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trocar, and evacuated. There was a collection of small cysts in the left wall of the main one, but these did not need emptying. The mass was then withdrawn from the abdomen, and the pedicle tied with a Staffordshire knot. There was some oozing from parietal peritoneum, so the cavity was flushed with hot water, which stopped it. A glass drainage tube was passed down into the pouch of Douglas, and the abdominal wound closed with silk sutures.
The cyst, which was found to grow from left ovary, contained nineteen pints of fluid of a thick treacly consistence, with some firmer flakes. Solid matter of cyst weighed 28 ounces. patient vomited a few times after operation, but did not complain of any pain. The drainage tube was withdrawn on the second day, The wound healed by first intention with no signs of suppuration. Temperature never rose above 100° F. The stitches were removed on the twelfth day, and patient left the hospital at the end of a month in good health. The most remarkable feature about this case was the entire absence of pain after the operation.
For many of these notes and much valuable assistance in the treatment of the cases, I am indebted to Mr. A. R. Green, Obstetric House Surgeon.
TRAUMATIC SPREADING INFECTIVE GANGRENE FOLLOWING COMPOUND FRACTURE OF FEMUR. UNDER THE CARE OF MR. BARLING, B.S, F.R.C S. REPORTED BY J. A. BERLYN, M.R.C.S.
W. M., male, aged 25, was admitted to the General Hospital June 14th, 1893, at 9 a.m., having been thrown from a high dog cart.
On examination, he was found to have sustained a fracture of the right femur in two places-in the upper third and just above the condyles. Over the latter there was a punctured wound, which looked as though it might have been produced by a
fragment of bone, but there was no positive evidence that the fracture was actually a compound one. The knee joint was full of fluid.
The limb was thoroughly cleaned with 1-20 carbolic acid lotion and dressed with sal-alembroth gauze, and splints were applied before the patient was admitted into the ward. The temperature in the evening was 98.6.
June 15th. The patient was very restless at night, and appeared to have a good deal of pain in his thigh. The splinting was undone and some increased swelling of the thigh. noticed, but nothing more, and the splinting was re-applied. Morning temperature 100'4. In the evening of this day the patient was restless, sweating freely, and delirious, much as though he were in the commencement of delirium tremens. Evening temperature 104'6.
June 16th. Patient had a fairly good night with repeated doses of chloral and the bromides. Morning temperature 102 ̊4, pulse 120. Wound dressed, looked quite healthy; the swelling of the knee increased, the circulation in the limb good, foot warm. Towards evening patient became noisy and, later, restless, but did not complain of pain. He got little sleep, although the same sedative was used as the night before. Evening temperature 104, pulse 150.
June 17th, 10 a.m. Morning temperature 100, pulse 146, very dicrotic. Patient expressed himself as being comfortable and feeling better, but his facial expression was bad. Gannow for the first time made its appearance. grene On examining the limb, a patch of dark red blood-staining was noticed in the groin, the thigh was more swollen, very tense, and tender. The circulation below the knee was good, but at the knee and in the thigh it was very sluggish, and stagnant almost in places. Emphysematous crackling was felt in the thigh, and extended up the side and flank as high as the level of the umbilicus. The wound still looked healthy and was free from suppuration, but a little gas of foetid odour escaped from it. As the result of a consultation, a number of punctures were made over the thigh. Through these there escaped gases of
foetid odour and some blood. The urine contained a cloud of albumen. At 2 p m. temperature 97, pulse 150. During the afternoon the patient vomited 13 oz. of "coffee-ground" fluid which answered the guiacum reaction for blood. The appearance of the thigh was now characteristic of gangrene, and the emphysema had spread to the costal margin in the nipple line. During the evening the temperature again ran up to 103, and the patient got rapidly weaker but suffered no pain. At 11 p.m. he vomited more blood, and expired almost immediately after. Post mortem. An examination of the viscera only was made. All were found healthy.
BY FRED EDGE, WOLVERHAMPTON.
