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POTT'S DISEASE AND PREGNANCY

T. HALSTED MYERS
J Bone Joint Surg Am. 1891;s1-4:124-131.

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 POTT'S DISEASE AND PREGNANCY.

By T. HALSTED MYERS, M.D.,

NEWYORK.

THE subject naturally divides itself into two parts—the effects of

Pott's disease on pregnancy, and the effect of pregnancy on Pott's
disease.
The regions of the spine which are of interest to us from their
relation to the gravid uterus are the lower dorsal, the lumbar, and
the sacral. A kyphosis in the lower dorsal necessitates an increased
inclination of the lower ribs to the pelvis, and in the marked cases
these sink deeply between the iliac crests. In the mid-lumbar
region the deformity is not apt to be so marked; in fact, exceptional
cases are seen here in which there is no curvature (Percival Pott:
vol. iii. p. 473, ed. 1873); but in the lumbo-sacral region the de
formity is again greater, owing to the diminished inclination of the
pelvis. Were it not for the compensatory curvatures, these deformi
ties would be even more marked.
In all these cases the abdominal cavity is diminished in its vertical
diameter, and in the first instance also laterally, from the pressure of
the ribs. Furthermore, abscess usually complicates disease in these
portions of the spine, and this may still further diminish the capacity
of either the abdominal or pelvic cavity. (Zweifel reports such a
case:Lehrbuclmder Geburtslmülfe.)
In the pelvis, too, we find changes due to the spinal disease. A
caries, in very exceptional cases,is stillgiven as the cause of
spondylolisthesis, and there seems to me no reason why disease of
the sacro-lumbar junction could not produce this effect. The
kyphotic pelvis is, however, the one we expect to find associated
with Pott's disease. I refer you to Winckel's Text-book on Midwifery
for an excellent description of these changes. The great majority of
@rr'

HALSTED MYERS. 125

cases of Pott's disease occur in children, and the younger the patient,
other things being equal, the greater the consequent pelvic changes,
which have been proven by Breisky to be due to the change in the
direction in which the weight of the trunk is carried to the upper
surface of the sacrum. Osteitis at the lumbo-sacral junction will
produce atrophy of the growing bones involved, just as elsewhere;
and bone-erosion here will cause, by the compensatory lumbar lordosis
above, a deformity like the “¿pelvis obtecta,― or even simulate a
spondylolisthesis if of more severe degree. A kyphosis in the lumbar
region will diminish the inclination of the pelvic plane, but in the
dorsal will generally increase it from the compensatory lumbar
lordosis. A lateral deviation will diminish the pelvic cavity on the
side of the convexity (Parvin: Amer. Sys. Obstet., p. 752). Bar
bour has proven that the lower the spinal disease the greater is the
increase in the conjugate diameter of the brim, but that the second
characteristic feature of this pelvis, the contraction of the transverse
diameter at the outlet, is not definitely related to this (Spinal
Deformity in Relation to Obstetrics).
In these cases of kyphotic pelves only the voluntary forces of
labor are much affected. These are impaired directly in proportion
to the deformity on simple mechanical principles, and the obliquity
of the uterine axis prevents the effective application of that strength
which remains. The histories of these cases show that the delay
usually occurs in the second stage. However, there are a consider
able number of cases of labor in tabetic and paraplegic women reported,
which prove that the assistance of the abdominal muscles is not abso
lutely necessary to the accomplishment of parturition in the absence
of obstruction from deformity of the pelvis or from resistant soft
parts at the outlet (Benecke: Zeitschr. f aeburts/zulfe u. ayniik., i.
77, 28; Parvin: Amer. Sy8t. Obstet., vol. i. p. 704; Farre: Tanner
on Preçjnancy, p. 337; Epley: .2V Y. Med. Journ., 1883, xxxvii.
233, etc.
The essential involuntary muscles, luckily, cannot be much affected
by disease of the spine, since though tine motor centre of the uterus
has not been satisfactorily demonstrated yet, it has been located in
the medulla (Winckel), in the hypogastric plexus (Frankenhauser),
in the brain or cord (Kehrer), and in the peritoneal coat of the
uterus (Dembo), so that amid these conflicting opinions we must con
126 POTT'S DISEASE AND PREGNANCY.

