of Rhodes. Spurious works Andronicus.

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

. (page 75 of 109)
Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 75 of 109)
Font size
QR-code for this ebook


the bone indicated the site of section and encroached slightly upon



Digitized by VjOOQIC



WILLIAMS: IS PUBIOTOMY A JUSTIFIABLE OPESATION. 727

the pelvic cavity. From these reports and my own experience
it would therefore seem that fibrous healing is the rule and bony
union the exception.

The findings at the site of the bone section, likewise, vary
considerably according as the patient is examined within a few
weeks or after a longer period. In the first instance there is
usually considerable thickening upon the anterior surface
of the pubic bone, while no trace of the incision can be felt
upon its posterior surface. On the other hand, a subsequent
examination will frequently show that the anterior thickening
has disappeared, while the site of the incision on the posterior
surface may be indicated by a shallow depression, which some-
times terminates by a slight notch at its superior and inferior
extremity. Only once in our series of cases could definite
separation between the ends of the bone be detected on palpation
(case XXIV), but in this instance a shallow groove i cm. in width
lay between them, and buckled slightly upon passive movement
of the thigh.

Effect Upon the Pelvis, — ^Upon reexamination all of my patients
were subjected to careful mensuration for the purpose of deter-
mining what effect, if any, the operation had exerted upon the
size of the pelvis. Changes were noted in eleven instances:
cases II, VI, VII, XI, XV, XVI, XVII, XVIII, XIX, XXIII,
and XIV. In several they were so slight that it was questionable
whether they were due to actual enlargement or merely to some
slight error in pelvimetry. In others, on the contrary, the changes
were so pronounced that there could be no doubt as to their
significance. In eight patients the distance between the tubera
ischii had undoubtedly become increased following the operation.
This varied from i to 2 1/2 cm., and in several instances, as will
be pointed out later, apparently led to suflScient enlargement
to make possible the spontaneous ending of subsequent labors.
The increase in the diagonal conjugate was less marked, but
in five patients the measurement was 0.5 to 1.25 cm. longer
than previously, while in two it was also associated with an in-
crease in the distance between the tubera ischii.

These findings are of considerable interest, as they appear to
indicate that permanent enlargement of the pelvis may occur in
something less than one-half of the cases, and is more pronounced
in the transverse diameter of the outlet than at the superior
strait. Moreover, to a certain extent, they appear to be contra-
dictory of the statement of Mayer, who holds that the practical



Digitized by VjOOQ IC



728 wnxiAMs: is pubiotomy a justifiable opesaiion.

effect of pubiotomy is to accentuate the funnel shape of the
pelvis, as a result of rotation of the innominate bones about a
horizontal axis, whereby the area of the superior strait becomes
abs<dutely increased and that of the inferior strait relatively
decreased. However this may be, the fact remains that the
distance between the tubera ischii is frequently increased,
which would appear to indicate that pubiotomy is eq>ecially
adapted to the treatment of d3rstocia due to contractions of the
pelvic outlet.

Ejgfect Upon Labor, — Of the fifteen patients operated upon
prior to January i, 1909, six have subsequently become pr^;nant
once and one twice, and I shall give a brief abstract of the
history of each case in order to determine if possible the effect
of the operation upon the course of subsequent labors.

Case II. — Generally contracted funnel pelvis; C. D., 10 cm.;
tubers, 7 cm.; pubiotomy child weighed 2,660 grains. The
first subsequent pregnancy terminated prematurely at the
seventh month, while the second ended spontaneously with the
birth of a child weighing 3,640 grams. Mensuration showed that
the tubera ischii were i cm. wider apart than before operation,
while the child was 980 grams heavier.

Case IV.— Flat rhachitic pelvis; C. D., 81/2 cm. The pubi-
otomy child weighed 3,230 grams. The subsequent labor was
spontaneous, and the child weighed 3,100 grains; no change in
pelvic measurements.

Case V. — Generally contracted rhachitic pelvis; C. D., 9.75
cm. The pubiotomy child weighed 4,050 g^ms, while in the
subsequent labor a child weighing 2,500 grains was delivered
by Cesarean section. Examination showed no change in the
pelvic measurements.

Case VI. — Generally contracted rhachitic pelvis; CD., 9.5
cm. The pubiotomy child weighed 3,230 grams, while the sub-
sequent child delivered by Cesarean section weighed 3,430 grams.
The previous operation led to marked changes in the pelvic
dimensions which will be considered below.

