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Roentgenography as an aid in obstetrical diagnosis
ROENTGENOGRAPHY
OBSTETRICAL
AS AN AID IN
DIAGNOSIS*
JULIUS JARCHO, M.D., F.A.C.S. NEW YORK
A
LTHOUGH roentgenography has been empIoyed to the utmost advantage in medicine and surgery, it has not been sufficiently utihzed in the heId of obstetrics. Yet roentgenography in obstetrics, as compared with the ordinary methods of physica examination, gives such accurate and dehnite information that it shouId be regarded as a necessity in every maternity institution or hospita1 where obstetrics is practiced. One reason why it has not been more generaIIy empIoyed may be the knowIedge that therapeutic doses of x-rays have a deleterious effect on the fetus, frequentIy resuIting in deformities. This objection is no longer vaIid, since diagnostic roentgenography has been accepted and recognized as a harmIess procedure. Most observers now agree that there can be no possibIe danger to mother or chiId from the brief exposures required to obtain roentgenograms, provided they are not too often repeated. This has been ampIy proved by the work of Reinberger and Schreier.l According to GarIand,2 who made a carefu1 survey of the Iiterature, no singIe case of injury to either fetus or mother foIIowing the use of x-rays for pureIy diagnostic purposes has ever been reported. Another reason for the deIay in adopting roentgenography as a routine diagnostic procedure is probabIy the fact that many of the methods that have been proposed have appeared so cumbersome and compIicated that obstetricians have regarded them as rather impractica1. This obstacIe to the use of roentgenography in cases in which it is indicated has been surmounted by the deveIopment and simpIification of the technique. Roentgenography has been shown to be
especiaIIy vaIuabIe in obstetrics in the diagnosis of pregnancy in obscure cases, the recognition of twins, the differentiation between pregnancy and tumors, the diagnosis of tuba1 and ovarian pregnancy, and in reveaIing the presence of a feta1 monster. It has aIso proved its vaIue in suppIying a more accurate method of peIvimetry than any heretofore proposed, in furnishing a method of cephaIometry in utero, in giving information as to the presentation and position of the fetus, and in demonstrating the mechanism of Iabor. In reviewing the history of peIvic roentgenography it seems that the first resuIts obtained by roentgenograms in obstetrics were not encouraging. In 1897, Levy-Dorn3 recognized the skuI1 of an eight months’ fetus in utero by means of a roentgenogram, and the foIIowing year MiiIIerheim4 described a simiIar finding. Other obstetricians, however, after making exposures Iasting one and one-half hours, reported faiIure to secure any definite resuIts. In 1908, Bouchacourt5 came to the conclusion that it was impossibIe to secure a roentgenogram of a Iiving fetus, or that if a shadow was secured, it was a sign of feta1 death. AIbers-Schbnberg,6 in 1904, so improved the technique in roentgenography that its use became more popuIar in obstetrics. Later BarthoIomew,? Sheuton,s Horner,g and Candy lo showed that the diagnosis of pregnancy could be definiteIy made after the fifth month. DIAGNOSISOF PREGNANCYBY ROENTGEN RAYS OrdinariIy the diagnosis of pregnancy can be made earlier by cIinica1 methods than by roentgenography. In cases of fibroids and other conditions simuIating
* Submitted for pubtication March 25, 1931. 417
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pregnancy, however, x-ray study may heIp in differentia1 diagnosis. This is ilIustrated by the case of H. C.,
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tender, no feta1 parts were feIt, no feta1 heart sound couId be eIicited, and no feta1 movements were observed. There was
FIG. 2. Four and a haIf months’ pregnancy. In this case, cIinica1 examination could not establish the diagnosis of pregnancy and onIy the roentgenogram saved the patient from a hysterectomy on the supposition that the condition was one of fibroids. (Slightly retouched.) Fro. I. Hat roentgenogram, taken with patient lying on her abdomen, showing six and one-half months’ pregnancy with Ieft breech presentation.
aged forty, who compIained of amenorrhea and increasing size of the abdomen. She had one chiId, fifteen years oId. She had been operated upon one year previousIy. Three months before the operation, she had had a therapeutic abortion induced because of a Iarge fibroma. After the abortion, she had a fever and had to be removed to the hospita1. A month Iater a Iaparotomy was done. She was under the impression, which Iater proved erroneous, that she had a hysterectomy done for a fibroid uterus and a Iarge dermoid cyst. After the operation, she had some scanty bIeeding every month. During the Iast six months, the monthIy bIeeding ceased and she noticed that her abdomen was growing Iarger. A diagnosis of ovarian cyst was made by her physician. It was rmpossibIe to obtain a correct report of the nature of the operation. The physica examination was unsatisfactory: The abdomen was very tense and
onIy a suspicion of the presence of interna baIIottement. A ffat roentgenogram with the patient Iying on the abdomen (see Fig, I) showed a six and one-haIf months’ pregnancy with a right breech presentation. In another case (see Fig. 2) the history and physical examination strongIy suggested a condition of uterine fibroids. The roentgenogram reveaIed a four and a haIf months’ pregnancy and thus saved the patient from an unnecessary hysterectomy. Figure 3 iIIustrates a simiIar case in a five months’ pregnancy. The diagnosis of pregnancy can be made by recognizing the feta1 bones roentgenographicaIIy as earIy as the fourteenth week. With proper preparation and careful technique, it is often possibIe to demonstrate the fetus during the third month. Leiser,‘l of Warnekros’ cIinic at Dresden, reports the use of the x-ray for the earIy diagnosis of pregnancy in 61 cases. The Potter-Bucky diaphragm was used with a current of IOO ma. and an exposure of two and one-haIf seconds. A ventrodorsa1
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exposure was usuaIIy empIoyed and occasionaIIy a dorsoventra1 exposure as weI1. In a few instances the Iatter demonstrated the presence of a fetus when the former gave negative resuIts. Of the 61 cases studied, there were 41 in which the presence of a fetus was cIearIy demonstrated; and in I of these cases, the diagnosis of pregnancy, as against that of an intra-uterine tumor, was established. in In 20 cases no fetus was demonstrated; 2 cases a diagnosis of myoma was made and proved correct at operation; in 4 cases a subsequent curettage showed onIy pIacenta1 tissue. In 14 cases pregnancy was not demonstrated aIthough diagnosed cIinicaIIy. In a11 of these cases examination was made in the eighth to tweIfth week of pregnancy. In the 41 cases in which a definite roentgenoIogica1 diagnosis was made, the pregnancy was in the fourteenth to twentieth week. It was not possibIe, therefore, to make a diagnosis of pregnancy prior to the fourteenth week; but the method did not fai1 after that time. Obesity or the coexistence of a tumor does not prevent the correct diagnosis of pregnancy after the fourteenth week. At this period a11 the feta1 bones are not necessariIy shown in the roentgenogram. Sometimes only a few vertebrae, ribs, or bones of the extremities are visibIe; the feta1 head is Iess frequentIy shown than the vertebra1 coIumn. The position of the fetus in utero can, however, be determined. Jungmann’s12 method for the demonstration of earIy pregnancy incIudes the use of the Potter-Bucky diaphragm. As a ruIe, the rays are directed axiaIIy through the peIvis from in front and above downward and backward, as for an axial roentgenogram of the bIadder. In this way, the maternal bones are not shown except for a smaI1 portion of the Iower part of the sacra1 bone and the coccyx. In some cases, the patient is put in the obIique haIf-dorsa1 position and the rays are directed from an antero-inferior position on the Ieft side backward and upward to
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the right side. This method is used when the uterus is high. In earIy pregnancy, onIy some of the
FIG. 3. Five months’ pregnancy. In this case, clinical examination couId not estabbsh the diagnosis of pregnancy and onIy the roentgenogram saved the patient from a hysterectomy on the supposition that the condition was one of fibroids. (SIightIy retouched.)
feta1 bones are demonstrabIe. The vertebrae and ribs are most frequentIy shown, their arrangement and appearance depending upon the position of the patient and the direction of the rays. With his method Jungmann has found it possible to demonstrate pregnancy in the eighth to the ninth week in some cases. From the tenth week on he has been abIe to demonstrate pregnancy as a ruIe, except under especiaIIy diffIcuIt circumstances. For the diagnosis of earIy pregnancy by x-ray, DujoI and MicheIon13 use a 40 ma. current, the Potter-Bucky diaphragm, and an exposure of two to four seconds. The patient is pIaced in the dorsa1 decubitus and the tube inchned at 35’ as for roentgenography of the bIadder, in such a way as to enIarge the image of the peIvis and thus facilitate demonstration of the presence of the feta1 bones. In 34 cases studied in pregnancies of twenty-two weeks or Iess, there were I I cases in which no feta1 skeIeton was demonstrated. In no instance was it demonstrated
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before the fourteenth week, but in one case a cIear image of the feta1 skeIeton was obtained in the fourteenth week, an un-
FIG. 4. Twin pregnancy. Only the roentgenogram cIosed the true condition. (Slightly retouched.)
