection Reginald Miiller
(Lancet, Dec. 18, 1909) states that (rheumatic) chorea declares
itself first by symptoms significant of general nervous instability.
In dealing with children suffering from nervous disorders of many
kinds special care should be taken to exclude the possibility of
their having originated from a slight rheumatic infection. The
well-known association between rheumatism and nervous insta-



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718 BRIEF OF CURRENT LITERATURE.

bility is not to be explained by considering that the infection is
specially prone to attack neurotic children, but by regarding the
nervousness as in most cases the outcome of an infection already
present (latent chorea). The mental depression and headache
in rheumatic children are usually to be attributed to the disease
and not to its treatment by salicylates. The recognition of latent
chorea in children suffering from obvious acute rheumatism
affords strong evidence that chorea is a rheumatic condition.

Contribution to the Treatment of Scoliosis — Auto-Modeleur
of Menciire, with Pneumatic Pressure. — Louis Menci^re (Arch.
Prov. de Chir., Sept., 1909) states that the treatment of scoliosis
is based on progressive mobilization of the spine and thorax,
progressive redressemeni force, and fixation by an appropriate
apparatus, with modeling of the thorax by pneumatic pressure
and respiratory gymnastic exercises. The thorax of the patient
is placed, during the exercises, in an apparatus which models
it, an essentially active process. While respiratory movements
are being made the thorax is induced to change its form and size
by pneumatic pressure, continued and elastic. To accomplish
this a cast of the thorax is made with pads over the depressed
portion, from which a positive in plaster is made with a space
over the depressed region, and a pneumatic pad, which can be
inflated from a compressed air apparatus over the prominent
region. From this a modeling apparatus is made such that a
pneumatic cushion gives pressure upon the projecting portion
of the thorax and the depressed portion is allowed space to
expand. This apparatus follows the movements of the thorax
in respiration owing to the elasticity of the gas in the pneumatic
cushion. In this apparatus the patient takes active breathing
exercises. The gymnastics assure a dilatation of the thorax
and increase of its antero-posterior and transverse diameters,
while the apparatus supports the thorax and abdomen. The
head must be in extension. This is obtained by hanging the
child from a head sling during the exercises. The arms are
exercised by rings suspended on pulleys. The passive part
of the treatment consists of manual or instrumental redressemeni
ford, mobilization of the spine, and mechanotherapy. In
scoliosis parts of the lungs are not used in respiration and these
lose their function, which causes partial ankylosis of the costo-
vertebral articulations. The respiratory gymnastics fill these
unused portions of the lungs and mobilize the articulations.
Nasal obstruction plays an important part in noninflation in
scoliosis. All these exercises should be carefully supervised by
the physician.

Internal Contagion in Hospitals for Children. — P. Chatin
{Lyon med., Dec. 5, 1909) says that the frequency of the occur-
rence of contagious diseases in hospitals for children that are
not intended for such diseases is appalling. Diseases that are
simple when occurring at home are fatal in many cases in the
hospital. Measles in the Charity Hospital at Lyon attacked



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BRIEF OF CURRENT LITERATURE. 719

loo patients of whom twenty died. Of these cases forty-one
might be considered as brought into the hospital, while the
other fifty-nine acquired the diseaise there. Of forty-four cases
of scarlatina six died. Only thirteen or fourteen brought the
disease in with them. Bronchopneumonia is another disease
that is brought in and causes many deaths. The special wards
for scarlatina, measles, etc., do not seem to have put an end to
this trouble. The author believes that the only way to do so
is to have wards in which each patient has a special compart-
ment into which he is received and where he is isolated for a
sufficient length of time to have passed over the incubation of
these various contagious diseases. This method has been
attempted with success at several hospitals, and it would be
well to see it introduced in every hospital for children.

