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WILLIAMS: IS PUBIOTOMY A JUSTIFIABLE OPERATION. 745

less. Has suckled her child which has done excellently. Exami-
nation shows normal genitalia, except for a movable retroflexed
uterus. The pubic bone is not thickened and shows no trace
of section on either its anterior or posterior surface. Definite
motility on passive movement of thigh. Mensuration shows no
appreciable change.

Case XXII. — No. 4107. Wescott. Black, aged sixteen
years, o-para. Pelvis, generally contracted funnel; measure-
ments, 24.5, 26.5, 31, 19, 10.75, and 9 cm. Pubic arch narrow,
tubers 7 i / 2 cm. Child in R. O. P.

Patient had slight pains three days. On admission the mem-
branes were bulging; cervix completely dilated, head freely
movable at superior strait. On account of the history of pro-
longed labor and the fact that the child seems to be large, pubi-
otomy was decided upon.

September 16, 1909. — Typical left-sided pubiotomy, Dr.
Ainley. Very little hemorrhage. Scanzoni application of
forceps; easy extraction; bones separated about 5 cm. Commu-
nicating vaginal tear in left sulcus 6 to 7 cm. long closed with
catgut. Slight perineal laceration, two sutures.

Puerperium febrile, but otherwise satisfactory; temperature
103.2 on the tenth day. Gonococci in uterine lochia. Not
catheterized. Patient out of bed on twentieth day; left hospital
on twenty-ninth day. On discharge the pubiotomy wound was
excellent; on anterior surface of pubic bone a slight furrow, with
a notch at its lower end; posterior surface smooth; marked
motility on passive movement; locomotion excellent and with-
out pain. Uterus retroflexed, movable, well involuted ; perineum
well healed.

The male child was bom somewhat asphyxiated, but was
readily resuscitated. Weighed 3,700 grams at birth and 3,630
on discharge. Mixed feeding. Head measurements, 13. 5,
12, 9.75* 925. and 8 cm.

Case XXIII. — ^No. 41 11. Jackson, black, aged twenty-five
years. One diflScult but spontaneous labor March, 1904.
Pelvis generally contracted, rhachitic; measurements, 23.5,
24, 28, 17, and 10 cm. Pubic arch normal; tubers 13 cm.

The patient was seen by the out-patient department^ twenty
hours after the onset of labor. The membranes ruptured
spontaneously an hour or so later, and as the head did not engage
she was sent to the hospital. On admission the head was in
R. O. P. above the superior strait; severe and frequent pains.

September 18, 1909. — ^Pubiotomy by Dr. Ainley on the left
side five hours after rupture of the membranes. Operation easy.
Head rotated manually to R. O. T., easy forceps delivery during
which the ends of the bone gaped for 3 cm. Perineum or
vagina not torn.

Convalescence most saitsfactory, no discomfort; highest
temperature 100. Patient turned spontaneously on her side
the night of the operation, and in the absence of the nurse on the



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746 WILLIAMS: IS PUBIOTOMY A JUSTIFIABLE OPESATION.

fifth day got out of bed and took a few steps, but suffered no ill
effects from it. Catheterization not necessary. Walked with-
out difficulty at the end of the second week and was discharged on
the twenty-sixth day. At that time there was no trace of the
bone wound on either surface of the pubis, but shallow notches
were felt on its upper and lower margins. Slight motility on
passive movement. Genitalia in excellent condition. The
child weighed 2,860 grams at birth and 3,350 on discharge-
Suckle by mother. Head measurements, 13.25, 11.25, 9.75,
9.5, and 8 cm.

Subsequent note, February 3, 1910. — ^Patient reports that
she walks as well and works as hard as at any time in her life,
and suffers no pain or discomfort. On examination the genitalia
are normal; no thickening at site of section, but a shallow depres-
sion marks its situation on the anterior surface, while nothing
can be felt posteriorly. Distinct motility on passive movements.
Pelvic measurements indicate that the diagonal conjugate had
become 0.75 cm. longer.

