of Rhodes. Spurious works Andronicus.

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

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a definite indication had arisen on the part of the mother or child,
which seemed to call for the immediate termination of labor.
Moreover, I consider that the great value of the operation lies in
the fact that in "border-line" cases it enables one to observe
an expectant attitude during the second stage and thus give
nature every facility to overcome the disproportion, while at
the same time it leaves the patient in such a condition that the
operation may safely be undertaken if necessary. For this
reason I am opposed to the so-called prophylactic operation and
consequently have not waited for the spontaneous extrusion of
the child after section of the bone.

Moreover, should conditions arise in a patient with a ** border-
line" pelvis which seem to indicate the necessity for prompt de-
livery while the cervix is still only partially dilated, I feel that
the most satisfactory results will be obtained by completing
the dilatation manually, placing the saw in position and then
applying forceps tentatively, so that, in case the head fails to
follow the first few gentle tractions, the bone may be sawed
through and the resistance be overcome.

This prophylactic placing of the saw seems to me to have a
comparatively wide field of application. It was done in case
XXI preparatory to version from a transverse presentation, and
the pubis was sawed through when it was found that extraction
could not be effected without too great a risk to the child; while
in case XXVI the saw was laid prophylactically but not used
as the extraction of the child presenting by the breech was readily



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WILLIAMS: IS PUBIOTOMY A JUSTIFIABLE OPERATION. 737

ejflfected. It would also seem a wise precaution in certain breech
presentations when the size of the pelvis or of the child, or the
history of past labors makes it probable that diflSiculty may be
experienced in extraction. In such cases the prophylactic
placing of the saw makes it possible for one to resort promptly
to pubiotomy if necessary; whereas, if the saw is not laid until
the indication for its use becomes imperative, the probabilities
are that so much time will have elapsed between recognizing
the necessity for interference and severing the bone that whatever
chances the child had of living would have been sacrificed.

In my previous communication I stated my views concerning
the relation of pubiotomy to the induction of premature labor
and the performance of Cesarean section. At that time I held
that it should practically supplant the former in "border-line"
cases, whereas it should not be considered as entering into com-
petition with the classical indications for the latter. I still
hold the same views, and consider that it is inferior to Cesa-
rean section upon uninfected women at the end of pregnancy,
but is far superior to it when done after a prolonged test of the
powers of nature in the second stage.

For this reason, when the conjugata vera measures 7 cm. or
less or when the past history of the patient is such as to make
it fairly probable that labor must be ended artificially in one
way or another, I consider that the best and most conservative
results will be obtained if primary Cesarean section is done at the
end of pregnancy. Such a course was followed in the sub-
sequent pregnancies of cases V and VI, and would have been in
the subsequent labor of case VII had the patient been seen suffi-
ciently early; but as she was not admitted until the time of
election had already passed, she was allowed to go into the second
stage, and a second pubiotomy was performed after nature had
shown herself inefficient to overcome the disproportion.

During the past few years the development of suprasym-
physeal Cesarean section in Germany by Franck, Sellheim,
Doederlein, and Latzo have led to a considerable restriction in
the performance of pubiotomy in its favor. Personally I am
not prepared to express a decided opinion as to its merits, but
theoretically I am inclined to believe that the extensive con-
nective-tissue wounds necessarily associated with it will not lead
to a marked improvement over the results following the classical
operation. That such a belief is probably correct is shown by the
recent statistics of Holzapfel, who reports a maternal mortality



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738 WILLIAMS: IS pubiotomy a justifiable operation.

of 8 per cent, in 162 suprasymphyseal Cesarean sections collected
from the literature. This figure includes five deaths in fifteen
eclamptic patients, but even after deducting them there were
eight deaths in the 147 remaining operations, a net mortality of
5^ per cent., which is much greater than that of pubiotomy and
approximately that of the classical Cesarean section. The future,
however, can only decide whether the operation will have an
extended field of employment or not, but I am prepared to let
others make the experiment.

I might add that I do not consider pubiotomy an ideal surgical
procedure, but for the present I feel that it is a valuable adjunct
in the treatment of "border-line" cases of pelvic contraction, in
that it enables one to subject the patient to a rigorous test of
labor and then resort to operation without materially increasing
her danger, and with every prospect of saving more than 90 per
cent, of the children.