Case VII.— Generally contracted rhachitic pelvis; C. D., 8.75
cm. The pubiotomy child weighed 3,040 grams, while the subse-
quent labor was ended by a repeated pubiotomy (case XV of
this series), although the child weighed only 2,110 grams, the
pelvic measurements showed an increase of 1.25 cm. in the dis-
tance between the tubera ischii.

Case IX. — Flat rhachitic pelvis; C. D., 10.5 cm. Unfortu-
nately the weight of the pubiotomy child was lost, but the sub-
sequent labor ended spontaneously with the birth of a 3,400
gram child, although no change had occurred in the pelvic
measurements.

Case XII. — Funnel pelvis; tubers, 7 cm. The pubiotomy



Digitized by



Google



WILLIAMS: IS PUBIOTOMY A JUSTIFIABLE OPEBATION. 729

and subsequent chUd weighed 3,275 and 3,850 grams, respectively.
It seems that the spontaneQUs delivery of the latter, which was
575 grams heavier than the first child, was probably due to an
increase of i cm. in the distance between the tubera ischii.

From the data just adduced, it would appear that in two in-
stcmces the subsequent pregnancy was terminated by Cesarean
section, in one by a repeated pubiotomy, in four by spontane-
ous labor at term, and in one by spontaneous premature labor.
Naturally it is difficult to determine whether the pubiotomy
played any part in the spontaneous outcome in the four patients
who were delivered naturally at term. In two of them, namely,
cases II and XII, the children bom spontaneously were, respect-
ively, 980 and 575 grams heavier than those delivered by pubi-
otomy. In the first instance the pelvis was of the generally
contracted funnel t3rpe and in the second of the typical funnel
variety, and in each the operation was followed by an increase in
the distance between the tubera ischii, so that it might appear
that the fortunate outcome was due to the enlargement following
pubiotomy. Concerning the other two patients with spontaneous
labor no definite statement can be made; as in case IV the second
child was 130 grams lighter than the first, while in case IX the
weight of the first child was not available for comparison, but
in neither instance did the pelvic measurements show any
enlargement.

Cases VI of former and XXVI of present article give some
idea of the difficulty of formulating a prognosis in this regard.
The patient had a generally contracted rhachitic pelvis with a
diagonal conjugate of 9.5 cm. Her first labor was terminated
by the delivery of a 3,230 gram child after pubiotomy, and the
head presented a deep depression over the left parietal bone
where it had passed over the promontory of the sacrum. When
she reentered the hospital in the latter part of her subsequent
pregnancy no appreciable change could be detected in the pelvic
measurements, although there was definite motility at the
pubic section. In view of the fact that the pubiotomy delivery
was very difficult and the present child seemed to be larger than
the previous one, Cesarean section at the onset of labor seemed to
oflfer the most conservative method of treatment. Accordingly,
no further vaginal examinations were made, and the operation
was performed as soon as possible after the onset of labor. Un-
fortunately, however, she died from an infection resulting from
an error in technique.



Digitized by VjOOQIC



730 WILLIAMS: IS PUBIOTOMY A JUSTIFIABLE OPERATION.

The autopsy findings were most remarkable (case XXVI), and
throw a new light upon the changes occurring in the pelvis dur-
ing pregnancy subsequent to a pubiotomy which had healed by
fibrous union. Upon removing the pelvis from the body and
paring oflf the soft parts as well as possible, it was found that
marked motility existed at the site of the bone section, and that
the fibrous tissue uniting the ends of the bone had undergone
such pronounced softening and stretching that it was possible
to cause it to "buckle" by compressing the sides of the pelvis;
while it permitted the ends of the bones to make a vertical
excursion of 2 . 5 cm. when movement was imparted to the two
sides of the pelvis. This condition was also associated with a
considerable enlargement of the various pelvic measurements.
Thus the conjugata vera was increased to 9 cm., while the dis-
tance between the anterior superior spines and crests of the ilium
could be increased from 20 to 21 cm. and the length of the
transverse diameter of the superior strait from 12 to 13 cm.
accordingly as the cut ends of the bone were forced together or
drawn apart. In the same way the transverse diameter of the
outlet could be increased from 11 to 13 cm., although its antero-
posterior diameter was not eflfected by passive movements.