Case XXIV. — No. 4185. Thanner. White, aged twenty-
two years, o-para. Simple flat pelvis, 25.75, 27, 31.5, 18, and
9.75 cm. Pubic arch fair, tubera ischii 9 cm. Patient fell
into labor at 8 A. m., November 14, 1909, and entered the hospi-
tal that evening with the cervical canal obliterated and the ex-
ternal OS admitting one finger. Child in L. O. T. overlapping the
symphysis. The cervix became fully dilated after thirty-four
hours of labor when the membranes were ruptured artificially.
No advance after three hours of strong second-stage pains.
Marked posterior parietal presentation with the sagittal suture
2 cm. behind the symphysis.

November 15, 1909. — Typical left-sided pubiotomy by Dr.
Ainley. Forceps extraction without difficulty, the bone wound
gaping 4 cm. Moderate amount of bleeding; slight nick in
fourchette and a tear 4 cm. long extending up the left anterior
vaginal sulcus and communicating with pubiotomy wound.
Repaired with catgut.

Puerperium was satisfactory, highest temperature 10 1.5 on
the third day. Slight edema of the labium majus. Imperfect
healing of vaginal wound. Patient walked in the third week
and was discharged in good condition on the thirtieth day,
when she walked without difficulty, There was a distinct sepa-
ration between the cut ends of the pubic bone of at least i cm.
and definite motility on passive movement. Genitalia in
excellent conditon.

The male child weighed 2,830 grams as birth and 3,530 on dis-
charge. Head measurements, 13, 11, 8.5, 8.25, and 7 cm.

Patient returned for inspection January 24, 19 10. States that
she has done very well. For sometime after returning home she
suffered considerable pain in the pubiotomy wound, which has
gradually disappeared so that she can walk miles without
difficulty. Pelvic examination negative, except for small



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WILLIAMS: IS PUBIOTOMY A JUSTIFIABLE OPERATION. 747

retroverted uterus (lactation atrophy). Mensuration shows
definite enlargement of pelvis. Conjugata diagonalis 10.75
instead of 9.75 cm., and transverse of outlet 10.5 instead of
9cm.; an increase of i and 1.5 cm., respectively.

Case XXV. — ^No. 4253. Wilson. Black, aged twenty-two
years, I-para. Operative labor, the child dying the day after-
ward. Generally contracted rhachitic pelvis, 25, 24.5, 29.5,
16, and 10.25 cm. Pubic arch fair; tubers 8.5 cm. The pelvis
is also somewhat oblique owing to a rachitic kyphoscoliosis
with a hump in the dorsal region and the convexity of the scolio-
sis to the right side.

Child in L. O. A., not engaged. The membranes ruptured
after fifteen hours of first-stage pains when the cervix was 5 cm.
in diameter; seven hours later it was fully dilated. No engage-
ment after two hours of strong second-stage pains with marked
overlapping of the bones and a large caput. At the same time
the temperature rose to 100.2 and the fetal pulse to nearly
160 per minute. In view of these conditions pubiotomy was
decided upon.

January 12, 19 10. — Left-sided pubiotomy by Dr. Ainley.
Easy, high forceps, during which the cut ends of the bone
separated 3 cm. ; vagina not torn, and only a slight nick in the
perineal mucosa. Convalescence most satisfactory, and the
patient scarcely complained of pain at any time. Highest tem-
perature 101.4 on the fifth day. Turned spontaneously on the
third, sat up on the eleventh and was out of bed on the twenty-
first day. Slight edema of the left labium majus which did not
cause discomfort. Catheterization not necessary.

The child was somewhat asphyiciated, but was readily resus-
citated. It weighed 3,025 grams at birth, and its head measured
12 .5, 10. 5, 9, 8 . 25, and 7 cm. Was suckled by mother.

On discharge on the twenty-seventh day, patient walked
perfectly and suffered absolutely no discomfort of any kind.
The genitalia were normal; no callus on either surface of the
bone section, but slight motility on passive movement of the
thigh. Mensuration of the pelvis indicated that permanent
enlargement had not resulted.