dis-
usua1 and remarkabIe picture. In the fifteenth week, 2 cases were examined, both positive; in the sixteenth week, of 3 examinations I showed the feta1 skeIeton cIearIy and 2 rather indefinite shadows suggesting a vertebra1 coIumn in one instance and a head shadow in the other. In this group of cases studied by DujoI and MicheIon, a definite diagnosis of pregnancy as against tumor was made by demonstration of the feta1 skeIeton. In 3 cases the presence of a dead fetus was demonstrated. Bouchacourt5 is of the opinion that roentgenographica1 diagnosis of pregnancy cannot be made before the third to the fourth month. Then the feta1 skeIeton is aIways demonstrabre, but in norma cases roentgenography is not necessary for the diagnosis of pregnancy at that time. It is]of vaIue in the later months of pregnancy, however, in determining the position of the
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fetus; in the diagnosis of twin pregnancy and feta1 malformations, such as hydrocephaIus; and for the diagnosis of the death of the fetus in utero. It is aIso of vaIue for the diagnosis of tumors compIicating pregnancy, and for measurement of the size of the feta1 head in reIation to the peIvis. For roentgenoIogica1 study of the pregnant uterus, Bouchacourt5 uses, as a ruIe, the Potter-Bucky diaphragm with the patient in ventra1 decubitus. LateraI views are aIso of definite vaIue in the Iate stages of pregnancy, as they avoid the superposition of the materna1 on the feta1 skeleton. Jaubert de Beaujeu l4 has not empIoyed the Potter-Bucky diaphragm for the earIy diagnosis of pregnancy, but has directed the rays very obIiqueIy with a short foca1 distance with instantaneous exposure. The patient is in ventra1 decubitus and the fiIm with two intensifying screens covers the subpubic rectangIe: The rays are directed obIiqueIy from behind forward in the Iine of the neck of the femur and from above downward so as to pass in front of the coccyx. LateraI exposures may aIso be made. The images obtained are deformed and enIarged, but sufficient to demonstrate the presence of the feta1 bones. This method avoids a superposition of the materna1 bones on those of the fetus. By this method it was found possibIe to demonstrate the feta1 bones from the third to the fourth month. The earIiest pregnancy in which this was done was three months and ten days. DIAGNOSIS
OF TWIN
PREGNANCY
The diagnosis of muItipIe pregnancy during the earIier months often presents diffIcuIties. In such cases roentgenoIogica1 study cIears up a11 doubt. Figure 4 shows a twin pregnancy at term. In this case two feta1 hearts couId not be heard, nor was there a muItipIicity of feta1 parts detectabIe on paIpation. OnIy discIosed the true the roentgenogram condition.
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Figure 3 is the roentgenogram of a woman, seven and a haIf months pregnant, over whose abdomen feta1 heart sounds
FIG. 5. Norma1 pregnancy at seven and a haIf months. On physical examination, it was impossibIe to make out the presenting part. As fetal heart sounds were heard in several areas, the possibility of twins was suspected. The film shows one fetus only, in the left occipito-transverse position.
were heard in severa areas. The possibility of twin pregnancy was therefore However, suspected. the fiIm showed onIy one fetus, in the Ieft occipito-transverse position. In this case it was impossibIe to Iocate the presenting part by physica examination. The IateraI view is of particuIar vaIue in the recognition of twin pregnancy (Grier).15 The procedure, however, may be dificult. The abdomen is usuaIIy Iarge and the quantity of amniotic ffuid great. In earIy pregnancy, it may be impossibIe to demonstrate the feta1 bones in the anterior view, but they may be seen in the IateraI view. I have observed severa cases in which onIy the roentgenogram discIosed the existence of twins. In other cases, where there appeared to be a muItipIicity of feta1 parts and feta1 heart sounds were heard in
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sever4 distant areas, it was the roentgenogram which proved that onIy one fetus was present.
FIG. 6. Right
occipito-posterior presentation, months’ gestation.
DIAGNOSIS
OF
PRESENTATION
POSITION OF
eight
AND
FETUS
X-ray fiIms after the sixth month cIearIy show the presentation, position and posture of the fetus. In Figure 6 a right occipito-posterior presentation in an eight months’ gestation is cIearIy reveaIed. Figure 7 shows a Ieft occipito-transverse position with marked overriding in a patient who was in Iabor twenty-four hours and overdue. Face presentation at term is cIearIy shown in Figures 8 and g. NBIIe’” has found the x-rays of definite vaIue in determining the position of the fetus and in the diagnosis of twin pregnancy and of feta1 maIformations, especiaIIy in the presence of hydramnios. In 2 cases he was able by this means to diagnose an anencephaIus prior to Iabor. An irreguIar bony formation was shown above the cervica1 vertebrae corresponding to
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the base of the skull; the vauIt of the skuI1 was entirely absent. BIanche17 (1927) states that he has
FIG. 7. Left occipito-transverse position with marked overriding; patient twenty-four hours in Iabor and overdue.
demonstrated the feta1 bones in utero as earIy as three months and a haIf in pregnancy and in I case in which the pregnancy was onIy a few days over the third month, but in another recent series of examinations he was not abIe to obtain definiteIy positive roentgenographica1 evidence of pregnancy unti1 toward the end of the fourth month. In those cases in which the feta1 bones were demonstrated in the roentgenagram before the fifth month of pregnancy, the cervico-dorsa1 portion of the vertebra1 column was most frequentIy visibIe and aIso the points of ossification of the head, especiaIIy the occipita1; much more rareIy the ribs and onIy exceptionaIIy one of the Iong bones couId be seen. The presence of the feta1 skeIeton can be demonstrated about three weeks before there are cIinica1 signs of feta1 Iife.
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In the Iater months of pregnancy, with good technique the fetal skeIeton is usualIy shown in its entirety. This makes it possibIe
FIG. 8. Left mento-posterior position at term. Patient in labor three days; ruptured membranes; marked Bandl’s ring; cesarean section done with peritonea1 exclusion. Anterior view.
to determine the position of the fetus in utero before Iabor and the exact position of the head in reIation to the superior strait. Roentgenography in the Iater months of pregnancy aIso shows the presence of twins, of feta1 anomaIies, and of feta1 death; it makes it possibIe to differentiate a tumor from pregnancy and aIso as a ruIe to diagnose the presence of a tumor compIicating pregnancy. BIanche” has not found roentgenography of vaIue in the diagnosis of extra-uterine pregnancy, unIess it has become encysted or caIcified (Iithopedion). In the roentgenography of the pregnant uterus, he has found the best technique to in&de the use of a 60 to 80 ma. current with hard rays (70 to 80 kv.) and the
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Potter-Bucky diaphragm, with exposure of one second. The patient is in the ventral position, as a rule, but IateraI views are
FIG. 9. Same as Fig. 8, posterior view.
taken in some cases. In early pregnancy the x-rays should be centered on the axis of the pelvic cavity. DIAGNOSIS
OF ABNORMALITIES IN
OF THE FETUS
UTERO
The recognition of monstrosities is greatIy aided by x-ray examination (Grier15). This subject has been covered in great detail in a monograph by Dorland and Hubeny. I* Both anteroposterior and IateraI views are indispensable for this purpose. Anencephaly has been recognized from the anteroposterior view, but for the detection of abnormal deveIopment of other parts of the skeIeton the IateraI view is more vaIuabIe. Absence of the vertebrae and bones of the pelvis, decrease in the number of ribs, and abnorma1 development of the bones of the skuI1 have been recognized in utero in the IateraI view.