I feel very strongly that pubiotomy should always be con-
sidered a primary operation, and should not be performed after
other unsuccessful attempts at delivery have been made, although
an exception in this respect may be made in those cases in which
the saw is placed prophylactically. Moreover, I believe that
it should not be employed in definitely infected women, as under
such circumstances the maternal mortality according to Rossier
rises to such an extent as to make it unjustifiable — 2.9 to 17
per cent. With such results it would seem unwise to subject
the patient to so great a risk for the sake of saving a child whose
chances are probably already compromised, and under such con-
ditions I consider tentative forceps followed by craniotomy, if
necessary, the preferable procedure.

case histories.

(Continuing Cases I to XIII in Amer. Jour. Obst.,
1908, Iviii, No. 2.)

Case XIV. — ^No. 3484. Freyer, twenty-seven years old,
Ill-para, and two miscarriages. All labors very slow, lasting
two or three days and ended instrumentally. Generally con-
tracted rhachitic pelvis, 24, 25.75, 30.5, 18 and 10.25 c™-
Pubic arch fair, tubers 9 cm. Large child in L. S. A. frank
breech. The first stage of labor lasted forty-seven hours, and
in spite of good second-stage pains for two hours there was only
slight engagement. At that time the uterus had become
tetanically contracted, pulse 120, and temperature 99.6. In
view of these conditions, the history of the previous labors



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WILLIAMS: IS PUBIOTOMY A JUSTIFIABLE OPERATION. 739

and the fact that the child seemed to be large, pubiotomy was
decided upon.

June 6, 1908. — ^Left-sided pubiotomy. Considerable hemor-
rhage immediately after severing the bone, readily controlled
by pressure. The bone wound gaped spontaneously for i cm.
which increased to 4 cm. during extraction. As the tetanic
condition of the uterus made it impossible to bring down a foot,
typical frank breech extraction was readily effected without
perineal or vaginal tear.

The convalescence was satisfactory and the patient suffered
but little pain. She was placed on her side on the second day
and the following day turned without assistance and was out
of bed on the twentieth day. The highest temperature was
102 . 5 on the ninth day, which was apparently connected with
some infiltration of the left labium majus.

Discharged on the thirtieth day in excellent condition. Defi-
nite motility at the bone incision; some thickening on the an-
terior surface, posterior surface perfectly smooth. Sacro-iliac
joints negative, internal genitalia normal. Walks fairly well, but
with a slight limp which she attributes to pain in the left hip.

The female child was bom in excellent condition and weighed
3»3io grams at birth and 3,830 on discharge. Was suckled by
mother. Head measurements at birth 12.5, 11.25, 9.5, 9, and
8 cm.

Further history not obtained, as a letter written January,
1910, was returned unanswered.

Case XV. — ^No. 3631. Roles, aged nineteen years. Same
patient as case VII, upon whom pubiotomy was performed
February 3, 1907. Generally contracted rhachitic assimilation
pelvis, 23, 23, 27, 14.25, 8.5, and 7 cm. Pubic arch wide,
tubers 11.75 cm. Was seen by the out-patient service, when
the child which lay transversely was converted into R. O. T.
by external maneuvres.

She was later sent into the hospital. After two and one-half
hours of strong second -stage pains the head was still above the
superior strait in the posterior parietal position and could not be
impressed even under anesthesia.

September 18, 1908. — Right-sided pubiotomy. Dr. Storrs.
Considerable bleeding, readily controlled by pressure. The child
was turned and extracted without diflBculty, the ends of the bone
separating 5 cm. As the former pubiotomy had been on the
left side. Dr. Storrs thought it simpler to do the second on the
opposite side, so as to avoid any complications due to possible
adhesions.

Typical recovery, the highest temperature being 100.4 the
day of delivery. The patient turned spontaneously in bed on
the fourth day, and had no complications except for slight
separation of the skin wound. Catheterization not necessary.
Was up on the eleventh, walked on the twenty-second, and was
discharged on the thirtieth day. At that time no callus could



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740 WILLIAMS: IS PUBIOTOMY A JUSTIFIABLE OPERATION.

be felt on the posterior surface of the bone, but instead a slight
depression indicated the line of section. Sacro-iliac joints
normal. Definite motility of both the old and new pubiotomy
wounds. Patient walked perfectly and complained of no pain.
When seen some months later she reported that she had gone to
a dance one month after leaving the hospital.

The child was bom in excellent conditi6n, but presented a
distinct depression on the right parietal bone. Head measure-
ments 12.5, 10.5, 9.5, 8.5, and 7 cm. Suckled by mother.
Weighed 2,1 10 grams at birth and 2,390 grams at discharge.