elude that the uterus may be excited to contraction by the most

varied peripheral and central influences, and that destruction of
all its motor ganglia is well-nigh impossible, however marked the
lesion.
To consider now the effect of pregnancy on the Pott's disease.
The indication par excellence for treatment in Pott's disease is
acknowledged by all to be the removal of the weight of the trunk
from the bodies of the diseased vertebrie. The mechanical effect of
a weight placed anteriorly is a most disastrous crushing together of
these very vertebral bodies, already softened by disease and totally
unable to sustain even the ordinary weight of the body. The prob
ability of abscess-formation, estimated at 70 per cent., in the lumbar
region (Parker: Brit. Med. Journ., January 12, 1884), with all the
danger that that involves, is, therefore, greatly increased by the weight
alone of the gravid uterus. The danger of rupture of already exist
ing abscess, or of precipitating pressure paralysis, is aggravated.
Aside from this, also during gestation a hyperammic condition of the
cord and its membranes, and of the pelvis generally, is thought or
known to exist (Hasse: Krankheiten des Nerven Apparates), and
the effect of this on existing disease of the vertebram must be per
nicious. I would call attention also to the anatomical fact that new
centres of ossification appear in the vertebrme at sixteen years, and
again at twenty-one years, indicating an unusual activity of the
nutritive processes at these periods—a condition favorable to the
onset of Pott's disease, or rekindling of old inflammatory foci.
This fact is important, as at this age marriage most often occurs.
Is it safe for a girl who has, or has had, Pott's disease in these
locations to marry? To answer these questions I have studied the
Imistories at St. Luke's Hospital and at the Sloan Maternity; Dr.
Simaffer has also kindly placed the New York Orthopedic Dispensary
records at my service, and I have received valuable aid from Drs.
Partridge, Lusk, R. A. Murray, Coe, Garrigues, Gibney, and
Tucker.
From the data at my disposal, it appears that of the 32 married
women observed 10 are known to have died from causes directly
connected with the disease (2 from operations necessitated by the
contracted pelves, 3 of phthisis, 4 from exhaustion from abscess, 1
from cerebro-spinal meningitis)—a mortality of 31 per cent., which
 J-IALSTEI) NYERS. 127

is probably too small, as many of th@ histories are not complete;

while of 62 other cases, occurring in unmarried women over sixteen
years of age, but 2 are known to have died. While I do not
think this shows the true ratio, I do believe it indicates a greater
mortality among the married women.
I have collected 24 cases of labor occurring in 14 cured cases of
Pott's disease of the lower dorsal, lumbar, or sacral vertebra@, and
find that in no instance has there been a relcindlin,q of the old dis
ease. The chief danger to the mother in these cured cases lies,
therefore, in the malformations produced in the pelvis and abdomen,
and in the great strain on a vitality already enfeebled. Indeed,
Neidert (Inaugural Address, Munich, 1886'@found that the cause of
death in patients with severe deformity wlnose spinal disease had
been cured was generally heart-fiLilure.
I have also notes on 7 cases in whicln active Pott's disease compli
cated pregnancy (4 dorsal, 3 dorso-lumbar). In 6 of these the
pregnancy either originated or greatly increased the severity of the
disease. In the remaining case, though an active stage of the spinal
osteitis existed, pregnancy and parturition were peculiarly harmless
under careful protective treatment, and the patient is to-day well.
On account of the great rarity of these cases, I will give a brief
outline of each.
CASE 1.—Mrs. 0. D., aged twenty-two years. Duration of dis
ease, one year; location, ninth dorsal to second lumbar. Concep
tion when disease had existed nine months. Child born at term,
easily; slight increase in pain for two weeks. Cured a few months
later.
CASE IT—Mrs. M. J. R., aged twenty-three years. Duration of
disease, four months; location, mid-dorsal. Fourth child born after
disease had existed two weeks. Labor easy. Died from rupture of
abscess into cesophagus two and a half years later, after maying three
attacks of paraplegia.
CASE 111.—Mrs. M. D., aged thirty-three years. Duration of
disease, fifteen months; dorso-lumbar region. Conception with
onset of disease. Instrumental delivery. Lumbar abscess followed;
exhaustion; phthisis. Death in twenty-two months.
CASE IV.—1'sIrs. E. C., aged twenty-four years. Onset of dis
ease with birth of second clnild; lower dorsal region. A third
128 POTT'S DISEASE AND PREGNANCY.

child, born nineteen months later, again prostrated mother greatly,

and she died soon after. Cause unknown.
CASE V. (Benecke's case).—Aged twenty-eight years. Mid-dorsal
region. Disease began with last (tenth) pregnancy. Complete para
plegia had developed before labor, which was, of course, painless,
but otherwise normal. At last note patient was completely para
plegic.
CASE VI.—Mrs. E. F. D. Lower dorsal. Married at thirty years.
Disease developed with birth of first child; increased steadily.
After second child, born seventeen montlms later, mother became
paraplegic. Labors easy and at term. Gradual, slow recovery.
Twenty-oneyearslater:remainscured.
CASE VII.—Mrs. R. Duration of disease, six years; lower
dorsal. Third child born four and a half months after onset of dis
ease; fourth sixteen months later; fifth three years after last.
Great deal of pain during gestations; relieved soon after labor.
Now tires easily, and at times has epigastric spinal pain.
Cases I. an@dVII. immediately followed severe traumatisms, which
suggests fracture as the original lesion.
Dr. Shaffer has also given me an “¿intermediate― case of great
interest. There had been no symptoms for a year and a half; yet
patient (Mrs. W.) wore a brace still, and felt she needed its support.
Easy labor at term occurred, and no untoward symptoms in the spine
resulted.
We have four points to consider in reference to treatment: Is the
diseased cured or progressive? Is the pelvis contracted or prac
tically normal?
Cases of spinal caries come to us naturally as orthopedic surgeons,
and we must remember that changes are caused in the pelvis by
spinal disease at a distance, even in the lower dorsal region if it
occurs during the period of active growth. It is our part to make
the diagnosis, as it is very important that these cases should be
put into the obstetrician's hands at as early a period of gestation as
possible, in order that abortion or premature labor may be induced,
if necessary.
In case timePott's disease is cured, the amount of pelvic deformity
will be our guide as to treatment. There can be no fixed rule in
these cases; each must be judged by itself. The researches of
 DISCIJSSION. 129