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Albanolg reports a case in which a diagnosis of hydrocephalus with the fetus in breech presentation was made in the
FIG. IO. Left transverse presentation, two weeks before term. Patient in labor for two hours. Strong pains, tearing in character, at frequent intervals. hlembranes not ruptured. Roentgenogram shows fetus lying high above crests of iIium. Under deep anesthesia external cephaIic version performed. Head held on brim of pelvis for nearIy an hour. Pains practically ceased. Pituitin 0.2 cc. given to strengthen pains and facilitate engagement. Patient dcIivered spontaneously of 696 pound living baby.
early stage of labor where the correct diagnosis could not have been established clinicahy. Craniotomy was found to be necessary for the extraction of the fetus. Th e puerpermm . was normaI. A mistaken diagnosis in this case would have endangered the mother’s life. This case iIIustrates the great value of roentgenoIogicaI diagnosis in cases of fetal abnormaIities at or near term. RoentgenoIogy is aIso vaIuabIe in the differential diagnosis of obscure abdominal masses and pregnancy. Hydramnios is so commonIy associated with monstrosities that a routine roentgenogram is necessary. EarIy recognition of these deformities
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wouId prevent the continuation of such a a proIonged labor, or even pregnancy, cesarian section. Hauch20 has not found the x-rays of specia1 vaIue in the earIy diagnosis of pregnancy, as the diagnosis may be made equaIIv earIy by other methods. But he has found-it of definite vaIue in differentiating between a pregnancy and a tumor; for the diagnosis of Iate extrauterine pregnancy; for demonstrating the presence of a dead fetus; for the diagnosis of twin pregnancy; and finaIIy for the diagnosis of feta1 maIformations and monstrosities before or at the time of Iabor. Favreau21 states that in some cases the feta1 skeIeton is demonstrabIe in the roentgenogram before the feta1 heart sounds can be heard. In I case at Ieast, it was demonstrated before the fourth month. As a ruIe, however, he has found that the feta1 skeIeton cannot be demonstrated with certainty before the fourth month. In some cases a very carefu1 examination of the roentgenogram must be made before evidence of the feta1 skeIeton is found. As a ruIe, in a five months’ pregnancy, the vertebra1 coIumn, sIightIy curved, and the base of the skuI1 are visibIe, and in some cases the bones of the extremities. The death of the fetus in utero is indicated by overlapping of the crania1 bones and the disappearance of the cerebra1 In case of maceration, the contents. smaIIer than norma skeIeton appears for the duration of the pregnancy and the outIines of the bones are somewhat obriterated. Case22 (1917) reported the first instance of roentgen diagnosis of anencephaIus, before birth, and in 1926, he reported have 3 additiona cases. Other authors of 15, reported I I cases, making a tota RoentgenoIogicaI examination in anencephaIus shows an absence of the feta1 crania1 vauIt, smaI1 orbits, absence of seIIa turcica, and a tendency to cervicaI spina bifida. Two cases of anencephaIy diagnosed by roentgenoIogy are reported by Beath.23
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Diagnosis
The first patient, a primipara thirty-nine years of age, appeared to be in about the eighth month of her pregnancy. The roentgenogram showed a normaIIy deveIoped fetus as regards trunk and Iimbs, but no crania1 shadow. Induction was decided upon and an anencepharic chiId weighing 5 Ib. removed. The mother recovered. The second case was that of a primipara at fuI1 term. The roentgenogram showed feta1 shadows of the thorax and Iimbs, but no crania1 shadow. Before any measures couId be taken the patient entered into Iabor, which Iasted two days. DeIivery was diffIcuIt and the mother died from shock. Beath thinks these 2 cases prove quite definiteIy the vaIue of earIy roentgenoIogy in doubtfu1 abnormalities of pregnancy. There IS a syndrome which is strongIy suggestive of deformed fetuses in utero (FaIIsz4). Roentgenograms wiI1 cIearIy demonstrate the deformity in anencephaIic, hydrocephaIic or spina bifida fetuses as early as the sixth month; but a negative x-ray does not excIude the possibiIity of deformity. The syndrome is as foIIows: I. Hydramnios occurring about the seventh month, associated with uterine tension and easy baIIottement. 2. InabiIity definiteIy to outline the feta1 head suggests anencephaIy, whiIe abnormal size or consistency suggests hydrocephaIus. 3. AnencephaIy is suggested by d&uIty in differentiating between the feta1 parts either by abdomina1 or vagina1 paIpation. AIso a soft meningoceIe surrounded by a bony ring may be feIt on vagina1 examination with a finger inside the cervix in cephaIic presentations. 4. FetaI heart tones heard faintly or absent. when hydramnios is marked. 5. AbnormaIIy active feta1 movements, which may become convulsive if pressure is made on the head in cases of anencephaIic monsters. OVARIAN
PREGNANCY
Ovarian pregnancy has been diagnosed by skiagrams (Candy25). The appearance
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was that of normaI pregnancy of about eight and one-half months, but the patient compIained of great discomfort and distention. PaIpation and vagina1 examination under anesthesia faiIed to reveal the presenting part. X-ray examination showed a fuIIy deveIoped fetus, the position and attitude of which were extremeIy irreguIar. The head and cervicaI spine were acuteIy flexed upon the chest, the cervica1 spine forming an acute projection against the anterior abdomina1 waI1 of the mother. The head was outside the peIvis and could not be made to engage. The IateraI view showed the fetus to Iie in a much more ventral position than normaI. Cesarean section was performed and a fuIItime ovarian pregnancy reveaIed. The uterus was in the peIvis and was sIightIy enIarged. The right faIIopian tube was flattened and stretched over the gestation sac. The tissue of the right ovary was thinned out and constituted the outer layer of the sac, which Iay above the broad Iigament. The child appeared to have been dead for two or three weeks. Tuba1 pregnancy is apt to rupture before reaching a size permitting of its roentgenoother than by the IogicaI recognition specia1 method of UterosaIpingography. THE
MECHANISM
OF
LABOR
AS
STUDIED
BY
X-RAYS
The oIder texts on obstetrics taught that, at the onset of Iabor, the fetus is forced towards the path of Ieast resistance, i.e., the Iower uterine segment and the cervica1 cana1. In the mechanism of Iabor the passages are the determining factors. The different diameters of the peIvic pIanes and the varied measurements of the manifold circumferences of the fetaI-presenting part necessitate the rotation, flexion, etc., of the fetus, in order that it may pass through the birth cana1. Recent studies have somewhat modified this teaching. The anterior rotation of the child is governed by the Iaw of accommodation of elastic resistance to the shape of the container. The birth cana is shaped
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Iike a straight tube with a sharp upward curve at its Iower end; the fetus, Iike two ovoids, head and trunk, united by a hinge, the cervica1 vertebrae. The birth cana would, therefore, force such a bicorporate hinged object to bend in the same direction, i.e., the Iower ovoid, or presenting part, wouId be forced upward or anteriorjy. The fetus, due to uniform interna pressure, assumes a cyIindrica1 contour, with a maximum bending faciIity in certain directions only: the head backwards and the body in a diametricaIIy opposite pIane. In order, therefore, for the fetus to pass the Iower upward curve of the birth cana1, it must proceed with a spiraI-Iike motion so that it approaches the curved portion of the cana with that part of the feta1 ovoid possessing the greatest bending facilit)- in that direction. WarnekrosZ6 was abIe to obtain roentgenograms of the fetus in a11stages of labor; and he has shown definiteIy that, when the head of the fetus enters the peIvis, the occiput and sinciput are on the same IeveI, in a position between ffexion and extension. In the first stage of labor, the uterine contractions cause the fetus to assume a more pronounced attitude of ffexion, which is, however, oniy transitory; between pains, the chiId assumes a more natura1 and comfortabIe attitude of semiffexion. A reactive influence upon the fetus sets in with the rupture of the membranes, causing it to stretch out, so that the fundus uteri can be observed rising towards the ensiform process. The spina coIumn is so constructed that each division tends to bend in the opposite direction of the other so that orthostatic posture is maintained. The force of the feta1 axis pressure directed to the upper poIe wiI1 cause the entire coIumn to assume a form which will transmit this pressure to the Iower poIe. The dorsaI vertebrae assume a kyphotic curve and the cer\-ica1 vertebrae a compensatory Iordotic curve. When the force of the uterine contraction is transmitted to the head, attached to the vertebra1 coIumn at its condyIes, the
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sinciput is flexed and the occiput descends and is rotated anteriorIy. It has been further shown by Warnekros that the fetus is not an ovoid cyIinder with bony protections consisting of the bones of the upper and lower extremities. The feta1 extremities do not assume a reguIar attitude, but are thrown about in the uterus. The back of the fetus rotates anteriorIy before the head rotates, and when the head is at the orifice, with the occiput pointing directIy anteriorIy, the shouIders are then entering the peIvis transverseIy. The chest of the fetus appears compressed whiIe making its exit from the peIvic 0utIet. CIinicaI x-ray studies concerning the mechanism of Iabor help to expIain how puerpera1 fever may deveIop in the absence of infection introduced from without. They prove that the presenting part acts Iike a bacteria-smearing swab, whereby the damaged tissues with which it comes in contact may readiIy be inocuIated by microorganisms aIready present in the vagina. SUMMARY
Roentgenography has proved its vaIue in obstetrics principaIIy for the foIIowing diagnostic purposes : I. For the positive diagnosis of pregnancy in obscure cases. This can be accomplished by the fourteenth week, sometimes earlier. In some of the author’s cases, the clinica findings strongIy suggested uterine fibromyomata and onIy the roentgenogram
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JUNE,,931
saved the patient from an unnecessary hysterectomy. 2. For the recognition of twins. ParticuIarIy in obese patients, there may be diffrcuIty in hearing two separate feta1 hearts or paIpating a muItipIicity of feta1 parts; vice versa, the same feta1 heart may sometimes be heard cIearIy in wideIy separated Iocations, Ieading to an erroneous diagnosis of twin pregnancy. In such cases, roentgenography gives a definite answer. 3. For differentiation between pregnancy and tumors. Here roentgenography suppIements findings by the AschheimZondek test. 4. For diagnosis of tuba1 and ovarian pregnancy. 5. For reveaIing the presence of a feta1 monster. The recognition of anencephaIus and other forms of feta1 monstrosity is greatIy faciIitated by x-ray study. 6. For giving information as to the presentation and position of the fetus. As shown by severa of the author’s fiIms, the exact presentation and position are reveaIed with far greater accuracy than can be determined by physica examination aIone. This aIso obviates the need of a peIvic examination. 7. For demonstrating the mechanism of Iabor. 8. For suppIying a more accurate method of peIvimetry than any heretofore proposed and furnishing a means of cephaIometry in utero. This subject wiI1 be discussed in a subsequent paper appearing in a future issue of THE AMERICAN JOURNAL OF SURGERY.