Case XVI.— No. 3780. Novitski. Aged thirty-two, VII-
para, two children still-bom, the others bom alive spontaneously
after prolonged labors. The last labor was ended by version on
account of prolapsed extremities. Simple flat pelvis, 27.5,
29.5, 33.5, 18, and 10.5 cm. Pubic arch wide, tubers 12 cm.
Child presented in R. O. P. First stage of labor rapid, cervix
becoming completely dilated in four hours. As engagement
did not occur after four hours of rather inefifectual second-stage
pains, pubiotomy was determined upon.

January 6, 1909. — Left-sided pubiotomy. The child was
readily delivered after version and extraction. Placenta fol-
lowed immediately after its delivery. Unfortunately no note
was made as to the amount of separation of the pubic bones.
No vaginal or perineal tear.

Convalescence t)rpical, highest temperature 100.5 on the
fourth day; catheterization not necessary. Did not complain
of pain and stood up on the fourteenth day and walked perfectly
well at the end of three weeks. On discharge there was a certain
amount of induration on the anterior surface of the pubic bone,
but not on the posterior, where the site of incision was indicated
by a slight depression, whose ends were indicated by shallow
notches on the upper and lower margin of the bone. Definite
motility on passive movements; sacro-iliac joints normal;
patient walks readily and without pain. Internal genitalia
negative. Pelvic mensuration showed that the diagonal con-
jugate had increased i cm. and the transverse of outlet i 1/2 cm.

The child was born in good condition, weighed 2,990 grams at
birth and 3,690 on discharge and presented the following head
measurements: 13, 11.75, 9.5, 8.75, and 8.25 cm. Suckled
by mother.

January 27, 1901. — The patient returned for examination,
and stated that she was able to walk as well and work as hard
as at any time of her life. The conditions about the pubiotomy
wound have markedly changed. On the anterior surface of the
pubic bone there is a slight depression at the site of incision,
while posteriorly a rounded ridge i cm. wide and 0.5 cm.
high extends vertically over it. There is no motility on passive
movement of thigh, but slight movement is detected in walking.
Genitalia negative. The baby did well after leaving the hospital,
but died from typhoid fever when ten months old.



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WILLIAMS: IS PUBIOTOMY A JUSTIFIABLE OPERATION. 741

Case XVII. — ^No. 3797. Adler. A stout, white o-para,
aged thirty-two. Funnel pelvis, 23.75, 28, 32.5, and 20 cm.
Diagonal conjugate could not be measured; pubic arch narrow;
distance between tubera ischii 7 cm. Posterior sagittal 8 cm. ;
antero-posterior diameter of outlet 11 .5 cm. Child in R. O. T.
Patient was seen by Dr. Bergland in consultation after she had
been twenty-eight hours in labor. Examination under chloro-
form showed head below ischial spines; cervix not completely
dilated; membranes ruptured.

Admitted to the hospital with a pulse of 120; after having been
for thirty-six hours in the first stage of labor. On this account
it was determined to complete the dilatation of the cervix by
Harris' method and attempt delivery by forceps. During the
dilatation of the outlet a slight tear occurred in the left vaginal
sulcus, after which the cervix was dilated and the head rotated
manually to R. O. A. without difl5culty. Forceps were applied,
but, as there was no advance in spite of strong traction, Dr.
Storrs did a left-sided pubiotomy on January 22, 1909.

There was very little bleeding and delivery was readily effected
during which the ends of the bone gaped 4 cm. Immediate
expression of placenta, and, as the uterus did not react promptly
to a hypodermic injection of ergotol, an intrauterine pack was
placed. There was a first degree vaginal tear, as well as one in
the left vaginal sulcus extending 4 cm. above the hymen and
communicating with the pubiotomy wound. This was packed
but not sutured, and the patient put back to bed considerably
shocked.

She made a satisfactory recovery, the highest temperature
reaching 102 on the eighth day, due to a slight phlebitis in the
left groin, which, however, did not give rise to edema. The upper
pubiotomy incision broke down on the sixteenth day forming
a sinus which closed in some days. The general recovery was
good, and the patient conplained of but little discomfort.

On discharge locomotion has excellent, and the pubiotomy
wounds were in excellent condition; posterior surface of pubic
bone smooth, a slight ridge on anterior surface; slight motility;
sacro-iliac joints normal. It was also found that the distance
between the tubera ischii had increased 1.25 cm., measuring
8.25 instead of 7 cm., while the antero-posterior of outlet and
the diagonal conjugate were unchanged. The child was bom
in good condition, but presented a deep depression over its
forehead, where it had beenjdragged past the tip of the sacrum.
It presented the following head measurements: 13.75, ii-75»
9 25, 8.50, and 8 cm., and weighed 3,430 at birth and 3,940 on
discharge.