Case XXVI. — Prophylactic Placing of Gigli Saw. — ^No. 4125.
Miller. White, o-para, aged twenty-three years. Pelvis gener-
ally contracted, 23, 27, 35, 19, and 1 1 cm. ; tubera ischii 9 cm.

The patient was admitted to the hospital after having been in
labor nearly sixty hours, with the cervix fully dilated and a
frank breech at the spines in L. S. P. Accurate palpation was
impossible owing to the tense abdomen, though its large size
suggested an unusually large child. The pains were poor for
the next few hours and no advance occurred.

Thinking that the dystocia was probably due to the size of the
child. Dr. Ainley upon my advice placed a Gigli saw in position
on the left side before attempting extraction, so that pubiotomy
could be promptly performed if difl5culty were experienced.



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748 WILLIAMS: IS pubiotomy a justifiable operation.

The child, however, was readily extracted and was found to be
small and slightly asphyxiated. Following its delivery an
unruptured amniotic sac protruded from the cervix, and on
rupturing it a second child was found lying in R. S. A., which
was readily extracted by Mauriceau's method. A second degree
perineal tear resulted, which was repaired as well as the provi-
sional pubiotomy wound . The children were females and weighed
2,790 and 2,980 grams, respectively.

During the course of the night the patient complained of poor
vision and five hours after delivery had a typical convulsion,
which was followed by sixteen others. She recovered under the
usual treatment, although for the first few days there was marked
mental disturbance. The temperature rose to 103.4 ^^ ^^^
fifth and fell to normal on the tenth day. The patient and her
children were discharged on the nineteenth day in good condition.

Case XXVII. — Subsequent note to case VI (previous article).
Autopsy findings showing effect of pregnancy upon a pelvis
previously subjected to pubiotomy. No. 41 16. Black, I -para.
Generally contracted rhachitic pelvis, 21, 23, 29, 16.5, and 9.5
cm. Pubic arch wide, tubers 21.5 cm. Marked motility at
site of old pubiotomy wound.

Entered the hospital September 22, 1909, threatened with
premature labor. Under rest in bed and medicinal treatment
the symptoms passed off and she went uninterruptedly to term.
Examination on October 23 showed a moderately large child
in L. O. T. with the head projecting markedly over the pubis,
which could not be impressed into the pelvis by Miiller's method.
In view of the fact that the last labor had been ended by pubi-
otomy, with a child weighing 3,220 grams whose head presented
a deep promontory depression, it was thought that radical inter-
ference would be required at the approaching labor, and that
a primary Cesarean section at its onset would be more conser-
vative than a second pubiotomy. Accordingly, directions were
given that the patient should not be examined vaginally and prep-
arations be made for Cesarean section at the beginning of labor.

November 10, 1909. — Typical conservative Cesarean section
three hours after the first pains. The child was delivered in
good condition, weighed 3,430 grams and presented the following
head measurements : 135, 115, 95, 9. 75, and 8 . 5 cm. It was
fed artificially and weighed 3,645 grams when it left the hospital.
Owing to an unfortunate break in technique, the patient became
infected and died from general peritonitis the sixth day after
operation.

The anatomical diagnosis at autopsy was: Subinvolution of
uterus and retention of placental tissue and fetal membranes;
streptococcus endometritis; acute fibrino-purulent peritonitis;
acute sero-sanguineous pleurisy (bilateral), with compression of
left lung; bronchopneumonia; acute splenic tumor; cloudy
swelling of viscera, fatty degeneration of liver, generally con-
tracted rhachitic pelvis.



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WILLIAMS: IS PUBIOTOMY A JUSTIFIABLE OPERATION. 749

On completing the autopsy, the entire pelvis was excised to-
gether with the lumbar vertebra and the upper ends of the
femora, and its study showed most interesting conditions.
Unusual motility existed at the old pubiotomy wound which,
after removing the muscles as well as possible, was found to be
filled by a thick mass of soft connective tissue. This buckled
markedly when the two sides of the pelvis were pushed together,
and permitted a lateral excursion of i 1/2 cm., and a vertical one
of 2 1/2 cm.