REFERENCES 1. REINBERGER, J. R., and SCHREIER, P. C. VaIue of Y-.-n.7
*-,aJ
,+..,l:n, DLUU‘bD
;, 111
,\I...+n+,.;n, ““DLCLII\_J
“-j
a,,\
gynecoIogy*
Mempbis M. J., 7: IO, 1930. 2. GARLAND, L. H. X-rays in the diagnosis of pregnancy. CaliJornia and West. Med., 34: 150, 1931. 3. LEVY-D• RN, M. Zur Kritik und Ausgestaltung des Roentgenverfahrans. Deutscbe med. Wcbnscbr., 23: 800, 1897. 4. M~~LLERHEIM, R. Verwertung der RoentgenstrahIen in der GerburtshiIfe. Deutscbe med. Wcbnscbr., 24: 619, 1898. 5. BOUCHACOURT,L. Sur I’Ctat actue1 des applications a I’obstetricie de Ia visibiIit& radiographique du
6.
7. 8. 9. IO.
squeIette foeta1. J. de mkd. et cbir. prat., 98: 469, 1927. ALBERS-SCH~NBERG. ijber den Nachweis des Kindes in der Geblrmutter mitteIs RoentgenstrahIen. Zentralbl. f. Gyniik., 28: 1514, 1904. BARTHOLOMEW, R. A. Diagnosis of pregnancy by the roentgen ray. J. A. M. A., 76: 912, 1921. SHEUTON, E. W. H. X-rays in obstetrical practice. Lancel. 1: 860. 1022. HORNER; D. A: Roentgenography in bostetrics. Surg. Gynec. Obst., 35: 67, 1922. CANDY, T. I. Radiography of the fetus in utero. Arch. Radial. CT Electrotb., 28: 146, 1923. [For remainder of References see p. 442.1
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fieId, considering the few operations performed. AIthough it has been attended previousIy by high mortaIity, improvement in technique wiI1 markedly decrease this. In view of the absoIute certainty of death from this disease without operation, surgica1 remova shouId be attempted in every case where there is no evidence of metastasis.
JUNE,rgsr
chest is tightIy strapped, and hearing aIIowed for seven days before the stump of the esophagus in the neck is opened. The patient may then be aIIowed to drink. PostoperativeIy and preoperativeIy, the scientific use of the gastrostomy, and the administration of fluids by vein and subcutaneousIy wiI1 give these patients the most hopefu1 outIook from surgica1 treatment of carcinoma of the esophagus. OnIy by prompt diagnosis and earIy treatment wiI1 it be possibIe to offer these patients anything but a IOO per cent fata prognosis.
SUMMARY
At preliminary operation, a Janeway or WitzeI gastrostomy is performed under IocaI anesthesia and the Iiver and Iymphatits in the region of the diaphragmatic esophagus are inspected. Two to six weeks being aIIowed for recovery and upbuiIding of the patient, artificia1 pneumothorax is induced, the thorax is opened under narcosis and IocaI anesthesia, using gas in addition if needed. Protecting the pIeura with rubber sheets, the esophagus is dissected from its mediastina1 bed and drawn out through the neck. Infinite care is taken to contro1 hemostasis and protect the vagi nerves, consistent with compIete remova of the carcinoma. FinaIIy, a11 the air is removed from the thorax, the
REFERENCES
Carcinoma
REFERENCES
GOURSALDand NASILOFF. Quoted by Hermann Fischer. FISCHER, H. SurgicaI treatment of the esophagus. _ Arch. Surg., 6: 256, 1923. (This articIe gives an historica outIine of the progress in surgery of the esophagus.) TOREK, F. Carcinoma of the thoracic portion of the esophagus. Arch. Surg., IO: 353, 1925. EGGERS, C. Resection of the thoracic portion of the esophagus for carcinoma (tirst case). Arch. Surg., IO: 361, 1925. EGGERS, C. Report of second case of carcinoma of esophagus. Surg., Gynec. Oh., 50: 630-634, 1930. SAINT, J. H. Surgery of the esophagus (historical review). Arch. Surg., 19: 53, 1929.
OF
I I. LEISER, M. Die Friihdiagnose
der Schwangerschaft durch das RoentgenbiId. Arch. j. Gyniik., 129: 1036, 1927. 12. JUNGMANN, M. Die Roentgenfrtihdiagnose der Schwangerschaft. Fortscbr. ad. Geb. d. Roentgenstrablen., 35: 913, 1927. 13. DUJOI., G., and MICHELON, P. Le radiodiagnostic prbcoce de la grossesse dans les cinq premiers mois. Rev. franc. de gyntc. et d’obst., 24: 689, 1929. 14. BEAUJEU, A. J. de. Sur Ie diagnostic precoce de Ia Grossesse. Arch. d’flkctric m6d., 35 : 479, 1927. 15. GRIER, G. W. VaIue of Iateral view in diagnosis of pregnancy. Radiology, 14: 571, 1930. 16. NBLLE, H. Die Diagnose der AnencephaIus in der Sztyngerschaft. Zentralbl. f. GynSik., 52: 1345, du 17. BLANCHE, A. L a visibiIit& radiographique squeIette foeta1 “in utero.” Paris Mhd., 17: 136, 1927. 18. DORLAND, W. A., and HUBENY, M. J. The x-ray * Continued
DR.
JARCHO”
in Embryology and Obstetrics. Saint Paul, Minn., Bruce PubIishing Co., 1926. 19. ALBANO, G. Roentgendiagnose des Hydrocephalus Zentralbl. im Beginn der Ersffnungsperiode. f. Gyniik., 51: 2793, 1927. 20. HAUCH, E. QueIques expkriences avec Ies rayons-x dans la grossesse. Acta Obst. CT GynCc., g: 251, 1930. 21. FAVREAU, M. Le diagnostic radioIogique en obstetrique. J. de mkd. de Bordeaux, 58: 727, 1928. 22. CASE, J. T. AnencephaIy successfully diagnosed before birth. Surg. Gynec. Obst., 24: 312, 1917. 23. BEATH, R. M. Two cases of anencephaly demonstrated by x-rays. Brit. J. Radial., 3: 421, 1930. 24. FALLS, F. H. Diagnosis of fetaI deformities in utero. Am. J. Obst. @Gynec., 16: 801, 1928. 25. CANDY, T. I. Skiagrams of fuI1 time ovarian pregnancy. Brit. J. Radiol., 32: 174, 1927. 26. WARNEKROS. Schwangerschaft und Geburt in RoentgenbiIde. Ztscbr. f. Geburtsb. u. Gyniik., 80: 7x9, IgI7-18. from p. 426.