An %-ray photograph likewise revealed an interesting condi-
tion in that it indicated that the innominate bones had under-
gone a certain amount of rotation about the sacrum so that the
line of section, instead of the s)rmphysis pubis, lay opposite the
promontory of the sacrum. As a result the anterior portion of
the right sacro-iliac joint was opened up, thereby increasing the
length of the right oblique at the expense of the left oblique
diameter of the superior strait.

These observations would appear to indicate that the relaxa-
tion incident to the hyperemia of pregnancy resulted in an
enlargement of the pelvis sufficient to permit the occurrence of
spontaneous labor, had nature not been forestalled by the Cesa-
rean section. This possibility, however, was not considered, as
the degree of motility observed intra viiam was not sufficiently
pronounced to cause one to suspect the existence of the condi-
tions found at autopsy. For further details concerning the ana-
tomical findings in this case, the reader is referred to the de-
tailed history at the end of the article.

In spite of the phenomenal relaxation, it is interesting to note
that the patient walked perfectly well instead of suflFering from
the painful locomotion usually associated with relaxation at



Digitized by VjOOQIC



WILLIAMS: IS PUBIOTOMY A JUSTIMABLE OPERATION. 731

the symphysis pubis or sacro-iliac joints. In such cases the preg-
nant woman is usually bed-ridden or can walk only when the
ends of the bones are held together by a firm pelvic binder; and
consequently the question arises as to whether the difference in
location of the relaxation can explain the absence of symptoms :
This must probably be answered in the aflSirmative, as the or-
thopedists inform me that a pseudoarthrosis following the
fracture of a long bone is unattended by pain, whereas relaxation
occurring in the neighborhood of a joint is usually associated
with distressing symptoms* and it would seem that a similar
explanation might apply in this instance.

That such a degree of relaxation cannot always be expected
is shown by the fact that a second pubiotomy was necessary
in the subsequent labor of case VII, although the child weighed
930 grams less than at the first labor. Moreover, the absence of
enlargement of the pelvis in cases IV, V, and IX, on repeated
mensuration, would point to a similar conclusion. At the same
time the observation just recorded is of great interest, as it
throws new light upon the extent of the enlargement which
^ sometimes follows pubiotomy which has healed by fibrous union
and then been subjected to the influence of the hyperemia
incident to a repeated pregnancy, and likewise indicates that
in such cases a conservative policy may well be followed, as
it may possibly end in the spontaneous extrusion of a normal
sized child.

The repeated pubiotomy recorded in case XV is also of very
considerable interest. In this instance the first operation was
done upon the left and the second upon the right side, with the
idea that if it were repeated in the same location adhesions
might be encountered which would complicate its course. The
patient made an uninterrupted recovery and was able to walk
and work perfectly satisfactorily, notwithstanding the fact that
a movable segment had been interpolated in the anterior pelvic
wall.

On looking over the literature, I find that repeated pubi-
otomies upon the same patient have been reported by Preller,
Neu, Hoehne, Kupferberg, Reifferscheid, and Scheven. All of
these operators, with the exception of Hoehne, did the second
pubiotomy upon the opposite side to the first one, but the latter
repeated it at the site of the previous section in the hope that he
might secure a broader fibrous union, which would increase the
possibility of greater relaxation in a subsequent pregnancy.



Digitized by VjOOQ IC



732 WILLIAMS: IS pxjbiotomy a justifiable operation.

Literature. — Since the appearance of my article in 1908, the
literature upon pubiotomy has been comparatively scanty.
This is due in part to the great interest in the development of
suprasymphyseal Cesarean section in Germany and its tentative
emplo3rment by many authorities in place of pubiotomy.

Probably the most important contribution to the subject
during this period is the article of Schiafli from Herflf's clinic in
Basel. This is based upon the study of 700 cases of pubiotomy
reported in the literature, including eight of his own, and shows
a maternal and a fetal mortality of 9.6 and 4.82 per cent.,
respectively, which after certain justifiable corrections may be
reduced to 9.18 and 4.37 per cent. In view of this he con-
siders, as the dangers to the mother are very considerable
and the fate of the child so uncertain, that the operation
should be employed only in the presence of some pressing
necessity. For this reason he condemns prophylactic pubiotomy
and urges that the procedure be resorted to only after nature
has shown her absolute inability to lead the case to a successful
issue. From his own experience he reports that six of his eight
patients complained of considerable difficulty in walking, and
four suffered from incontinence of urine for a long period follow-
ing the operation.