Treatment of Inguinal Hernia in the Child. — Ch. Dam (Gas.
des. hdp., Dec. 14, 1909) says that surgical intervention is always
the proper treatment of inguinal hernia in the child, regardless
of age or sex, provided that the condition of health will permit
of an operation. The prolonged use of a bandage has* many
disadvantages. It causes irritation of the skin, even unceration,
atrophy of an already weak muscular structure, and prevents
the child from engaging in the sports of his age. Mental depres-
sion results. The pressure of the bandage causes the formation
of adhesions between the cremaster, the sac, and the elements
of the cord, and leads to the formation of cysts of the cord.
Finally atrophy of the cord occurs. If cure follows the use of
the bandage is often only temporary, and operation becomes
necessary later. Intestinal stasis causes inflammation of the
intestine, and febrile attacks which show that an acute affection
is beginning. The author makes a longitudinal incision, dissects
the sac high up, resects it, and sutures the edges of the ring.
The operation is simple, rapid and gives good results.

Congenital Stricture of the Urethra. — Gallois {Nord med.,
Dec. I, 1909) describes three cases of stricture of the urethra
of congenital origin observed "by him. Not many such cases
have as yet been published. There are three locations at which
the urethra is naturally narrowed, but there are also other
abnormal narrowings. The embryonic development of the
urethra enables us to understand the reason of congenital
stricture. The urethra is developed in three parts: the posterior
urethra results from the closure of the cloaca and the disappear-
ance of the cloacal pouch ; the spongy portion is derived from the
urogenital sinus; the balanitic portion is derived from the
balanitic layer. If these three portions are not normally
adherent into one or the lumen is not perfect an opportunity
is given for the formation of strictures by arrest of development.
The histological examination of such a case showed that there
is no modification of the urethral mucosa; the principal lesion is
an irregular sclerosis without any signs of inflammation. The
process is a subepithelial sclerosis. The stricture may be



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720 BRIEF OF CURRENT LITERATURE.

found at any time from birth, it having been observed as early
as the ninth day of life. It may be cylindrical or annular, or
there may be valvular structures in the course of the urethra.
The stricture is generally single. The symptoms may begin
as those of an acute condition and gradually become chronic.
First there is a period of abnormal length of the act of micturition
with small stream and frequency of urination; then retention
or habitual incontinence occurs.

Education of Deaf Children. — ^J. D. Wright (Jour. Amer. Med.
Assn.f 1909, liii, 2156) is not an advocate of beginning the actual
teaching of speech to a totally deaf child as young as two or
three years of age. If there is some perception of sound it may
be possible to train and develop that imperfect hearing so that
it may greatly aid in the acquisition of speech, and this may be
begun earlier than articulation teaching to a totally deaf child.
But the training to tmderstand spoken language by lip reading
cannot be begun too early in any case. The child should be
placed under trained and experienced instruction not later than
six years of age, and, if physically strong and well developed, it
is better to begin at four and a half or five. Centuries of in-
heritance have rendered the years from two to twelve the
principal language-learning time for the child. The deaf child
that has not acquired much language by twelve years of age is
doomed to a bitter and discouraging struggle, and it is cruel to
let anything interfere with the greatest possible progress in the
first ten years of the child's life. The educators of the deaf are
still somewhat divided, and there are still manualists who
employ the manual alphabet and gestural signs in the educational
process, and oralists who exclude all forms of commimication not
employed by hearing people. The writer strongly favors the
pure oral method.

Difficulties in the Diagnosis of Scarlet Fever. — In citing the
usual difficulties in the diagnosis of scarlatina, J. F. Schamberg
(Arch. Ped., Dec, 1909) makes a suggestion which is interesting
in view of the frequency with which an initial cathartic dose of
calomel is given and such drugs as aspirin are prescribed. He
says that in treating patients with an acute sore throat, it is
inadvisable to administer any drugs which are capable of exciting
an eruption of a scarlatinoid character for, if such a rash appear,
Hippocrates himself would be unable to exclude scarlet fever
from the diagnosis. The drugs which are most likely to produce
an eruption of this character are quinine, the salicylates, veronal,
antipyrin, calomel, belladonna, etc.

Reduction of Temperature in Children. — W. C. Hollopeter and
H. B. Mills {Penn. Med. Jour., Dec, 1909) urge abstinence
from the use of drugs and the employment of the ice-bag to the
head, sponging with water reduced gradually from 90° or 95*^
to 70°, colonic irrigation with water similarly lowered from
95° to 70°, and free ventilation with fresh air regardless of the
temperature of the patient.



