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exerted traction once and turned the case over to the House Surgeon for delivery. He made very moderate traction about four times while I held my hand upon the thigh in order that I might make counterpressure if necessary. With the last traction, I felt a grating vibration through the thigh and stopped the operator immediately. No sound was audible and the sensation was very similar to that of a slipping forceps blade upon a head tightly wedged in the pelvis. I removed the blades and found a separation of the symphysis almost two fingers breadth in width. The pelvis was supported upon either side, Elliot forceps applied and the head slowly delivered. As the perineum was very tense an episiotomy was performed. The head was brought to the perineum and delivered manually. As bleeding was profuse, the placenta was
extracted and the uterus packed with iodoform gauze. Upon examination the vagina was found to be lacerated laterally, the meatus torn and the urethra apparently split longitudinally. A cavity, the size of a lemon, could be felt through the torn meatus with the pubic bones protruding at either side of this cavity. The lacerations of the vagina were repaired but with difficulty and a self retaining catheter was then inserted into the bladder. Bleeding had been very profuse, necessitating stimulation and saline injections. A blood examination upon the third day showed two million red cells and 28 per cent hemaglobin. Fortunately, this patient was not infected, notwithstanding the great amount of manipu
lation and the loss of blood, and the repaired lacerations healed by primary union. She was discharged upon her forty-eighth day postpartum, had no pain and locomotion was not affected. She did not wear a belt and in fact, we had difficulty in keeping the pelvic binder in place after the first few days, frequently finding that the patient had removed it entirely. For six months, she had an incontinence of urine upon exertion while standing and still has this at intervals.
CASE III.-Confined at the Lying-In Hospital on February 25, 1914, was a para ii, thirty-one years of age, who had been delivered seven years previously with forceps. Upon examination, the cervix was rigid, badly scarred and two fingers dilated; the membranes ruptured; the head in the L. O. A. position and above the brim. The pelvis was generally contracted, the true conjugate being 9+ cm. and the outlet classed as medium. There were also two fibroids in the uterus, one the size of an orange. After twenty-four hours of fair pains, the cervix was only three fingers dilated and this was completed manually with little difficulty, because it was necessary to tear through the old scar tissue. High forceps (Lobenstine's) were applied and the head brought to the rim of the rigid cervix, which alone obstructed descent. With each traction upon the forceps, an effort was made to strip the cervix over the head and when these efforts finally succeeded, the head was brought to the perineum with three light tractions where the blades were removed and the head delivered manually. The child weighed three kilos. The cervix was repaired and the patient returned to bed.
Upon the first day postpartum, the patient complained that she could not move from side to side because of the pain in both groins and upon examination a depression was found over the symphysis with increased mobility of the joint. Her temperature ranged from 99° to 102° until the nineteenth day, when it became normal. Patient was out of bed upon the twenty-fifth day postpartum and upon discharge complained of pain over the symphysis and locomotion was bad, the patient waddling markedly.
CASE IV. Was a large primipara; thirty-three years of age who had been delivered of a nine pounds still-born child with high forceps after manual dilatation of the cervix, on May 21, 1912. The operation was said to have been a very easy one.
I saw the patient six days later and at this time her temperature was 103° F.; pulse 120, and there was a very profuse vaginal discharge which was purulent in character. She complained of great pain over both hips and the sacroiliac joints (none over the symphysis except upon pressure). This pain was continuous but intensified upon moving, especially when lifting herself upon the douche pan, an act which she had been compelled to perform for six days. Abdominal palpation showed a tumor resembling very much a distended bladder, except that it was firmer. The uterus was not felt. Upon vaginal examination, the uterus
was located posteriorly and the cervix was found badly lacerated also a deep tear in the left vaginal sulcus extending from the perineum to the cervix. Passing my finger through a transverse slit above the meatus, I found the entire anterior wall separated and acting as a flap to the vagina. Further up, was found an oblong cavity, anterior to the uterus, which proved to be the mass I had palpated externally. The dimensions of this cavity were about fifteen cm. across, eleven cm. high and three cm. in depth. At either end of this cavity, the rough ends of the pubic bone could be felt and the left apparently stripped of its periosteum for a distance of three cm. The bones were actually so far apart that I
Fig. 4. Case 4. Original diastasis 15 cm. Marked separation of ilio-sacral joint. could not touch both at the same time, although extending my fingers to the utmost, examining just as you would a widely dilated cervix. You can get an idea of the separation from the skiagraph shown by noticing the condition of the sacroiliac joint.