Symphysiotomy.The most important and most engrossing subject in this province of medical science during the last six months has been that of the operation of Symphysiotomy, its claims to replace Embryotomy and narrow the application of Cæsarean section. The results so far have been very good, and now that cases are being operated upon in the United Kingdom there will be more practical means of determining its value and its place. No doubt but that the complications and dangers have been toned down and the results glorified too highly, as is the case with all new methods of treatment, but judging from the high authorities by whom this operation has been performed and their evidence on the matter, there can be little doubt but that this operative procedure has arrived to stay as the best treatment in suitable cases.
Regnier (Centralblatt für Gynäkologie, 1893, No. 6) reports a
case where Professor Chrobak performed Symphysiotomy successfully four years and a half after Cæsarean section had been performed upon the same patient by Professor Breisky. The conjugata vera was 7.5 centimetres and the pelvis a flat rachitic one. The child was extracted by podalic version without difficulty and alive. The separated pubic bones were united by
Wehle (Arbeiten aus der Königlichen Frauenklinik in Dresden, 1893) has written a brilliant paper on "The Scientific Basis of Symphysiotomy" which is well worth full translation. It must be remembered that the position of Cæsarean section has been established very largely by Sänger and Leopold, of Dresden, with such excellent results that some authors have said that "the perforation of the living child is no longer justifiable; yet in these very institutions a substitute for Cæsarean section is being adopted. Jean Claude de la Courvée, in 1644, performed the first symphysiotomy. The next was in 1777, by Sigault; but a vesico vaginal fistula and non-union of the pubic bones resulted. Hunter was strongly opposed to symphysiotomy; but in Holland, Camper and Saloman performed the operation ten times. In 1778 Siebold performed the first operation in Germany. Everywhere it got into bad hands and fell into disuse. In Italy alone its supporters held on through ridicule and abuse. Baudelocque condemned it, and others, parrot like, repeated his damnation. Credé and Scanzoni said it was permissible in a dead woman with the foetal head wedged in the pelvis. Spiegelberg merely mentions it historically. Schröder, Fritsch, A. Martin, and Runze do not even notice it. Kehrer, Zweifel, and Winckel condemn it. Winckel says: "The good results from this operation have not been obtained, but lacerations of the bladder, injuries to the sacro-iliac joints, and necrosis of pubic bones have been plentiful. Let us hope that symphysiotomy is buried for ever." Morisani, in Italy, stuck to it, but had very bad results for some years. In 1892, Pinard, of Paris, published three successful cases, thus bringing the operation home to its native city once more,
To understand the opposition to this procedure, it is necessary to notice the reasons given for condemning it. It is continually stated that the division of the pubic joint gives very little additional space in the conjugata. This statement originated through Baudelocque seeing three unsuccessful cases of Sigault's, and from an experiment upon a pelvis with a true conjugate of 4'5 centimetres. In all these cases the pelvis was so contracted that Cæsarean section was the only operation justifiable. Kilian, Scanzoni, Fehling, Kehrer, Zweifel, and many more have repeated Baudelocque's objection without re-examination. Credé experimented, and found that the symphyses cannot be separated more than four centimetres without danger to the sacro-iliac synchondroses. The reason of this was that he used the pelves of non-puerperæ, and the wellknown laxity of the puerperal pelvic joints was thus not utilised. Zweifel and Fehling stated that ossification of the symphysis often makes the operation exceedingly difficult, and necessitates sawing of the bone. Now the author examined ten pelves from women over 60, and not one was ossified; in sixty female pelves the symphysis was only central eight times, and forty times it was on the left of mid-line, explaining the reason of Baudelocque's having to saw through the bone on the right side of the symphysis. The author fixed a puerperal pelvis to a post by means of screws passed through the intervertebral foramina, the symphysis was divided, and simple lateral pressure used to separate the bones. A new element was thus discovered, for it was found that the pubic bones moved not only laterally, but also downwards, owing to the inclination of the sacro-iliac joints, which act as hinges on which the ossa innominata work. This explains the increase of 15 centimetres in the conjugata vera for 7 centimetres of separation. No one denies the increase in lateral and oblique diameters.
The next objection of its opponents that its complications and accidents are great, and so grave as to contra-indicate the operation, are idle in the face of modern antisepsis, asepsis and technique, and the success which has followed their application