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TH h! A1VrF.TtIO.AJSr

JOURNAL OF OBSTETRICS

JUXD

DISEASES OF WOMEN AND CHILDREN.

VOL LXI. MAY, 1910. NO. 5

ORIGINAL COMMUNICATIONS.



IS PUBIOTOMY A JUSTIFIABLE OPERATION.*

Second Communication Based upon a Series of Twenty-
Five Successful Cases.

BY

J. WHITRIDGE WILLIAMS,

Professor of Obstetrics, Johns Hopldns University.

In a report made to the American Gynecological Society in
May, 1908, based upon thirteen successful operations, I held that
pubiotomy had a distinct field of usefulness under certain definite
conditions. Since that time twelve additional operations have
been performed in my service, making a total of twenty-five.
Moreover, seven of the women who had been subjected to pubi-
otomy have been delivered subsequently, and I have been able
to reexamine twenty-two of the patients at periods of from three
months to three years afterward.

On this occasion I shall consider in the first place the immedi-
ate results of the operation both for the mother and child, and
then take up its remote effect upon the general health and in-
dustrial eflSciency of the former, as well as its influence upon the
course of subsequent pregnancy and labor. I shall then review
the recent literature upon the subject, and finally consider the
technique and indication for the operation, as developed by my
own experience and literary studies.f

Immediate Restdis: — In the twelve cases here reported there
were no maternal or fetal deaths, so that in the entire series of
twenty-five operations all of the mothers and twenty-two of the

* Read before the American Gynecological Sodety, May 3, 1910.
t Histories at the end of the article.



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722 WILLIAMS: IS pubiotomy a justifiable operation.

children were saved, and it may be added that the death of only
one of the latter could be attributed to the operation; namely,
case V of the previous series.

On analyzing the histories of the twenty-five operations, one
finds that twelve of the patients were primiparous and thirteen
multiparous, while nine were white and sixteen black. More-
over, the accompanying table shows the incidence of the several
varieties of contracted pelvis and their partition between the
two races.



Tjrpc of pelvis



Total
number



In 9 white
women



In i6 bUck
women



Generally contracted rhachitic 14 2 12

Generally contracted funnel 3 2 \ 1

Generally contracted i ' i

Simple fliat 3 3 1

Flat rhachitic 2 I | 2

Typical funnel



2


2




'5 . 1


9


16



It thus appears that rhachitic pelves were noted in only two of
the nine white patients, as compared with fourteen of the six-
teen black patients, an incidence of 22 and 75 per cent, respect-
ively. In twenty cases presenting the usual types of pelvic
deformity the conjugata vera varied from 7 to 8.75 cm. ; whereas
in the five generally contracted and typical fimnel pelves the
distance between the tubera ischii measured 7 to 7, 75 cm.

In the entire series there were one transverse, four breech, and
twenty vertex presentations. In the latter category the posi-
tions noted were as follows: L. O. A., three; L. O. T., six; R. O. T.,
six; and R. O. P., five; thus indicating that in 55 per cent, of the
cases the occiput was directed toward the right side. More-
over, the fact that anterior positions were noted in only 15 per
cent, of the cases clearly emphasizes the effect of the pelvic
abnormality upon the position of the head.

Ordinarily the operation was not undertaken until a long test
of the second stage had demonstrated that nature was unable to
overcome the disproportion between the size of the head and the
pelvis, its average duration being three and one-half hours. In
five cases, on the other hand, interference was effected earlier.
Thus, in case XXI, in which the child presented transversely ^
the operation was undertaken one hour after complete dilata-