OBSTETRICAL
AS AN AID IN
DIAGNOSIS*
JULIUS JARCHO, M.D., F.A.C.S. NEW YORK
A
LTHOUGH roentgenography has been empIoyed to the utmost advantage in medicine and surgery, it has not been sufficiently utihzed in the heId of obstetrics. Yet roentgenography in obstetrics, as compared with the ordinary methods of physica examination, gives such accurate and dehnite information that it shouId be regarded as a necessity in every maternity institution or hospita1 where obstetrics is practiced. One reason why it has not been more generaIIy empIoyed may be the knowIedge that therapeutic doses of x-rays have a deleterious effect on the fetus, frequentIy resuIting in deformities. This objection is no longer vaIid, since diagnostic roentgenography has been accepted and recognized as a harmIess procedure. Most observers now agree that there can be no possibIe danger to mother or chiId from the brief exposures required to obtain roentgenograms, provided they are not too often repeated. This has been ampIy proved by the work of Reinberger and Schreier.l According to GarIand,2 who made a carefu1 survey of the Iiterature, no singIe case of injury to either fetus or mother foIIowing the use of x-rays for pureIy diagnostic purposes has ever been reported. Another reason for the deIay in adopting roentgenography as a routine diagnostic procedure is probabIy the fact that many of the methods that have been proposed have appeared so cumbersome and compIicated that obstetricians have regarded them as rather impractica1. This obstacIe to the use of roentgenography in cases in which it is indicated has been surmounted by the deveIopment and simpIification of the technique. Roentgenography has been shown to be
especiaIIy vaIuabIe in obstetrics in the diagnosis of pregnancy in obscure cases, the recognition of twins, the differentiation between pregnancy and tumors, the diagnosis of tuba1 and ovarian pregnancy, and in reveaIing the presence of a feta1 monster. It has aIso proved its vaIue in suppIying a more accurate method of peIvimetry than any heretofore proposed, in furnishing a method of cephaIometry in utero, in giving information as to the presentation and position of the fetus, and in demonstrating the mechanism of Iabor. In reviewing the history of peIvic roentgenography it seems that the first resuIts obtained by roentgenograms in obstetrics were not encouraging. In 1897, Levy-Dorn3 recognized the skuI1 of an eight months’ fetus in utero by means of a roentgenogram, and the foIIowing year MiiIIerheim4 described a simiIar finding. Other obstetricians, however, after making exposures Iasting one and one-half hours, reported faiIure to secure any definite resuIts. In 1908, Bouchacourt5 came to the conclusion that it was impossibIe to secure a roentgenogram of a Iiving fetus, or that if a shadow was secured, it was a sign of feta1 death. AIbers-Schbnberg,6 in 1904, so improved the technique in roentgenography that its use became more popuIar in obstetrics. Later BarthoIomew,? Sheuton,s Horner,g and Candy lo showed that the diagnosis of pregnancy could be definiteIy made after the fifth month. DIAGNOSISOF PREGNANCYBY ROENTGEN RAYS OrdinariIy the diagnosis of pregnancy can be made earlier by cIinica1 methods than by roentgenography. In cases of fibroids and other conditions simuIating
* Submitted for pubtication March 25, 1931. 417
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pregnancy, however, x-ray study may heIp in differentia1 diagnosis. This is ilIustrated by the case of H. C.,
Diagnosis
JUNE, ,931
tender, no feta1 parts were feIt, no feta1 heart sound couId be eIicited, and no feta1 movements were observed. There was
FIG. 2. Four and a haIf months’ pregnancy. In this case, cIinica1 examination could not establish the diagnosis of pregnancy and onIy the roentgenogram saved the patient from a hysterectomy on the supposition that the condition was one of fibroids. (Slightly retouched.) Fro. I. Hat roentgenogram, taken with patient lying on her abdomen, showing six and one-half months’ pregnancy with Ieft breech presentation.
aged forty, who compIained of amenorrhea and increasing size of the abdomen. She had one chiId, fifteen years oId. She had been operated upon one year previousIy. Three months before the operation, she had had a therapeutic abortion induced because of a Iarge fibroma. After the abortion, she had a fever and had to be removed to the hospita1. A month Iater a Iaparotomy was done. She was under the impression, which Iater proved erroneous, that she had a hysterectomy done for a fibroid uterus and a Iarge dermoid cyst. After the operation, she had some scanty bIeeding every month. During the Iast six months, the monthIy bIeeding ceased and she noticed that her abdomen was growing Iarger. A diagnosis of ovarian cyst was made by her physician. It was rmpossibIe to obtain a correct report of the nature of the operation. The physica examination was unsatisfactory: The abdomen was very tense and
onIy a suspicion of the presence of interna baIIottement. A ffat roentgenogram with the patient Iying on the abdomen (see Fig, I) showed a six and one-haIf months’ pregnancy with a right breech presentation. In another case (see Fig. 2) the history and physical examination strongIy suggested a condition of uterine fibroids. The roentgenogram reveaIed a four and a haIf months’ pregnancy and thus saved the patient from an unnecessary hysterectomy. Figure 3 iIIustrates a simiIar case in a five months’ pregnancy. The diagnosis of pregnancy can be made by recognizing the feta1 bones roentgenographicaIIy as earIy as the fourteenth week. With proper preparation and careful technique, it is often possibIe to demonstrate the fetus during the third month. Leiser,‘l of Warnekros’ cIinic at Dresden, reports the use of the x-ray for the earIy diagnosis of pregnancy in 61 cases. The Potter-Bucky diaphragm was used with a current of IOO ma. and an exposure of two and one-haIf seconds. A ventrodorsa1
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exposure was usuaIIy empIoyed and occasionaIIy a dorsoventra1 exposure as weI1. In a few instances the Iatter demonstrated the presence of a fetus when the former gave negative resuIts. Of the 61 cases studied, there were 41 in which the presence of a fetus was cIearIy demonstrated; and in I of these cases, the diagnosis of pregnancy, as against that of an intra-uterine tumor, was established. in In 20 cases no fetus was demonstrated; 2 cases a diagnosis of myoma was made and proved correct at operation; in 4 cases a subsequent curettage showed onIy pIacenta1 tissue. In 14 cases pregnancy was not demonstrated aIthough diagnosed cIinicaIIy. In a11 of these cases examination was made in the eighth to tweIfth week of pregnancy. In the 41 cases in which a definite roentgenoIogica1 diagnosis was made, the pregnancy was in the fourteenth to twentieth week. It was not possibIe, therefore, to make a diagnosis of pregnancy prior to the fourteenth week; but the method did not fai1 after that time. Obesity or the coexistence of a tumor does not prevent the correct diagnosis of pregnancy after the fourteenth week. At this period a11 the feta1 bones are not necessariIy shown in the roentgenogram. Sometimes only a few vertebrae, ribs, or bones of the extremities are visibIe; the feta1 head is Iess frequentIy shown than the vertebra1 coIumn. The position of the fetus in utero can, however, be determined. Jungmann’s12 method for the demonstration of earIy pregnancy incIudes the use of the Potter-Bucky diaphragm. As a ruIe, the rays are directed axiaIIy through the peIvis from in front and above downward and backward, as for an axial roentgenogram of the bIadder. In this way, the maternal bones are not shown except for a smaI1 portion of the Iower part of the sacra1 bone and the coccyx. In some cases, the patient is put in the obIique haIf-dorsa1 position and the rays are directed from an antero-inferior position on the Ieft side backward and upward to
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the right side. This method is used when the uterus is high. In earIy pregnancy, onIy some of the
FIG. 3. Five months’ pregnancy. In this case, clinical examination couId not estabbsh the diagnosis of pregnancy and onIy the roentgenogram saved the patient from a hysterectomy on the supposition that the condition was one of fibroids. (SIightIy retouched.)
feta1 bones are demonstrabIe. The vertebrae and ribs are most frequentIy shown, their arrangement and appearance depending upon the position of the patient and the direction of the rays. With his method Jungmann has found it possible to demonstrate pregnancy in the eighth to the ninth week in some cases. From the tenth week on he has been abIe to demonstrate pregnancy as a ruIe, except under especiaIIy diffIcuIt circumstances. For the diagnosis of earIy pregnancy by x-ray, DujoI and MicheIon13 use a 40 ma. current, the Potter-Bucky diaphragm, and an exposure of two to four seconds. The patient is pIaced in the dorsa1 decubitus and the tube inchned at 35’ as for roentgenography of the bIadder, in such a way as to enIarge the image of the peIvis and thus facilitate demonstration of the presence of the feta1 bones. In 34 cases studied in pregnancies of twenty-two weeks or Iess, there were I I cases in which no feta1 skeIeton was demonstrated. In no instance was it demonstrated
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before the fourteenth week, but in one case a cIear image of the feta1 skeIeton was obtained in the fourteenth week, an un-
FIG. 4. Twin pregnancy. Only the roentgenogram cIosed the true condition. (Slightly retouched.)