From my point of view his statements do not seem to place
the subject in a perfectly fair light; more especially as the 664
operations concerning which he was able to obtain more or less
full details were performed by . 142 operators. On analyzing
his figures more closely, I find that sixty-four operators reported
one operation, nineteen two operations, nineteen three opera-
tions, and six four operations each, making a total of 183 opera-
tions by 108 men; whereas the remaining 481 operations were
performed by thirty-eight men. It therefore appears justifia-
ble to assume that in the first group of cases the mortality would
naturally be much higher than in the second, as it represents
the casual results of the occasional operator instead of the ma-
tured experience of the trained man. That such a conclusion is
justified is apparently shown by the discussion before the
German Gynecological Society in 1907, when nineteen operators
reported 319 pubiotomies with six deaths, a maternal mortality
of 1 . 88 per cent.

Since that time the following series of operations have been
reported :

Bumm, 1908, fifty-two pubiotomies with one death.



Digitized by VjOOQ IC



WILLIAMS: IS PXJBIOTOMY A JUSTIFIABLE OPERATION.



733



Hoehne, 1908, twenty pubiotomies with one death.

Schauta, 1908, thirty pubiotomies with no death.

Reifferscheid, 1909, thirty pubiotomies with one death.

Baisch (Doederlein), 1909, forty- two pubiotomies with one
death.

Myself, twenty-five pubiotomies with no death.
Making a total of 199 cases with four deaths, a maternal mortal-
ity of 2 per cent., while the corresponding fetal mortality was
approximately 4 per cent. — figures which I believe represent the
results which may be obtained by competent operators in well-
chosen material.

Burger, in a monograph based upon the study of 5,288 cases of
contracted pelvis occurring in Schauta's clinic during the previous
fifteen years, speaks quite enthusiastically of the operation, and
states that it should play a great part in doing away with
craniotomy upon the living child. During this period the latter
was necessary in seventy-six instances, and had pubiotomy
been employed in the forty-five women who presented no signs
of infection, the incidence of craniotomy upon the living child
would have been reduced from i .7 to 0.8 per cent, and the fetal
mortality from 10.7 to 7. i per cent.

Moreover, Baisch in a recent article states that the application
of radical surgical procedures such as Cesarean section, supra-
symphyseal Cesarean section, and pubiotomy, to the exclusion of
the induction of premature labor and the so-called prophylactic
and compromise operations, leads to a marked increase in the
number of spontaneous labors occurring in large series of con-
tracted pelvis cases and to a considerable diminution in the
maternal mortality, as well as a lesser one on the part of the
fetus, as is clearly shown by the following table:



Spontaneous labors

Maternal mortality

Fetal mortality



Compromise

operations

Baumm. Pehling

and KHstner



50-60 per cent,
over I per cent,
over 10 per cent.



Compromise operations

plus

surgical procedures

Leopold, Schauta*

and Chrobak



70-75 per cent,
about 1/2 per cent,
about 10 per cent.



Radical surgical

procedures

Pixiard, Zweifel,

Doederlein, and

Bumm



80 per cent.

nearly o per cent.

Less tnan zo

per cent.



ScheflFzek, on the other hand, takes an opposite view and reports
1,011 contracted pelvis cases occurring in Baumm's clinic with
54 per cent, of spontaneous labors, including eighteen pubi-



Digitized by VjOOQIC



734 WILLIAMS: IS PUBIOTOMY A JUSTIFIABLE OPERATION.

otomies with two maternal and five fetal deaths. As a result of
his experience, he holds that the dangers to the mother are too
great to justify the continued employment of pubiotomy, as
deep tears, injury to the bladder, and fatal infection are very
liable to occur, while a patient who has once been subjected to
the operation will not willingly submit to another. As his
results with suprasymphyseal Cesarean section were no better,
he believes that the induction of premature labor is the treat-
ment par excellence in this class of cases.

The only French article upon the subject is that of Jeannin
and Cathala which is based upon three successful cases from
Bar's clinic. In noninfected cases they consider that pubiotomy
gives no better results than Cesarean section, while it is much less
dangerous in the presence of infection. At the same time they
hold that its performance under such conditions markedly
changes the results, as is shown by the tabulation of Rossier,
who in 189 cases found that the maternal mortality was 17 and
2 . 9 per cent, respectively, according as the operation was done
upon infected or upon uninfected women.