The true conjugate measured 9 cm. instead of 7.5 or 8 cm.
as calculated, although it is possible that the increase may have
been due to the relaxation incident to the removal of the pelvis
from the body. The transverse diameter of the superior strait
could be increased from 12 to 13 cm., the distance between the
anterior and superior spines from 20 to 21 cm., and that between
the tubera ischii from 11 to 13 cm. as the cut ends of the bone
were in contact or drawn apart. The antero-posterior diameter
of the outlet measured 1 1 cm. and was not affected by lateral
movements of the pelvis.

An oc-ray picture showed that the pelvis had become so rotated
on the sacrum that the median fragment of the left pubic bone,
instead of the symphysis pubis, lay in the midline opposite the
center of the sacral promontory, and that the anterior margin of
the right sacro-iliac joint had been somewhat spread apart in
consequence.

The entire pelvis was then hardened in formalin, and later, in
order to study the conditions at the pubiotomy wound, a block
measuring 6 . 75 cm. in length and i . 75 in height was sawed out
from the central portion of the anterior pelvic wall, approximately
equidistant from its upper and lower margins. On its upper
surface no trace of the median fragment of the left pubic bone
was visible, while the distal end of the latter was separated from
the symphyseal end of the right pubic bone by a mass of fibrous
tissue 3 . 5 cm. broad on its anterior and 2 . 5 cm. on its posterior
aspect. The portion of this tissue adjoining the right pubic
bone was composed of cartilage, while its left half presented a
different appearance, being made up partly of cartilage and
partly of fibrous and muscular tissue interpolated between the
former and the distal end of the left pubic bone. The free
surface of the latter was covered by a layer of cartilage i to i . 5
mm. thick under which there was a compact layer of bone
apparently continuous with that on its anterior and posterior
surfaces.

On the lower surface of the block a totally different condition
prevailed. The anterior ends of the bones being 3 and the
posterior ends 2 1/2 cm. apart, while the space between them
was filled out in great part by cartilage, in the center of which
was an oblong piece of bone 8x4 mm., corresponding to the
median fragment of the left pubic bone. This lay nearly i cm.
below the level of the superior margin of the horizontal ramus.



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750 WILLIAMS: IS PUBIOTOMY A JUSTIFIABLE OPERATION.

The space between it and the distal end of the left pubic bone was
in great part filled out by what appeared to be infolded muscular
tissue while the free end of the median fragment was covered by
cartilage.

On sawing the block longitudinally, it was found that the
median fragment of bone occupied only its lower portion, so
that its height was considerably less than one-half that of the
pubis. Whether this was due to its having sunk down or to the
elevation of the distal end of the severed bone cannot be ascer-
tained, but in any event it is apparent that the median fragment
had undergone marked atrophy; as originally it must have been
of the same height as the rest of the pubic bone, and extended
from the median side of the pubic spine to the symphysis pubis.

The following note was also made: **The extent of motility
was a great surprise to us, and was so pronounced that it seems
that spontaneous labor might have occurred had the patient been
left alone, provided of course that the same degree of motility
was present during life, as was noted in the excised pelvis."

CONCLUSIONS.

1. In twenty-five pubiotomies performed at the Johns Hopkins
Hospital there were no maternal and three fetal deaths, only
one of which was attributable to the operation.

2. All patients were delivered by forceps or version immediately
after the pubiotomy. There were no injuries to the bladder,
six perineal and five deep communicating vaginal tears, notwith-
standing the fact that twelve of the patients were primiparse.

3. The relative infrequency of injury to the soft parts is at-
tributed to restricting the operation to suitable grades of pelvic
contraction and to the employment of Doederlein's technique,
but particularly to extensive manual dilatation of the vagina
and perineum prior to operating. The occurrence of such
injuries may be still further decreased by making horizontal
instead of upward traction when delivering the head through
the vulva.