dis-
usua1 and remarkabIe picture. In the fifteenth week, 2 cases were examined, both positive; in the sixteenth week, of 3 examinations I showed the feta1 skeIeton cIearIy and 2 rather indefinite shadows suggesting a vertebra1 coIumn in one instance and a head shadow in the other. In this group of cases studied by DujoI and MicheIon, a definite diagnosis of pregnancy as against tumor was made by demonstration of the feta1 skeIeton. In 3 cases the presence of a dead fetus was demonstrated. Bouchacourt5 is of the opinion that roentgenographica1 diagnosis of pregnancy cannot be made before the third to the fourth month. Then the feta1 skeIeton is aIways demonstrabre, but in norma cases roentgenography is not necessary for the diagnosis of pregnancy at that time. It is]of vaIue in the later months of pregnancy, however, in determining the position of the
Diagnosis
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fetus; in the diagnosis of twin pregnancy and feta1 malformations, such as hydrocephaIus; and for the diagnosis of the death of the fetus in utero. It is aIso of vaIue for the diagnosis of tumors compIicating pregnancy, and for measurement of the size of the feta1 head in reIation to the peIvis. For roentgenoIogica1 study of the pregnant uterus, Bouchacourt5 uses, as a ruIe, the Potter-Bucky diaphragm with the patient in ventra1 decubitus. LateraI views are aIso of definite vaIue in the Iate stages of pregnancy, as they avoid the superposition of the materna1 on the feta1 skeleton. Jaubert de Beaujeu l4 has not empIoyed the Potter-Bucky diaphragm for the earIy diagnosis of pregnancy, but has directed the rays very obIiqueIy with a short foca1 distance with instantaneous exposure. The patient is in ventra1 decubitus and the fiIm with two intensifying screens covers the subpubic rectangIe: The rays are directed obIiqueIy from behind forward in the Iine of the neck of the femur and from above downward so as to pass in front of the coccyx. LateraI exposures may aIso be made. The images obtained are deformed and enIarged, but sufficient to demonstrate the presence of the feta1 bones. This method avoids a superposition of the materna1 bones on those of the fetus. By this method it was found possibIe to demonstrate the feta1 bones from the third to the fourth month. The earIiest pregnancy in which this was done was three months and ten days. DIAGNOSIS
OF TWIN
PREGNANCY
The diagnosis of muItipIe pregnancy during the earIier months often presents diffIcuIties. In such cases roentgenoIogica1 study cIears up a11 doubt. Figure 4 shows a twin pregnancy at term. In this case two feta1 hearts couId not be heard, nor was there a muItipIicity of feta1 parts detectabIe on paIpation. OnIy discIosed the true the roentgenogram condition.
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Figure 3 is the roentgenogram of a woman, seven and a haIf months pregnant, over whose abdomen feta1 heart sounds
FIG. 5. Norma1 pregnancy at seven and a haIf months. On physical examination, it was impossibIe to make out the presenting part. As fetal heart sounds were heard in several areas, the possibility of twins was suspected. The film shows one fetus only, in the left occipito-transverse position.
were heard in severa areas. The possibility of twin pregnancy was therefore However, suspected. the fiIm showed onIy one fetus, in the Ieft occipito-transverse position. In this case it was impossibIe to Iocate the presenting part by physica examination. The IateraI view is of particuIar vaIue in the recognition of twin pregnancy (Grier).15 The procedure, however, may be dificult. The abdomen is usuaIIy Iarge and the quantity of amniotic ffuid great. In earIy pregnancy, it may be impossibIe to demonstrate the feta1 bones in the anterior view, but they may be seen in the IateraI view. I have observed severa cases in which onIy the roentgenogram discIosed the existence of twins. In other cases, where there appeared to be a muItipIicity of feta1 parts and feta1 heart sounds were heard in
Diagnosis
American Journal of Surgery
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sever4 distant areas, it was the roentgenogram which proved that onIy one fetus was present.
FIG. 6. Right
occipito-posterior presentation, months’ gestation.
DIAGNOSIS
OF
PRESENTATION
POSITION OF
eight
AND
FETUS
X-ray fiIms after the sixth month cIearIy show the presentation, position and posture of the fetus. In Figure 6 a right occipito-posterior presentation in an eight months’ gestation is cIearIy reveaIed. Figure 7 shows a Ieft occipito-transverse position with marked overriding in a patient who was in Iabor twenty-four hours and overdue. Face presentation at term is cIearIy shown in Figures 8 and g. NBIIe’” has found the x-rays of definite vaIue in determining the position of the fetus and in the diagnosis of twin pregnancy and of feta1 maIformations, especiaIIy in the presence of hydramnios. In 2 cases he was able by this means to diagnose an anencephaIus prior to Iabor. An irreguIar bony formation was shown above the cervica1 vertebrae corresponding to
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the base of the skull; the vauIt of the skuI1 was entirely absent. BIanche17 (1927) states that he has
FIG. 7. Left occipito-transverse position with marked overriding; patient twenty-four hours in Iabor and overdue.
demonstrated the feta1 bones in utero as earIy as three months and a haIf in pregnancy and in I case in which the pregnancy was onIy a few days over the third month, but in another recent series of examinations he was not abIe to obtain definiteIy positive roentgenographica1 evidence of pregnancy unti1 toward the end of the fourth month. In those cases in which the feta1 bones were demonstrated in the roentgenagram before the fifth month of pregnancy, the cervico-dorsa1 portion of the vertebra1 column was most frequentIy visibIe and aIso the points of ossification of the head, especiaIIy the occipita1; much more rareIy the ribs and onIy exceptionaIIy one of the Iong bones couId be seen. The presence of the feta1 skeIeton can be demonstrated about three weeks before there are cIinica1 signs of feta1 Iife.
Diagnosis
JUNE,193‘
In the Iater months of pregnancy, with good technique the fetal skeIeton is usualIy shown in its entirety. This makes it possibIe
FIG. 8. Left mento-posterior position at term. Patient in labor three days; ruptured membranes; marked Bandl’s ring; cesarean section done with peritonea1 exclusion. Anterior view.
to determine the position of the fetus in utero before Iabor and the exact position of the head in reIation to the superior strait. Roentgenography in the Iater months of pregnancy aIso shows the presence of twins, of feta1 anomaIies, and of feta1 death; it makes it possibIe to differentiate a tumor from pregnancy and aIso as a ruIe to diagnose the presence of a tumor compIicating pregnancy. BIanche” has not found roentgenography of vaIue in the diagnosis of extra-uterine pregnancy, unIess it has become encysted or caIcified (Iithopedion). In the roentgenography of the pregnant uterus, he has found the best technique to in&de the use of a 60 to 80 ma. current with hard rays (70 to 80 kv.) and the
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Potter-Bucky diaphragm, with exposure of one second. The patient is in the ventral position, as a rule, but IateraI views are
FIG. 9. Same as Fig. 8, posterior view.
taken in some cases. In early pregnancy the x-rays should be centered on the axis of the pelvic cavity. DIAGNOSIS
OF ABNORMALITIES IN
OF THE FETUS
UTERO
The recognition of monstrosities is greatIy aided by x-ray examination (Grier15). This subject has been covered in great detail in a monograph by Dorland and Hubeny. I* Both anteroposterior and IateraI views are indispensable for this purpose. Anencephaly has been recognized from the anteroposterior view, but for the detection of abnormal deveIopment of other parts of the skeIeton the IateraI view is more vaIuabIe. Absence of the vertebrae and bones of the pelvis, decrease in the number of ribs, and abnorma1 development of the bones of the skuI1 have been recognized in utero in the IateraI view.