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WILLIAMS: IS PUBIOTOMY A JUSTIFIABLE OPERATION. 723

tion of the cervix and a large child readily delivered by version
and extraction; while in cases VII, IX, XVII, and XVIII
interference seemed indicated before the cervix had become
completely dilated. In these cases the external os varied from
5 to 8 cm. in diameter and was dilated manually before under-
taking the pubiotomy. In cases IX and XVII interference was
called for by exhaustion on the part of the mother, as indicated
by a rise in the pulse rate to 120 or more and a slight elevation
in temperature. In case VII manual dilatation of the cervix
and completion of labor seemed indicated on account of the pro-
lapse of a foot and its protrusion from the vulva, while in case
XVIII interference appears to have been unjustified. In this
instance the multiparous patient had a generally contracted
rhachitic pelvis with a diagonal conjugate of 9.75 cm. She
had previously gone through several difficult labors, and, having
lost the children, was most anxious for a live child. As her pulse
became somewhat rapid, manual dilatation of the very soft
cervix was undertaken when it had attained a diameter of 5 cm.
This was readily accomplished, and a small child weighing 2,080
grams delivered after pubiotomy and an easy forceps operation.
In this instance the operation was not justified, and was done
under a misapprehension concerning the size of the child, which
appeared much larger before delivery than afterward.

In all but the first case, in which the technique of Gigli was em-
ployed, the pubiotomy was done by Doederlein's subcutaneous
method, and in every instance the child was delivered immedi-
ately after sawing the bone, for the reason that the operation had
been deferred until demanded by the appearance of some indica-
tion for prompt delivery on the part of the mother or child, or
until a prolonged second stage had shown that nature was un-
able to complete the task. Delivery was effected by forceps in
eighteen, by breech extraction in four, by podalic version from
head presentations in two, and by version from a transverse pre-
sentation in one case. Moreover, in the hope of preventing in-
jury to the soft parts, the vaginal outlet was freely dilated with
the hand before severing the pubic bone.

Serious hemorrhage was noted only in case V, which was com-
plicated by a deep communicating vaginal tear following the
breech extraction of a 4,050 gram child. The patient was put
back to bed considerably shocked, but eventually made a satis-
factory recovery.

Perineal tears were noted in three primiparae and three mul-



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724 WILLIAMS: IS pubiotomy a justifiable operation.

tiparae. In five instances they were slight, but in case V, already
mentioned, the tear was deep; all were repaired immediately and
healed by first intention. Communicating vaginal tears were
noted in five instances, once in the first and four times in the
present series. Three occurred in primiparae and two in multi-
parse, and with one exception were immediately repaired by
sutures and healed without diflSculty. All but one of the women
so injured had fever, which was moderate in two and severe in
two cases. Of the latter, case V was seriously ill, while case
XXII had a temperature of 103.2, but, as intrauterine cultures
showed the existence of gonorrheal infection, it could not neces-
sarily be connected with the lesion.

As far as I can ascertain the method by which delivery is ef-
fected has only a slight influence in the production of such
tears, as two of them complicated seven breech extractions, and
three occurred during the course of eighteen forceps deliveries.
Moreover, it would appear that in not a few instances the tear
might have been avoided had the assistant, who performed the
operation, made horizontal instead of upward traction while de-
livering the head through the vulva.

In no instance was the bladder injured, nor did the patients at
any time pass bloody urine, while catheterization was necessary
in only six cases. In three instances it was limited to the day
of operation, while in only one of the remaining cases was it
continued for more than a few days. With the exception of case
V, none of the patients were seriously ill during the puerperium,
and the majority apparently suffered but little. In many in-
stances they turned spontaneously in bed the day after operation
and were anxious to sit up at the expiration of a few days. Sev-
eral got out of bed during the first week in the absence of a nurse,
but sustained no injury from so doing. Ordinarily the patients
were kept in bed for three weeks and discharged at the end of the
fourth, although my experience seems to show that so long a rest
in bed is not necessary and it will be shortened in the future.

During the puerperium fourteen of the twenty-five patients
presented a temperature of 100.5 or over — ^56 percent. — although
with one exception none of them appeared seriously ill. Thus,

In five cases the temperature varied from 100.5 to 100.9.

In seven cases the temperature varied from loi to 102.

In one case the temperature reached 102.5.

In one case the temperature reached 103.2.

