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in a uterus which had been subjected to an interposition operation and a Cesarean section, it was thought advisable to empty the uterus and at a subsequent time sterilize the patient. This was done in two stages. On opening the abdomen the bladder was found entirely over the uterus. The corneal ends of the tubes were also covered and could not be reached for purposes of excision. There were numerous adhesions present between the intestines and the posterior aspect of the uterus resulting probably from the scar of the previous Cesarean operation which was evidently done through the posterior wall. The uterus was firmly fixed in its new position. The tubes were resected and the abdominal wall closed. The patient made an uninterrupted recovery.
After a recital of these personal cases, it may be opportune to refer at this point, to a few out of many references to this subject in obstetric literature. Other references might be cited, but the following will sufficiently serve our purpose.
A. E. Giles (A Study of the After Results of Abdominal Operations on the Pelvic Organs, London, 1910.) in discussing the influence of operations for uterine displacements on subsequent pregnancy in personally observed cases, states that out of 144 women operated upon during the child bearing age, 48 or one-third became pregnant after the operation and between them had 60 deliveries. Thirty-five patients bore 44 full term children and five had miscarriages. Giles believes that hysteropexy as he calls it, really a ventral suspension, probably causes a slight predisposition to miscarriage, particularly when pregnancy ensues very soon after the operation. Out of 44 full term confinements there were only four that presented any important complications; two of these were breech presentations with unusually large children and the other two were transverse presentations at seven months. Of the remaining forty, there were several in which forceps were used, one with a rigid cervix but there is no reason to suppose that in all these cases the operation was responsible. As for the effect of pregnancy on ventral suspension, Giles believes that the results are usually as good as in cases where no pregnancy followed. As Giles believes fixation operations are contraindicated in every case, no statistics are available from his series of cases.
Küster (Monatschr. f. Geb. u. Gynäk. Feb. 1914) recently reported a case of vaginofixation done five years before the last pregnancy at which time the woman was thirty-five years of age, in which a prolonged labor resulted in the death of the child by attempts at delivery by craniotomy. The latter was carried out with difficulty and soon afterward the woman went into collapse. The autopsy showed the presence of air in the right chambers of the heart with extreme thinning out of the posterior uterine wall which had eventually ruptured. Fixation in this case was undoubtedly the direct cause for the dystocia. In five other cases observed by the same author, a ventral fixation and in six others in which a vagino fixation was done, the subsequent labors were observed. In
all of the first group operative labors were required and likewise in the second. The writer does not agree with the claims made by Shauta and other foreign operators that a conservative course can be safely pursued.
De Lee (Principles and Practice of Obstetrics. Philadelphia, 1913.) after referring to the comparatively slight effect of the various round ligament operations on pregnancy and labor, states that where adhesions of the uterus to the abdominal wall have resulted from ventrosuspension or fixation, serious dystocia is possible. The following complications were noted in his own experience: abortion, shoulder and breech presentations, obstructed labor requiring Cesarean section, placenta previa, inertia uteri, retention of placenta, and postpartum hemorrhage. He concludes that the frequency of these complications should forbid the practise of any form of ventral fixation in childbearing women. The worst forms of dystocia occur in those cases where the fixation involves the fundus. Vaginofixation he considers equally serious during pregnancy, for the thinning of the posterior wall of the uterus and the extreme upward displacement of the cervix may lead to serious interference with the progress of labor and even induce uterine rupture.
Williams (Text Book of Obstetrics, Third Edition, 1912.) believes that serious dystocia may follow the so-called suspension operations even when performed by competent operators with the most approved technic. This he thinks is due to fixation as the result of infection or other unknown condition. In four cases seen by Williams, Cesarean section was necessary in two, in another a difficult version was performed, while in a fourth a dead child was delivered after craniotomy. In one of these four cases the dystocia followed ventro fixation by an unknown operator but in the other three it had been preceded by a typical suspension performed by thoroughly competent operators. Williams has therefore revised his opinion as to the freedom from danger, even in suspensory operations, and believes that it ought not to be employed unless the ovaries are removed.
Andrews (Journal Obstetrics and Gynecology of the British Empire, 1905) collected the histories of 395 cases of pregnancy occurring in women who had been subjected to ventral fixation or suspension. In the 359 women who went to full term, delivery was effected by Cesarean section in twenty, by forceps in twenty-one, and by craniotomy in one. In three other cases uterine rupture occurred and transverse presentations were noted in ten.
Williams (Transactions of the Surgical and Gynecological Association, 1906) collected from the literature, 36 cases of Cesarean section as well as two additional cases of craniotomy following this class of operations. A number of other authors might be quoted to show the deleterious effects on labor of the various operations for the correction of retrodisplacement of the uterus, where this organ is not permitted to enlarge at will during pregnancy. Notwithstanding this warning we still meet
with operators who do not take into account the possible complications of pregnancy where the other deformity requires operation.
The uterus is created to serve a definite purpose. Its function is to fulfill a certain essential element during pregnancy. If for one reason or another it is necessary to perform an operation on this organ, should not the essential factor for its existence always be kept in mind? It would appear from the serious complications noted in the cases herewith presented and also in the writings of numerous authors, that this fact is not always kept in mind and that the gynecologist or surgeon who operates on the uterus for various degrees of malposition, is not sufficiently concerned with what may happen to his patient later on. He is more interested in restoring the uterus to its anatomical position than in preserving the organ for its essential uses. I have endeavored to trace several of the cases which I have personally observed and find that in a number of instances the previous operations were done by surgeons or gynecologists who seemed to give little thought to the possible complications associated with their work. We find unfortunately in many hospitals that the gynecological service is attended entirely by the surgeons who perform the gynecological operations as a matter of necessity rather than choice. Not having had a proper obstetrical training and not desiring to acquire any more definite knowledge of obstetrics later, they go about doing their work without a knowledge of what it may entail later on. In this matter the gynecologists, however, are not entirely blameless.