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Albanolg reports a case in which a diagnosis of hydrocephalus with the fetus in breech presentation was made in the
FIG. IO. Left transverse presentation, two weeks before term. Patient in labor for two hours. Strong pains, tearing in character, at frequent intervals. hlembranes not ruptured. Roentgenogram shows fetus lying high above crests of iIium. Under deep anesthesia external cephaIic version performed. Head held on brim of pelvis for nearIy an hour. Pains practically ceased. Pituitin 0.2 cc. given to strengthen pains and facilitate engagement. Patient dcIivered spontaneously of 696 pound living baby.
early stage of labor where the correct diagnosis could not have been established clinicahy. Craniotomy was found to be necessary for the extraction of the fetus. Th e puerpermm . was normaI. A mistaken diagnosis in this case would have endangered the mother’s life. This case iIIustrates the great value of roentgenoIogicaI diagnosis in cases of fetal abnormaIities at or near term. RoentgenoIogy is aIso vaIuabIe in the differential diagnosis of obscure abdominal masses and pregnancy. Hydramnios is so commonIy associated with monstrosities that a routine roentgenogram is necessary. EarIy recognition of these deformities
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wouId prevent the continuation of such a a proIonged labor, or even pregnancy, cesarian section. Hauch20 has not found the x-rays of specia1 vaIue in the earIy diagnosis of pregnancy, as the diagnosis may be made equaIIv earIy by other methods. But he has found-it of definite vaIue in differentiating between a pregnancy and a tumor; for the diagnosis of Iate extrauterine pregnancy; for demonstrating the presence of a dead fetus; for the diagnosis of twin pregnancy; and finaIIy for the diagnosis of feta1 maIformations and monstrosities before or at the time of Iabor. Favreau21 states that in some cases the feta1 skeIeton is demonstrabIe in the roentgenogram before the feta1 heart sounds can be heard. In I case at Ieast, it was demonstrated before the fourth month. As a ruIe, however, he has found that the feta1 skeIeton cannot be demonstrated with certainty before the fourth month. In some cases a very carefu1 examination of the roentgenogram must be made before evidence of the feta1 skeIeton is found. As a ruIe, in a five months’ pregnancy, the vertebra1 coIumn, sIightIy curved, and the base of the skuI1 are visibIe, and in some cases the bones of the extremities. The death of the fetus in utero is indicated by overlapping of the crania1 bones and the disappearance of the cerebra1 In case of maceration, the contents. smaIIer than norma skeIeton appears for the duration of the pregnancy and the outIines of the bones are somewhat obriterated. Case22 (1917) reported the first instance of roentgen diagnosis of anencephaIus, before birth, and in 1926, he reported have 3 additiona cases. Other authors of 15, reported I I cases, making a tota RoentgenoIogicaI examination in anencephaIus shows an absence of the feta1 crania1 vauIt, smaI1 orbits, absence of seIIa turcica, and a tendency to cervicaI spina bifida. Two cases of anencephaIy diagnosed by roentgenoIogy are reported by Beath.23
JUNE, 1931
Diagnosis
The first patient, a primipara thirty-nine years of age, appeared to be in about the eighth month of her pregnancy. The roentgenogram showed a normaIIy deveIoped fetus as regards trunk and Iimbs, but no crania1 shadow. Induction was decided upon and an anencepharic chiId weighing 5 Ib. removed. The mother recovered. The second case was that of a primipara at fuI1 term. The roentgenogram showed feta1 shadows of the thorax and Iimbs, but no crania1 shadow. Before any measures couId be taken the patient entered into Iabor, which Iasted two days. DeIivery was diffIcuIt and the mother died from shock. Beath thinks these 2 cases prove quite definiteIy the vaIue of earIy roentgenoIogy in doubtfu1 abnormalities of pregnancy. There IS a syndrome which is strongIy suggestive of deformed fetuses in utero (FaIIsz4). Roentgenograms wiI1 cIearIy demonstrate the deformity in anencephaIic, hydrocephaIic or spina bifida fetuses as early as the sixth month; but a negative x-ray does not excIude the possibiIity of deformity. The syndrome is as foIIows: I. Hydramnios occurring about the seventh month, associated with uterine tension and easy baIIottement. 2. InabiIity definiteIy to outline the feta1 head suggests anencephaIy, whiIe abnormal size or consistency suggests hydrocephaIus. 3. AnencephaIy is suggested by d&uIty in differentiating between the feta1 parts either by abdomina1 or vagina1 paIpation. AIso a soft meningoceIe surrounded by a bony ring may be feIt on vagina1 examination with a finger inside the cervix in cephaIic presentations. 4. FetaI heart tones heard faintly or absent. when hydramnios is marked. 5. AbnormaIIy active feta1 movements, which may become convulsive if pressure is made on the head in cases of anencephaIic monsters. OVARIAN
PREGNANCY
Ovarian pregnancy has been diagnosed by skiagrams (Candy25). The appearance
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was that of normaI pregnancy of about eight and one-half months, but the patient compIained of great discomfort and distention. PaIpation and vagina1 examination under anesthesia faiIed to reveal the presenting part. X-ray examination showed a fuIIy deveIoped fetus, the position and attitude of which were extremeIy irreguIar. The head and cervicaI spine were acuteIy flexed upon the chest, the cervica1 spine forming an acute projection against the anterior abdomina1 waI1 of the mother. The head was outside the peIvis and could not be made to engage. The IateraI view showed the fetus to Iie in a much more ventral position than normaI. Cesarean section was performed and a fuIItime ovarian pregnancy reveaIed. The uterus was in the peIvis and was sIightIy enIarged. The right faIIopian tube was flattened and stretched over the gestation sac. The tissue of the right ovary was thinned out and constituted the outer layer of the sac, which Iay above the broad Iigament. The child appeared to have been dead for two or three weeks. Tuba1 pregnancy is apt to rupture before reaching a size permitting of its roentgenoother than by the IogicaI recognition specia1 method of UterosaIpingography. THE
MECHANISM
OF
LABOR
AS
STUDIED
BY
X-RAYS
The oIder texts on obstetrics taught that, at the onset of Iabor, the fetus is forced towards the path of Ieast resistance, i.e., the Iower uterine segment and the cervica1 cana1. In the mechanism of Iabor the passages are the determining factors. The different diameters of the peIvic pIanes and the varied measurements of the manifold circumferences of the fetaI-presenting part necessitate the rotation, flexion, etc., of the fetus, in order that it may pass through the birth cana1. Recent studies have somewhat modified this teaching. The anterior rotation of the child is governed by the Iaw of accommodation of elastic resistance to the shape of the container. The birth cana is shaped
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Iike a straight tube with a sharp upward curve at its Iower end; the fetus, Iike two ovoids, head and trunk, united by a hinge, the cervica1 vertebrae. The birth cana would, therefore, force such a bicorporate hinged object to bend in the same direction, i.e., the Iower ovoid, or presenting part, wouId be forced upward or anteriorjy. The fetus, due to uniform interna pressure, assumes a cyIindrica1 contour, with a maximum bending faciIity in certain directions only: the head backwards and the body in a diametricaIIy opposite pIane. In order, therefore, for the fetus to pass the Iower upward curve of the birth cana1, it must proceed with a spiraI-Iike motion so that it approaches the curved portion of the cana with that part of the feta1 ovoid possessing the greatest bending facilit)- in that direction. WarnekrosZ6 was abIe to obtain roentgenograms of the fetus in a11stages of labor; and he has shown definiteIy that, when the head of the fetus enters the peIvis, the occiput and sinciput are on the same IeveI, in a position between ffexion and extension. In the first stage of labor, the uterine contractions cause the fetus to assume a more pronounced attitude of ffexion, which is, however, oniy transitory; between pains, the chiId assumes a more natura1 and comfortabIe attitude of semiffexion. A reactive influence upon the fetus sets in with the rupture of the membranes, causing it to stretch out, so that the fundus uteri can be observed rising towards the ensiform process. The spina coIumn is so constructed that each division tends to bend in the opposite direction of the other so that orthostatic posture is maintained. The force of the feta1 axis pressure directed to the upper poIe wiI1 cause the entire coIumn to assume a form which will transmit this pressure to the Iower poIe. The dorsaI vertebrae assume a kyphotic curve and the cer\-ica1 vertebrae a compensatory Iordotic curve. When the force of the uterine contraction is transmitted to the head, attached to the vertebra1 coIumn at its condyIes, the
426
American
Journal
of Surgery
Jarcho-ObstetricaI
sinciput is flexed and the occiput descends and is rotated anteriorIy. It has been further shown by Warnekros that the fetus is not an ovoid cyIinder with bony protections consisting of the bones of the upper and lower extremities. The feta1 extremities do not assume a reguIar attitude, but are thrown about in the uterus. The back of the fetus rotates anteriorIy before the head rotates, and when the head is at the orifice, with the occiput pointing directIy anteriorIy, the shouIders are then entering the peIvis transverseIy. The chest of the fetus appears compressed whiIe making its exit from the peIvic 0utIet. CIinicaI x-ray studies concerning the mechanism of Iabor help to expIain how puerpera1 fever may deveIop in the absence of infection introduced from without. They prove that the presenting part acts Iike a bacteria-smearing swab, whereby the damaged tissues with which it comes in contact may readiIy be inocuIated by microorganisms aIready present in the vagina. SUMMARY
Roentgenography has proved its vaIue in obstetrics principaIIy for the foIIowing diagnostic purposes : I. For the positive diagnosis of pregnancy in obscure cases. This can be accomplished by the fourteenth week, sometimes earlier. In some of the author’s cases, the clinica findings strongIy suggested uterine fibromyomata and onIy the roentgenogram
Diagnosis
JUNE,,931
saved the patient from an unnecessary hysterectomy. 2. For the recognition of twins. ParticuIarIy in obese patients, there may be diffrcuIty in hearing two separate feta1 hearts or paIpating a muItipIicity of feta1 parts; vice versa, the same feta1 heart may sometimes be heard cIearIy in wideIy separated Iocations, Ieading to an erroneous diagnosis of twin pregnancy. In such cases, roentgenography gives a definite answer. 3. For differentiation between pregnancy and tumors. Here roentgenography suppIements findings by the AschheimZondek test. 4. For diagnosis of tuba1 and ovarian pregnancy. 5. For reveaIing the presence of a feta1 monster. The recognition of anencephaIus and other forms of feta1 monstrosity is greatIy faciIitated by x-ray study. 6. For giving information as to the presentation and position of the fetus. As shown by severa of the author’s fiIms, the exact presentation and position are reveaIed with far greater accuracy than can be determined by physica examination aIone. This aIso obviates the need of a peIvic examination. 7. For demonstrating the mechanism of Iabor. 8. For suppIying a more accurate method of peIvimetry than any heretofore proposed and furnishing a means of cephaIometry in utero. This subject wiI1 be discussed in a subsequent paper appearing in a future issue of THE AMERICAN JOURNAL OF SURGERY.
