Clinical Notes BV BARTON COOKE HIRST, M.D. Philadelphia, Pa. REPRINTED FROM The American Journal op Obstetrics Tol. XXXV. No. 4.1897. NEWYORK WILLIAM WOOD & COMPANY, PUBLISHERS 1897 CLINICAL NOTES.1 I. THE OPERATIVE TREATMENT OF A PROLAPSED OVARY. 11. TWO CESAREAN SECTIONS. 111. SEPTIC SALPINGITIS OF CURIOUS ORIGIN. IV. INIENCEPHALUS. I. Prolapsus ovarii, pure and simple, without disease, en- largement, or adhesions of the organ, is, in my experience, a rather rare and a very peculiar gynecological affection. All of our members, I dare say, have become familiar with the curious behavior of such an ovary ; with the manner in which it sud- denly drops into the bottom of an elongated Douglas’ pouch, totally incapacitating the patient until it goes back spontane- ously or is replaced ; with its unaccountable retention in place for varying lengths of time, and its prolapse again in conse- quence of some slight jolt or jar, or without apparent cause at all. I had been at my wits’ end in the treatment of some troublesome cases of the kind a few years ago, when I deter- mined to try shortening the suspensory ligament of the ovary. I had an indistinct idea that something of the sort had been done by Kelly, but I could find no record of it. Accordingly I thought out a technique which should shorten the ovarian end of the suspensory ligament by making a loop in it, and carried it out by an operation in a typical case, with entire satis- faction and a complete symptomatic cure that has endured to the present time, more than two years after the operation. Shortly afterward there appeared a very helpful article on the subject in one of the German magazines, with a report of five cases, advocating the attachment of the suspensory ligament to the iliac fascia. Since then I have operated on two other cases by this method with the most gratifying result. As I have not heard of this operation being done by my friends and colleagues in the Society, I present the subject for discussion, in the hope of hearing criticisms upon it or of learning, perhaps, what expe- rience others have had with it. 1 Read before the Section on Gynecology, College of Physicians of Phila- delphia, February 18th, 1897, HIRST: CLINICAL NOTES. The technique of the operation may be briefly described as follows : A rather long incision is made through the abdominal walls; the patient is put in the Trendelenburg posture; a re- tractor on the side to be operated on displays the pelvic wall; a fine silk thread on a needle is passed around the suspensory ligament about an inch or a little more away from the ovary, and is then passed through about a quarter of an inch of the iliac fascia above the ilio-pectineal line and well in front of the iliac vessels ; the two ends of the thread are now tied together, Fig. I—Case on which Cesarean section was done. and the ovary rises into perfect position, coming into an exact line with its well-placed fellow on the opposite side. -11, Cesarean Section.—lt is quite a remarkable coincidence to see two pregnant rachitic dwarfs, due within a few days of one another, and both operated upon in the same week, I have recently had this experience in the University and in the How- ard Hospitals. The first woman (Fig. 1) gave the following measurements: height, 4 feet Binches; spinseilii, 22 centimetres; cristse ilii, centimetres; external conjugate, 16 centimetres; internal conjugate, diagonal, S-j- centimetres ; true conjugate. HIRST: CLINICAL NOTES* 3 estimated, 6f centimetres. The child’s measurements were: hi- parietal, 8 centimetres; fronto-occipital, lOf centimetres; fronto occipital circumference, centimetres. The woman made a good recovery, and the child lived and thrived on its mother’s breast. The second case had the following measurements : height, 4 feet 1 inch ; spinse ilii, 22i centimetres ; cristae ilii, 22 centimetres; external conjugate, centimetres; internal con- Fig. 2.—Cesarean section. Showing an assistant compressing the blood vessels of the broad ligaments, and at the same time approximating the abdominal walls to prevent soiling the peritoneal cavity when the womb is opened. jugate, diagonal, 8 centimetres ; true conjugate, estimated, 6 centimetres. There was two centimetres difference between the obliques as a result of a very marked rachitic scoliosis of the lumbar vertebrae. The first case, too, had an obliquely dis- torted pelvis on account of inequality of the two lower limbs. The second patient made a good recovery, and the child lived and thrived on artificial feeding. I was able in one of these 4 hirst: clinical notes. operations to secure a photograph of a useful step in the tech- nique, shown in Fig. 2—namely, the compression of the broad ligaments by an assistant, who at the same time approximates the abdominal walls and thus guards the peritoneal cavity from the entrance of blood, etc. No other means need be taken to control the hemorrhage. The use of Muller’s tube is not only unnecessary, but is actually disadvantageous. 111. A Septic Salpingitis and an Ovarian Abscess' of Curious Origin.—Mrs. 8., recently operated on in the Howard Fig. B.—lniencephalus. Hospital with success for pelvic inflammation on the left side, gave the following peculiar history : Two years before she had been delivered, as her physician thought, of twins After the birth of the second child the patient declared there was still another left behind within the womb. The physician laughed at the idea, and, after making an examination, assured the woman the womb was empty. She soon developed the symp- toms of sepsis with a very foul discharge, and on the ninth day spontaneously discharged a third child, small, deformed, dead HIRST: CLINICAL NOTES. 5 and putrid. I cannot remember ever to have heard of a whole child left behind in this way, though we have all seen the pla- centa, and even a child’s head, left in the womb for a consider- able time. This case teaches obviously a useful lesson. IV. The illustration (Fig. 3) shows a typical iniencephalus, recently added to the unrivalled teratological collection in the Wistar Institute. Lewis has recently 1 published such a full account of this type of monstrosity that it is unnecessary to add more. He collected twenty-two cases in all. There is nothing of interest in the mother’s history during pregnancy or in her labor. 1 American Journal of Obstetrics. January, 1897.