I have no wish to condemn the Kelly or the Gilliam operation as it has served a very useful purpose in my hands but we cannot always exclude the possibility of fixation in such cases and it would be desirable to resort to other procedures to avoid this possibility. If good results have been obtained by the various operations which plicate the round ligaments and the broad ligaments, it would be preferable to resort to these in place of those which create artificial supports for the uterus. The various vaginofixation procedures which have been devised undoubtedly result in a symptomatic cure but in view of the unfortunate results which have and are still being reported, ought it not to be made a universally recognized rule that they should not be resorted to in childbearing women, or if so, that effective means of sterilization be employed? Undoubtedly the advocates of these procedures will point to cases which have been delivered without trouble but on the other hand we now have numerous examples of serious dystocia with danger to the life of the mother following their employment. It seems to me that we may safely conclude therefore, that the warning presented in this resumè should be more widely circulated and that the possibility of obstetrical complications following operations for cure of uterine displacements be considered, particularly by surgeons who perform gynecological operations and also by gynecologists themselves. They must always bear in mind
that the uterus provides a means for the growth and protection of a gestation and that as long as the means are left behind which provide this possibility, it is likely to occur.
TREATMENT AND END RESULTS OF BIRTH FRACTURE OF THE FEMUR.
By EDWARD D. TRUESDELL, M. D., Attending Surgeon.
ALTHOUGH birth-fracture of the femur is an uncommon obstetrical complication, the occurrence of five cases on the various divisions of the Lying-In Hospital during the past three years has afforded an exceptional opportunity for the study of this injury. In addition to these cases two others have been under observation elsewhere, which, by their conformity in type and behavior have contributed additional data upon which to base the conclusions arrived at by the study of the entire series. In three cases the fracture was produced during breech extraction, one of these having been preceded by version, in two the fracture occurred as the child was being delivered through the uterine wound during Cesarean section, and in one case the fracture was caused by the overactive efforts of a midwife to induce primary respiration, the infant having been swung about by the foot. The cause of the fracture was not learned in one case. The site of fracture in each case was at or near the center of the shaft of the bone. The line of fracture was more or less oblique in four instances, passing from above and behind downward and forward. The line of fracture was twice found to be practically transverse, and in the remaining case the first radiographs were not made until long after the fracture-line had been obliterated. In every case excessive bony deformity was observed, a condition at once fixing the interest of the surgeon, and indicating the desirability of efficient treatment. The usual deformity found was a well marked anterior angulation, due to the action of the muscles upon the upper fragment, and with this there was a definite tendency to more or less external angular deformity as well. In contrast to fractures of the humerus in infants, some degree of over-riding was uniformly present. This varied proportionately, from a very little to a great deal. Fractures of the long bones in infants are difficult to deal with in any case and particularly so when it is the femur that is involved.
The treatment of the five cases occurring at the hospital came under the supervision of the writer, although two of these cases were four weeks or more old when first seen, the union then being firm, the position faulty, and the opportunity to improve existing conditions slight. In the others the treatment was begun the day of birth. Three methods of treatment were tried, traction with the leg in extension, traction with the leg flexed at a right angle with the body, and fixation with the leg in flexion but
without traction, employing the Van Arsdale splint. A long side-splint was used in the first method. This reached from the axilla to the toes and beyond, terminating in a cross-piece. The splint was fixed to the body by webbing straps, one of these passing about the perineum. Traction was made by means of adhesive plaster strips applied to the sides of the leg, ending below in buckles, which in turn were attached to a webbing strap passing about the cross-piece. Coaptation splints were applied about the thigh, and the whole apparatus was covered by a gauze bandage and guttapercha tissue, this preventing soiling. This method was convenient, since the infant was readily taken up for changing and nursing, but the anterior angular deformity was not satisfactorily overcome, and in this regard it failed to meet one of the chief indications. Traction with the leg flexed at a right angle with the body was applied by means of a splint as wide as the body, reaching from the buttocks well above the head, at the end of which a vertical upright was erected opposite the injured leg. The adhesive strips were applied as before and traction was made by means of a pulley and weight over the top of the vertical portion of the splint. The infants body was held to the body-board by webbing straps, and additional straps were passed about the thigh above and below the point of fracture, encircling the vertical portion of the splint, which did much to affect alignment of the fragments. This dressing, also, was protected by the gutta-percha tissue for cleanliness, the infant could be moved freely about, and radiographs were made with the splint in place, which helped greatly to prove the effectiveness of the treatment. The vertical arm of the splint was but slightly wider than the leg applied to it, and but one leg was extended in this way, permitting the more accurate application of the circular straps, and affording the freedom of the other leg to the infant. This method seemed more practical than the suspension of the infant in its cradle by both legs, with or without counterweights, as is so successfully done in older children with fracture of the femur. By the use of this splint the angular deformity was quite successfully eliminated, ⚫ as was also the shortening, a matter of far less importance.
The Van Arsdale splint was also found efficient in eliminating the angular deformity. This is a right-angled gutter-splint applied with the apex of the angle in the groin. The splint was cut from sheet aluminum, and shaped in the flat like two aces of spades laid point to point, the stems of the aces being employed to hold the winged portions which go to form the two gutters at right angles. The splint was covered with canton flannel and held in place by means of gauze bandages, reinforced by adhesive plaster. By this method the fragments could be gotten into alignment, although the overriding was apt to be relatively great, and apparently sufficient to preclude the method as one justifiable. This method is the easiest to apply and to maintain from every point of consideration, and with care will yield perfect results, as one case shows.
The most important conclusion arrived at from the study of these