REFERENCES 1. REINBERGER, J. R., and SCHREIER, P. C. VaIue of Y-.-n.7
*-,aJ
,+..,l:n, DLUU‘bD
;, 111
,\I...+n+,.;n, ““DLCLII\_J
“-j
a,,\
gynecoIogy*
Mempbis M. J., 7: IO, 1930. 2. GARLAND, L. H. X-rays in the diagnosis of pregnancy. CaliJornia and West. Med., 34: 150, 1931. 3. LEVY-D• RN, M. Zur Kritik und Ausgestaltung des Roentgenverfahrans. Deutscbe med. Wcbnscbr., 23: 800, 1897. 4. M~~LLERHEIM, R. Verwertung der RoentgenstrahIen in der GerburtshiIfe. Deutscbe med. Wcbnscbr., 24: 619, 1898. 5. BOUCHACOURT,L. Sur I’Ctat actue1 des applications a I’obstetricie de Ia visibiIit& radiographique du
6.
7. 8. 9. IO.
squeIette foeta1. J. de mkd. et cbir. prat., 98: 469, 1927. ALBERS-SCH~NBERG. ijber den Nachweis des Kindes in der Geblrmutter mitteIs RoentgenstrahIen. Zentralbl. f. Gyniik., 28: 1514, 1904. BARTHOLOMEW, R. A. Diagnosis of pregnancy by the roentgen ray. J. A. M. A., 76: 912, 1921. SHEUTON, E. W. H. X-rays in obstetrical practice. Lancel. 1: 860. 1022. HORNER; D. A: Roentgenography in bostetrics. Surg. Gynec. Obst., 35: 67, 1922. CANDY, T. I. Radiography of the fetus in utero. Arch. Radial. CT Electrotb., 28: 146, 1923. [For remainder of References see p. 442.1
442
American .hrd
of Surgery
Bessesen-EsophageaI
fieId, considering the few operations performed. AIthough it has been attended previousIy by high mortaIity, improvement in technique wiI1 markedly decrease this. In view of the absoIute certainty of death from this disease without operation, surgica1 remova shouId be attempted in every case where there is no evidence of metastasis.
JUNE,rgsr
chest is tightIy strapped, and hearing aIIowed for seven days before the stump of the esophagus in the neck is opened. The patient may then be aIIowed to drink. PostoperativeIy and preoperativeIy, the scientific use of the gastrostomy, and the administration of fluids by vein and subcutaneousIy wiI1 give these patients the most hopefu1 outIook from surgica1 treatment of carcinoma of the esophagus. OnIy by prompt diagnosis and earIy treatment wiI1 it be possibIe to offer these patients anything but a IOO per cent fata prognosis.
SUMMARY
At preliminary operation, a Janeway or WitzeI gastrostomy is performed under IocaI anesthesia and the Iiver and Iymphatits in the region of the diaphragmatic esophagus are inspected. Two to six weeks being aIIowed for recovery and upbuiIding of the patient, artificia1 pneumothorax is induced, the thorax is opened under narcosis and IocaI anesthesia, using gas in addition if needed. Protecting the pIeura with rubber sheets, the esophagus is dissected from its mediastina1 bed and drawn out through the neck. Infinite care is taken to contro1 hemostasis and protect the vagi nerves, consistent with compIete remova of the carcinoma. FinaIIy, a11 the air is removed from the thorax, the
REFERENCES
Carcinoma
REFERENCES
GOURSALDand NASILOFF. Quoted by Hermann Fischer. FISCHER, H. SurgicaI treatment of the esophagus. _ Arch. Surg., 6: 256, 1923. (This articIe gives an historica outIine of the progress in surgery of the esophagus.) TOREK, F. Carcinoma of the thoracic portion of the esophagus. Arch. Surg., IO: 353, 1925. EGGERS, C. Resection of the thoracic portion of the esophagus for carcinoma (tirst case). Arch. Surg., IO: 361, 1925. EGGERS, C. Report of second case of carcinoma of esophagus. Surg., Gynec. Oh., 50: 630-634, 1930. SAINT, J. H. Surgery of the esophagus (historical review). Arch. Surg., 19: 53, 1929.
OF
I I. LEISER, M. Die Friihdiagnose
der Schwangerschaft durch das RoentgenbiId. Arch. j. Gyniik., 129: 1036, 1927. 12. JUNGMANN, M. Die Roentgenfrtihdiagnose der Schwangerschaft. Fortscbr. ad. Geb. d. Roentgenstrablen., 35: 913, 1927. 13. DUJOI., G., and MICHELON, P. Le radiodiagnostic prbcoce de la grossesse dans les cinq premiers mois. Rev. franc. de gyntc. et d’obst., 24: 689, 1929. 14. BEAUJEU, A. J. de. Sur Ie diagnostic precoce de Ia Grossesse. Arch. d’flkctric m6d., 35 : 479, 1927. 15. GRIER, G. W. VaIue of Iateral view in diagnosis of pregnancy. Radiology, 14: 571, 1930. 16. NBLLE, H. Die Diagnose der AnencephaIus in der Sztyngerschaft. Zentralbl. f. GynSik., 52: 1345, du 17. BLANCHE, A. L a visibiIit& radiographique squeIette foeta1 “in utero.” Paris Mhd., 17: 136, 1927. 18. DORLAND, W. A., and HUBENY, M. J. The x-ray * Continued
DR.
JARCHO”
in Embryology and Obstetrics. Saint Paul, Minn., Bruce PubIishing Co., 1926. 19. ALBANO, G. Roentgendiagnose des Hydrocephalus Zentralbl. im Beginn der Ersffnungsperiode. f. Gyniik., 51: 2793, 1927. 20. HAUCH, E. QueIques expkriences avec Ies rayons-x dans la grossesse. Acta Obst. CT GynCc., g: 251, 1930. 21. FAVREAU, M. Le diagnostic radioIogique en obstetrique. J. de mkd. de Bordeaux, 58: 727, 1928. 22. CASE, J. T. AnencephaIy successfully diagnosed before birth. Surg. Gynec. Obst., 24: 312, 1917. 23. BEATH, R. M. Two cases of anencephaly demonstrated by x-rays. Brit. J. Radial., 3: 421, 1930. 24. FALLS, F. H. Diagnosis of fetaI deformities in utero. Am. J. Obst. @Gynec., 16: 801, 1928. 25. CANDY, T. I. Skiagrams of fuI1 time ovarian pregnancy. Brit. J. Radiol., 32: 174, 1927. 26. WARNEKROS. Schwangerschaft und Geburt in RoentgenbiIde. Ztscbr. f. Geburtsb. u. Gyniik., 80: 7x9, IgI7-18. from p. 426.