In the last instance it is doubtful whether the fever should be



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WILLIAMS: IS PUBIOTOMY A JUSTIFIABLE OPERATION. 725

ascribed entirely to the operation, as gonococci were demon-
strated in the uterine lochia. In all patients there was a cer-
tain amount of oedema about the vulva for the first few days
following the operation, which, however, disappeared spontane-
ously. In cases I and IV quite a marked hematoma developed
in the labium majus on the side of the operation, while in cases
VII and XVII the convalescence was complicated by a mild
phlebitis.

On discharge at the end of the fourth week the pubiotomy
sldn incision, as well as any tears which might have occurred
during delivery, were found to be satisfactorily healed. Gener-
ally speaking, there was considerable thickening upon the anterior
surface of the severed pubic bone, while no trace of the section
could be felt posteriorly. On passive movement of the thigh def-
inite motility at the site of section was elicited in sixteen out of
the twenty-five patients, thus showing that healing had occurred
by fibrous rather than by bony union. In only one instance,
case I, was any injury sustained by the sacro-iliac joint, but
gave rise to only transient trouble.

That the fibrous union had no effect upon locomotion was
shown by the fact that all of the patients, except case XIX
were able to walk without difficulty at the time of discharge.
In this instance, however, the painful locomotion could hardly
be ascribed to the operation, as the patient had suffered during
pregnancy from such marked relaxation of the sacro-iliac joints
that she was able to walk only when wearing a tight binder,
while the condition has gradually improved since delivery. In
all cases the condition of the internal genitalia was excellent, and
retrodisplacement of the uterus was noted only in two instances.

Remote Effects of the Operation Upon Patient. — ^I have person-
ally reexamined twenty-one out of the twenty-five patients of
this series, and have heard by letter from two others, at periods
varying from two months to three and a half years after the
pubiotomy, and in every instance have found that they were
well satisfied with its results. Indeed, after a lapse of several
months, none of the patients complained of any untoward
symptoms, except 'case XIX, who nine months after operation
stated that she still had some difficulty in walking, although this
was gradually improving, and this was the patient already men-
tioned who had suffered from relaxation of the sacro-iliac joints
during pregnancy. All of the other women reported that they
were able to walk as well and work quite as hard as previously,



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726 WILLIAMS: IS PUBIOTOMY a jaSTEFIABLE OPERATION.

and, indeed, several stated that they would be perfectly willing
to submit to another operation should it become necessary.

My experience, however, seems to indicate that the immediate
results are more satisfactory in slightly built than in heavy
women, as nearly all of the rhachitic negresses stated that they
suffered but very little; while some of the heavier white women
reported that they had experienced some difficulty in locomotion
for several months after leaving the hospital, which, however,
eventually disappeared. In such cases they were able to walk
reasonable distances without discomfort, but suffered more or
less pain when greater distances were attempted, yet in no in-
stance except case XIX did the S3rmptoms persist longer than a
few months.

It is interesting to note that in the majority of patients the
upper skin wound, which originally lay above and parallel to the
superior margin of the pubic bone, gradually changes its position,
so that in the course of time its cicatrix occupies a position cor-
responding to the middle or even the lower margin of the bone,
and, being completely covered by pubic hair, is often difficult
to locate.

On reexamination no change was noted in the motility at the
site of section, as the condition persisted in those women in
whom it was present at the time of discharge, and did not appear
in those in whom it was originally absent. As has already been
indicated, definite motility was noted in two-thirds of the patients,
and it would accordingly appear that if bony union is to occur
it must develop during the weeks immediately following delivery,
whereas if it has not been effected by that time fibrous union will
persist.

Up to the present time the literature records autopsy findings
in five patients upon whom pubiotomy had been performed
one to four years previously. These were reported by Obem-
dorfer, Welponer and Cristofoletti (two cases), Reifferscheid
and Mayer. In four the union was entirely fibrous, and in the
case reported by Mayer the connective-tissue formation was so
slight that the cut ends of the bone were merely united by a few
shreds, the integrity of the pelvic girdle being maintained by the
fibrous tissue which had developed upon the anterior and posterior
surfaces of the bone. On the other hand, true bony union had
occurred in one of the cases reported by Welponer and Cristo-
foletti, while an elevated bony ridge upon the posterior surface of



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 74 of 109)