Sulger-Buel demonstrate that normal birth often follows where

measurements would indicate that it was impossible (Arch. f.
Gynà ic., Band xxxviii., 1890). The maternal mortality Barbour
found to be 59 per cent. in thirty-two cases, and Winckel found it
66 per cent. in twenty-one cases, yet neither of these observers speak
of active spinal disease complicating their cases—so, I presume, do
not take this additional danger into account.
We are still confronted with the question, What will be the effect
on the diseased vertebrse? My cases show very plainly that in cured
cases no injury has been done; furthermore, none of the gentlemen
I have referred to have ever seen in a single instance the tubercular
process rekindled by the traumatism of labor. On the other hand,
the cases in which pregnancy complicated active disease of the spine
tell no uncertain tale either, and in view of them I should advise the
termination of pregnancy, in case the disease were active, at the
earliest possible date in almost every case.

DISCUSSION.

DR. CHARLES C. FOSTER asked the opinion of the members of the

Association as to the desirability of advising women who have had
Pott's disease not to marry.

DR. H. L. TAYLOR knew of very many cured cases where mar

riage had been followed by the birth of healthy children. The
simple fact of the existence of Pott's disease, in his opinion, did not
justify one in advising against marriage.

Pa. GEORGE W. RYAN thougint it was chiefly a question of the

advisability of advising marriage in the tuberculous, for Pott's dis
ease is but one expression of tuberculosis. He knew of two married
women who had had Pott's disease, one of whom had had three
children, and the other two, and none of these children presented
any evidence of tuberculous taint.

DR. R. H. SAYRE said that, under ordinary circumstances, he

could not agree with the author as to the propriety of advising
Ortho Soc 9
 130 POTT'S DISEASE AND PREGNANCY.

premature delivery in timese cases. He had observed one case of

Pott's disease in the sacro-lumbar region, and yet she was delivered
by forceps without any especial difficulty.

Dn. SAMUEL KETCH had at present under his care a woman who
had become pregnant, gone to full term, and had a healthy child
during time progressive stage of Pott's disease. She is still under
mechanical treatment, and is naturally robust and healthy.

DR. A@ M. VANCE had seen a number of timese cases, and lmad

thought that parturition had presented about the average difficulty.
The mother, however, was liable subsequently to suffer from the
depressing effects upon her system of the pregnancy and of lactation.

DR. H. A. WILsON, of Philadelphia, was of the opinion that,

owing to the greatly improved statistics of the modern Camsarean
section, gynecologists would not give such advice as was contained
in the paper. He knew of a caseon wimichCamsareansection
had
twice been successfully performed.

DR. BENJAMIN LEE believed it was extremely rare for Pott's dis
ease, even in the lumbar region, to produce a narrowing of the pelvis.
ile had had under his care a little lady with a very large prominence
in the lumbar region, and who had Pott's disease between twelve and
sixteenyearsof age. She has had twelvechildren, and although
she has at times required the aid of forceps, none of the deliveries
could have been particularly difficult or dangerous. She is at present
in very fair health, as are also the living children, with the exception
of one withinfantile paralysis.We shouldnot adviseagainstmar
riage unless there is present a deformed or contracted pelvis. His
experience had been thatthephysician was likelytobe consulted in
regardtotheadvisability ofmarriage, and he had foundthatcareful
mothers were usually very anxious about the future of timeirdaughters
with Pott's disease. Witim regard to the propagation of tuberculosis,
he could not recall a single instance in which consumption of the
lungs had followed what is supposed by most physicians to be in
variably tubercle in the spine.
 DISCUSSION. 131

DR. A. J. STEELE, of St. Louis, referred to a case in which a

brace was applied to the spine and an abscess absorbed. He was con
sulted subsequently concerning the question of marriage, and gave a
favorable opinion. The first labor was with forceps, and since then
she has had five or six healthy children, and the mother inerself pre
sents no evidence of general tuberculosis, nor do the children. We
are likely to be consulted about the marriage of people not only with
spinal disease, but with chronic disease of other joints.

DR. MYERS, in closing the discussion, said that in his cases the
children, so far as he knew, were healthy. Parturition, as a rule,
was not severe, except in cases of very marked deformity of the pelvis.
The diminished power of the abdominal muscles which is present in
these cases causes delay, principally in the second stage, and this
usually can be overcome by forceps. His statistics show that in
cases where the disease is active, however, the mother suffers severely,
either at once or soon after, and that the mortality is very high.
But where the disease has been cured, there seems to be no danger
of rekindling it, and the risk to the mother depends on the amount
of deformity present.