A tight pelvic binder was applied and immediate relief of the excruciating pain in the hips and sacrum followed. The patient was transferred to the Lying-In Hospital and her temperature subsided and became normal seven days later. The profuse discharge caused a great deal of annoyance because of the frequent dressings and the irritation to the buttocks and continued in large amounts for forty-five days. The patient
was allowed up in bed upon her fortieth day and was discharged two weeks later. Bladder control was perfect. The patient wore a leather pelvic belt and experienced no pain and walked without waddling. Several months later, a prolapse of the vaginal wall occurred.
Until I saw this one case of ruptured symphysis occur, I had always imagined that they were probably due to faulty manipulation and that we would have more reports of such cases if the majority of practitioners did not hold a similar view and feel that they would be ridiculed for mismanagement if they should make their cases public, but since observing this case, I am convinced that there are other factors present over which the operator has no control and of which he is unaware. I believe that union never occurs after a rupture.
Some of the theories as to the cause of ruptured symphysis as advanced by most authors are pathological softening of the cartilage and ligaments, frequent child-bearing, caries, rachitis, osteomalacia, chronic rheumatism. infantilism, neoplasms of the joint, contracted pelvis, especially the generally contracted and the funnel shaped pelvis. Mayer classed these as antepartum forms and as subpartum such cases as disproportion between the birth canal and the head and shoulders, too great expulsive force or power acting in the wrong direction and muscular traction upon the pelvis. A slight motility can be detected in practically all pelves by employing Budin's method of examination-i.e., with bimanual pressure, having the patient stand first upon one foot and then the other. The point to be feared in these cases is not really the separation of the pubic bones but the frightful lacerations of the soft parts or even of the viscera that may take place; and not in the fear of loss of locomotion but in the invalidism that may follow the prolapse of the uterus, bladder and vagina.
The mortality rate has been reported as high as thirty-five per cent but I believe this to be excessive, naturally in view of my own personal experience where the mortality was nil. The cases in which there is marked relaxation of the pelvic ligaments, even to the extent of causing great pain and loss of locomotion and which usually occur between the sixth and eighth month are the ones that you would expect to have this accident, usually go through their labor without trouble or mishap. Although this accident is usually unavoidable, we can make our patients more comfortable and frequently prevent sepsis by an early diagnosis. There is hardly any excuse for failing to diagnose this condition until the fourth or twelfth day and yet this seems to be the average time at which it is discovered.
REPORT ON A CASE OF CONGENITAL ATRESIA OF THE
J. R. LOSEE, M. D.,
ANOMALIES of the gastrointestinal tract in the new-born are sufficiently infrequent to warrant a detailed report in almost every case. During the past four years, we have observed in the service of the Hospital two cases of esophago-tracheal fistula, one case of absence of the cecum and ileocecal junction, and one case of atresia of the duodenum.
Although confirmatory evidence is obtained only at autopsy, it has been our experience to observe these cases about once in every 5000 deliveries. Additional effort is always made to obtain permission for postmortem examination when a congenital condition is believed to be present. I wish to refer, particularly, to the case of atresia of the duodenum which has occurred once in 22,800 cases.
These anomalies may be classified anatomically into two main
1. Those in which the first portion of the duodenum terminates in a large dilated pouch, and has no connection whatever with the remainder of the intestine.
2. Those in which the proximal and distal portions of the intestine are united by a fibrous band.
The latter variety are more numerous than the former, and the occlusion is almost always observed in the vicinity of the papilla. Complete occlusion of the lumen of this portion of the intestine is more common than stenosis, for of 57 cases collected by Cordes in 1901, there were nine cases of stenosis, and forty-eight of atresia. In 1905 Little and Helmholz collected 26 cases in which the obstruction was above the papilla and added another to the series. Since then Clogg, Shaw and Roe, McDonald, Hauser, and Weber have each reported a case.
The case here reported was that of an infant which had a normal delivery, and did well up to the second day, at which time it began to vomit everything taken into its stomach. The vomitus at first was mucus, milk and water, later it was a dark fluid which contained considerable blood. There was no jaundice. Meconium was passed during the first two days, but the abdomen became distended, vomiting continued, and the little patient died at the end of the third day. At autopsy the body of a fully developed female infant at term was observed, without any external evidences of an anomaly. Section of the abdomen showed a very large, distended stomach, which was lying directly be