Subsequent note, February i, 1910. — ^Patient is delighted with
the result of the operation, and says she can do whatever she
did before. Weighs 168 pounds and has suckled baby for one
year. Definite shallow depression i cm. in width on anterior, but



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742 WILLIAMS: IS pubiotomy a jtstifiable operation.

no trace of section on posterior surface of bone. Definite motility
on passive movements. Genitalia normal.

Case XVIII. — ^No. 3844. Fingold, white, Ill-para, aged
twenty-five. Two children bom dead at term after operative
delivery, one being followed by a complete perineal tear; one
spontaneous premature labor at seven and one-half months.
Generally contracted rhachitic pelvis, 23.75, 25, 28.75, ^7; ^^^
g.ys cm. Pubic arch narrow, distance between tubera ischii

8 cm. Anterior and posterior sagittal diameters 5 and 7 . 75 cm.
and antero-posterior of outlet 12 cm. Membranes ruptured
spontaneously three days before the onset of labor. After ten
and one-half hours of pain the child was found in L. O. T.,
head not engaged but bulging markedly over the symphysis
pubis. External os 5 cm. in diameter with soft margins. On
account of the past history and the unfavorable position of the
child it was thought best to interfere, although no radical indica-
tions were present.

February 24, 1909. — Easy manual dilatation of cervix;
typical left-sided pubiotomy. Very slight bleeding; delivered
by forceps without difficulty, the bone wound separating 3 cm.
The vagina was not torn, but there was a slight nick in the scar
of the previous perineal operation.

The puerperium was most satisfactory. The highest tempera-
ture was 100.5 except for a rise to loi on the day of delivery.
There was slight edema of the left labium majus and the catheter
was employed once. The upper pubiotomy incision broke down
to some extent, but the patient was out of bed on the sixteenth
day and discharged on the thirty-second day. At that time she
walked well and without pain. There was no callus on either
surface of the pubic bone, although a slight depression on the
anterior surface indicated the site of section, at either end of which
there was a definite notch. Definite motility on passive move-
ment of thigh.

The child was bom asphyxiated and was resuscitated with
difficulty. It weighed 2,080 grams and presented the following
head measurements: 12.25, 10.25, 8.25, 7.25, and 6.25 cm.
It died on the twenty-seventh day from a streptococcus infection.

This operation was probably unnecessary, as the size of the
child had been miscalculated; it being probable that spontaneous
labor would have occurred had nothing been done. We were
led to interfere more particularly by the fact that the woman was
intensely desirous of having a living child. When reexamined
eight months later she was in excellent condition.

Case XIX.— No. 3897. Flynn. White, aged thirty-two
years, III -para. One craniotomy and two operative labors with
dead children. Flat pelvis, 26, 29, 34, 18, and 10.75 cm. Tubers

9 cm. Child in R. O. T. At the end of three hours of strong
second-stage pains the head was still movable at the superior
strait, bulging over the symphysis pubis, and showed no ten-
dency to enter the pelvis.



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WILLIAMS: IS PUBIOTOMY A JUSTIFIABLE OPERATION. 743

April i8, 1909. — Left-sided pubiotomy by Dr. Storrs. The
operation was typical and easy; very slight hemorrhage. Child
readily delivered by high forceps, during which the bone wound
gaped 4 cm. No vaginal or perineal tear. Convalescence most
satisfactory, highest temperature loo on the fifth day. Prac-
tically no pain. Catheterization not necessary. Out of bed
on the twentieth and discharged on the thirty-fourth day. At
that time the pubiotomy wounds were well healed; no callus on
either surface; marked motility on passive movement; sacro-
iliac joints normal. Patient walks with some difficulty, but
locomotion is far better than before labor when there was
marked relaxation of the left sacro-iliac joint, which was only*
relieved by strapping the pelvis.

The child was bom in excellent condition; head measure-
ments, 13, 11.75, 9-5» ?-5» and 8 cm. It weighed 4,870 grams
at birth and 5,350 on discharge, and was suckled by its mother.