4. The after-treatment is not so onerous as is generally stated,
and most of the patients suffer but little. Immobilization of
the pelvis is not necessary, a 4-inch adhesive strip around the
trochanters being sufficient. The patients usually move
spontaneously in bed between the second and fourth days, get
up between the fifteenth and twentieth, and are discharged on the
thirtieth day with satisfactory locomotion. Healing generally
occurs by fibrous union, so that there is definite motility between
the ends of the bone in at least two-thirds of the cases.

5. The maternal mortality should not exceed 2 per cent.



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WILLIAMS: IS PUBIOTOMY A JUSTIFIABLE OPERATION. 751

provided the operation is performed by competent operators
upon uninfected women who have not been exhausted by pre-
vious attempts at delivery.

6. It is indicated in contracted pelves when the conjugata
vera exceeds 7 cm., and after a test of several hours in the second
stage of labor has shown that the disproportion cannot be over-
come, as well as in certain funnel-shaped pelves.

7. Prophylactic placing of the saw is indicated prior to breech
extractions or versions from transverse presentations when it
appears problematical whether the head can pass through the
pelvis, and the bone sawed through immediately after discovering
that the disproportion cannot be overcome.

8. In multiparse with a history of repeated difficult labors, or
in primiparse presenting excessive disproportion, pubiotomy is
inferior to Cesarean section performed at the end of pregnancy
or at the onset of labor; otherwise it does not enter into competi-
tion with it, as the former is the operation of choice in borderline
pelves after the patient has been subjected to the test of labor,
and at that time it is many times less dangerous than the classical
Cesarean section.

9. In uninfected women it should replace high forceps, pro-
phylactic version, induction of premature labor and craniotomy
upon the living child. In how far it may compete with supra-
symphyseal Cesarean section must be shown by future ob-
servation.

ID. It should not be employed in infected patients or after
failure to deliver by other means. It should be regarded as a
primary operation whose dangers are infection, deep tears, and
hemorrhage.

11. Where the separation between the cut ends of the bone
does not exceed 4 or 5 cm., the patients recover perfectly and
are able to walk and work as well as ever.

12. In view of the fact that the bone section usually heals by
fibrous union, a certain degree of permanent enlargement of
the pelvis may follow, particularly in the transverse diameter
of the outlet and less so in the conjugate vera. Under the in-
fluence of the hyperemia incident to a subsequent pregnancy,
this may occasionally become markedly exaggerated and be
sufficient to permit spontaneous labor. Should, this not occur,
a second pubiotomy may be performed, while Cesarean section
should be limited to those cases in which the pelvic contraction is
marked and the child large.



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752 WILLIAMS: IS pubiotomy a justifiable operation.

LITERATURE.

Baisch. Hebosteotomie und extraperitonealer Kaiserschnitt.
Deutsche med. Wochenschr., 1909, No. 46, 2005-2007.

Bumm. Zur Indikationsstellung bei der Pubiotomie. Zen-
tralbt.f, Gyn,y 1908, 609-613.

Burger. Die Geburtsleitung bei engem Becken. Wien, 1908,

p. 195.

Hoehne. Ueber Wiederholte Hebosteotomie. Beitrdge z,
Geb, u. Gyn,, 1909, xiii, 395-402.

Hoehne. Die Erfolge und Dauererfolge der Hebosteotomie
an der Kieler Universitatsfrauenklinik. Volkmann's SarttnUung
klin. Vortrdge, 1908, Nos. 497-498, p. 20.

Jeannin et Cathalla. Du Prognostic et des Indications de
THebotomie. UOhsteiriquey 1908, i, n. s., 440-508.

Kupferberg. Die Therapie bei Beckenverengungen mittleren
Grades. Zentralhtf, Gyn,, 1909, 1553-1558.

Lobenstine. A Case of Pubiotomy. Amer. Jour. Obst.,
1909, lix, 668-691.

Mayer. Die Beckenerweitemden Operationen. Berlin, 1908,
p. 218.

Neu. Dislokation der ausgesagten Knochenstiicke nach
doppelseitiger Hebosteotomie. Monatschr. /. Geb, u. Gyn,,

1908, xxvii, 381-383-

Obemdorfer. Zur Frage der Heilung der Hebosteotomie-
wunde. Zentralbi, f. Gyn., 1908, 201-207.