In this country Vorhees and Lobenstine have each reported
one operation, and are quite prepared to give it a further trial,
although the results in neither of their cases was ideal. On the
other hand, C. B. Reed in an editorial in Surgery, Gynecology and
Obstetrics for 1909, as well as in an article entitled "Pubiotomy,
an operation for the general practitioner," takes an unduly
optimistic view, as he states that it is a simple operation which
can be safely performed by the general practitioner and consti-
tutes the ideal procedure for the treatment of 75 per cent, of the
cases complicated by contracted pelvis.

Indications and Technique. — ^My own experience as well as the
results reported in the literature tend to show that when pubi-
otomy is properly performed under suitable indications upon
uninfected women, the maternal mortality should not exceed
2 per cent., while approximately 95 per cent, of the children should
be saved. As injuries to the bladder did not occur in any of my
patients, and were noted but rarely in the statistics of those who
employed Doederlein's operative technique, I feel that their occur-
rence should probably be attributed to the use of the purely
subcutaneous method, to excessive separation of the ends of the
bone,, or to the employment of undue violence in delivering the
child.

For these reasons such injuries may be considered as prevent-



Digitized by VjOOQIC



WILLIAMS: IS PUBIOTOMY A JUSTIFIABLE OPEBATION. 735

able; while, on the other hand, it would appear that the chief
dangers of the operation are hemorrhage, communicating vaginal
tears, and infection, which cannot always be avoided. In only
one of my cases was the hemorrhage alarming at the time of
operation, and the entire literature records only two instances in
which it led to a fatal issue; namely, those reported by Ros-
thom and Raineri. Ordinarily the hemorrhage is venous in
character; frequently it is very slight in amount and even when
abundant usually yields to pressure. At the same time the
occurrence of the two fatal cases shows that serious hemorrhage
is a danger to be reckoned with, even though it occur but rarely.

Communicating vaginal tears have been noted in all series of
the cases thus far reported, and appear to some extent at least to
be unavoidable accompaniments of the operation, and to occupy
relatively the same position as do extensive perineal tears in the
usual obstetrical operations. Nevertheless, it appears that the
frequency of their occurrence can be minimized by two precau-
tions; namely, extensive manual dilatation of the vaginal outlet
before commencing the operation, but more particularly by
paying attention to the direction in which traction is made dur-
ing forceps delivery. Under such circumstances, as the head
emerges from the vulva, traction should be made almost hori-
zontally, instead of upward and forward as in typical forceps
operations. In several pubiotomies performed in my presence
by my assistants, it has seemed to me that the injury might
have been prevented had such a precaution been taken, and its
importance was likewise recognized by Kannenstiel.

As has already been indicated abnormal puerperia were noted
in 55 per cent, of my cases. Only one patient was seriously
ill, although another who had a gonorrheal infection presented
a temperature of 103.2. Doubtless, a certain proportion of
rises in temperature would have occurred had the labor been
normal, or some simple operative procedure been undertaken.
At the same time their incidence is too great to be attributed
solely to the usual factors, and it must be admitted that there is
something about pubiotomy which predisposes to infection.
Possibly it is due to the unfavorable situation of the wound,
and more particularly to the extensive opening up of connective
tissue spaces. Nevertheless, it would seem that its frequency
might be materially decreased by sharpening our aseptic precau-
tions, as well by changing gloves or having some one who had
not assisted directly at the delivery close the external pubiotomy



Digitized by VjOOQIC



736 WILLIAMS: IS pxjbiotomy a justifiable operation.

wounds, as by so doing certain possibilities for contamination
might be eliminated.

I feel very strongly that a conjugata vera of 7 cm. should
constitute the lowest limit of pelvic deformity in which the
operation is permissible; for if it be exceeded the amount of
gaping necessary to permit delivery of the child is so great as
almost necessarily to lead to injury of the sacro-iliac joints, to
which I am inclined to attribute a large part of the disturbances
in locomotion reported by certain writers. Moreover, in my
experience those patients have done best in whom the extent
of gaping between the cut ends of the bone did not exceed 4 or,
at most, 5 cm.

As already indicated, the pubiotomy in all my cases was fol-
lowed by the immediate delivery of the child by forceps or version
and extraction as the case might be. This was due to the fact
that with a few exceptions I did not resort to the operation until



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 75 of 109)