Patient returned for examination, January 27, 1910, weighing
168 pounds. She complained of some pain and discomfort in
the left hip on exertion, but stated that she can do ordinary
housework without dilBiculty; can walk about a half a mile with
ease, but begins to limp when she goes further. She does not
complain of this as she states that it is far less troublesome than
before delivery. On the anterior surface of the pubic bone
there is a slight depression corresponding to the incision and a
still shallower one on the posterior surface. Medism to the latter
is a vertical ridge which apparently corresponds to the symphy-
seal cartilage; sacro-iliac joints normal; marked motility on
passive movements of thigh; genitalia normal, except for mod-
erate relaxation of outlet and a bilateral cervical tear. Pelvic
mensuration shows that the Baudelocque has increased 2 cm.
and the diagonal conjugate i 1/4 cm., while the outlet measure-
ments are unchanged.

Case XX. — ^No. 3905. Glascoe. Black, aged twenty-five
years, one previous spontaneous labor. Pelvis generally con-
tracted, rhachitic. Measurements, 21.75, 22.5, 28, 17, and
10 cm. Pubic arch normal. Child in R. O. T. Membranes
ruptured spontaneously eight hours after onset of labor, when
the cervix was 3 cm. in diameter and the head movable above
the pelvic brim, overlapping the pubis. Following this a caput
developed, and six and one-half hours after the rupture of the
membranes the cervix was almost completely dilated; the
head still floating, and as the fetal heart sounds had become
irregular, pubiotomy was decided upon.

June 18, 1909. — ^Left-sided operation. Dr. Storrs, preceded by
preliminary stretching of the outlet and completion of the
cervical dilatation. After severing the bone, which separated
4 cm., the head could be forced into the pelvis, whence it was
extracted by forceps in good condition. No perineal or vaginal
tear.

The convalescence was quite satisfactory, although there was



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744 WILLIAMS: IS pubiotomy a justifiable operation.

considerable abdominal distention for the first few days. The
temperature reached 102 . 2 on the second day, but at no time
was the patient seriously sick, nor did she suflfer materially.
Some slight swelling of the labium ma jus. Not catheterized.
Out of bed on the twentieth and discharged on the thirty-first
day in good condition. Locomotion good, no complaint, no
note as to motility; genitalia normal.

The female child was born in good condition and weighed 3,750
grams at birth and 4,550 at discharge. Head measurements,
14, 12, 9.25, 9.50, and 7.75 cm. Suckled by mother.

Patient wrote from Philadelphia, January 2, 19 10, that she
• walks as well as before the operation and could make no complaint
of any kind.

Case XXI. — ^No. 4092. Solen. White, Il-para. Both children
bom dead after operative delivery elsewhere. Pelvis generally
contracted, rhachitic. Measurements, 24, 25.25, 28.75, i7» and
10. 5 cm. Patient admitted at 8 p. m., after having been in labor
three hours. Child in L. Ac. dorso-posterior position, attempts
at external version unavailing. Vaginal examination one hour
later showed the cervix fully dilated and the membranes un-
ruptured. In view of the history of two dead-bom children and
the pelvic measurements, it was decided to place a Gigli saw
prophylactically, rupture the membranes and turn and extract
the child, and to resort to pubiotomy in case of diflficulty.

At 10.15 P- M., September 7, 1909, Dr. Slemons placed the
saw in position as for a left-sided pubiotomy, and after rupturing
the membranes, readily performed version and extracted the
child up to the head without diflficulty. As that did not follow
after one minute's vigorous traction, aided by pressure from
above, the pubis was sawed through. The ends of the bone
gaped 3 to 4 cm. and readily permitted the extraction of a live
child. A slight tear extended up the left anterior vaginal sulcus
and communicated with the bone wound. Repaired with catgut.
Perineum not torn.

Puerperium satisfactory. Very slight edema of left labium.
Very little complaint; highest temperature 100.4 on the fifth
day. Not catheterized. Up on the nineteenth day and dis-
charged on the twenty-fifth day, feeling perfectly well, walking
without difficulty and complaining of no pain. Wounds well
healed; some callous tissue on anterior surface of pubic bone.
Moderate motility.

The male child was slightly asphyxiated, but readily resusci-
tated and weighed 4,000 grams at birth and 4,240 on discharge.
Head measurements, 12.5, 115,9.5,95, and 7 . 5 cm. Suckled
by mother.

Subsequent note, February 5, 19 10. — ^Patient states that she
has done very satisfactorily since the operation, walks as well
as ever, and can attend to her ordinary household duties without
difficulty. When, however, she seriously overexerts herself she
suffers some pain in the left hip, which is gradually growing



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 76 of 109)