Preller. Ein Fall von wiederholter Pubiotomie an derselben
Patientin. Zentralbi. f, Gyn., 1907, 44-47.

Reed, C. B. Pubiotomy. Surgery^ Gynecology and Obstetrics^

1909, viii, 531-532.

Reed, C. B. Pubiotomy: An Operation for the General Prac-
titioner. Amer. Jour. Obst., 1909, Ix, 100-108.

ReiflFerscheid. Ueber die Berechtigung der Hebosteotomie.
Zentralbt.f. Gyn,, 1910, No. 3, 65-72.

Schauta. The Treatment of Labor in Contracted Pelves.
Jour, of Obst. and Gyn. of the British Empire, 1909, xv, 311-322.

Scheffzek. Riickblick und Ausblick in der Therapie des
engen Becken. Archiv.f. Gyn., 1909, Ixxxviii, 536-603.

Scheven. Fall von wiederholter Hebosteotomie. Miinchener
med. Wochenschr., 1909, 2448-2449.

Schlafli. 700 Hebosteotomien. Zeit. Chir. f. Geb. u. Gyn.,
1909, Ixiv, 85-135.

Vorhees. A Case of Pubiotomy. Amer. Jour. Obst., 1909,
lix, 684-688.

Welponer and Cristofoletti. Zwei Beckenpraparte nach
Hebosteotomie. Gyn. Rundschau, 1909, iii, 11-18.



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NORRIS AND BARNARD: DYSMENORRHEA IN NULLIPAROUS WOMEN. 753



DYSMENORRHEA IN NULLIPAROUS WOMEN WITH-
OUT GROSS LOCAL PATHOLOGICAL LESIONS.*

REPORT OF SEVENTY-THREE CASES.

BY

C. C. NORRIS,

Instructor in Gynecology, University of Pennsylvania; Attending Physician, Maternity
Hospital; Assistant Obstetrician and Gynecologist to the Philadelphia Hospital

AND

E. P. BARNARD,

Attending Physician, Maternity Hospital.
Philadelphia.

This form of dysmenorrhea is frequent and is, as a rule, most
unsatisfactory to treat. The cause for this is, that all cases are
usually subjected to some form of dilatation operation without
sufficient regard for the etiology of each individual case. The
causes for dysmenorrhea are so numerous and complex that a
careful study of each case is absolutely essential before treatment
is instigated.

ETIOLOGY OF DYSMENORRHEA.

The causes may be divided into three groups : general, failure
of development, and stenosis of the cervix.

General, — a. Anemias; b. gout and rheumatism; c. hysteria
and neuralgia; d. eye strain; e. sedentary life; f. secondary to
chronic diseases as phthisis, nephritis, chronic heart or liver
diseases, syphilis, etc.; g. chronic appendicitis; h. higher types
of civilization (d)rsmenorrhea is unknown among savage races);
i. bad hygiene and malnutrition.

Of these tuberculosis is perhaps the most frequent. Cotte
has recently studied this condition. He believes that nearly
all phthisical women suflFer from dysmenorrhea and has found
that the pulmonary lesion is usually aggravated at the menstrual
period. Of seventy women treated for tuberculosis, all of whom
had dysmenorrhea, forty were entirely cured of their dysmenor-
rhea by tuberculin. Cotte believes the dysmenorrhea is due
to a tuberculosis toxemia. Chronic appendicitis is also a fre-
quent cause for dysmenorrhea. According to Peirsol, this may

♦ Read before the Philadelphia Obstetrical Society, April 7, 1910.
3



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754 NORRIS AND BARNARD: DYSMENORRHEA IN NULLIPAROUS WOMEN.

be accounted for by the close anatomical relationship between
the meso-appendix and the broad ligament. Von Rosthom,
however, denies the existence of the appendicnlar-ovarian
ligament. The clinical fact that chronic inflammation of the
appendix or adhesions of this organ usually produce dj^menor-
rhea is well known.



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 77 of 109)