General history.?Patient is a thin, sparelooking woman, with a countenance full of suffering and anxiety. Height, about 5 feet 5 inches. Has always had a healthy appetite previous to the appearance of the present disease, Has history of syphilis, gout, or rheumatism.
no
Family history.?Patient is a widow, was supported by her husband twelve years ago when
alive; but since his death she has no particular occupation; her son supports her. Has luid six children, three are now alive, married and well,
% Jflivvor of gospitat fnaciue. A CASE OF OVARIAN
TUMOUR; OPERA-
TION?RECOVERY. By Surgeon G. H. FINK, i.m.s., Civil Surgeon, Bijnor.
Bhuiiya, aged 50 years, Hindu female, was admitted into the Female Hospital, Bijuor, 011 the 20th April 1891, for ovarian tumour.
the rest are dead. She has once given birth to twins (females), who only lived two mouths. Has only had one abortion. No members of her family, as far as she can recollect, have suffered from a similar disease as she has at the present time. Past slate of health.?Has always enjoyed good health, and luis had no uterine troubles before. Menstruation was very regular, and then stopped as a natural consequence of age. She does not recollect the exact date of the change in life. Present illness.?About three or four years ago, she began to feel a growth springing from the left inguinal region, which appeared to be solid in character and gradually it extended upwards in the abdominal region. She did not pay any particular attention to this at first, as it caused her no inconvenience beyond pressure The period of slow growth on the abdomen. occupied seme years ; but within the last four months it has taken on rapid action, and has given rise to very great inconvenience. Gradual weakness and loss of appetite have also set in within these last four months, and occasional severe pains in the back and groin have come on with harassed breathing and great exhaustion after walking a few paces, which act is performed with great difficulty. Present state of health? I. Objective symptoms. The patient is a thin, spare-looking woman, with a suffering anxious countenance; prominent cheek bones, hollow cheeks, sunken sockets, angles of mouth drawn down, and wrinkles present all over the face, particularly round the eyes and mouth. The skin covering the abdomen is tightly stretched, feels thin and smooth. Two superficial veins are enlarged, and the umbilicus is pouched out. The abdomen is enormously enlarged, very much bulged out in the umbilical and hypogastric regions, but also bulged at the sides towards the flanks. The measurements are as follows:? 38 inches. (a) Over the umbilicus 34 (b) One inch below umbilicus ,, (c) Three inches above umbilicus 37 ? The general appearance of the patient is thin and half-starved, with the ovarian features very marked.
Aug.
FINK'S CASE OF OVARIAN TUMOUR.
1891.]
Reveals a large swelling of the Palpation abdominal cavity generally, and by deep pressure of both hands over the abdomen, a tumour within this large swelling, extending above the ?
umbilicus and on either side of the umbilicus for four or five inches, and a roughness over the surface of a lobular character is present. Percussion?Denotes dulness below and resonance above the umbilicus, with presence of the percussion wave, denoting fluid as being present in appreciable quantity. Dulness is most marked towards the left side of abdomen. The vagina is shortened in length and the os uteri pushed downwards. A tumour can be felt pressing on the left side and above, by rectal examination ; on passing the catheter a very little urine coines away. Micturition has been difficult for some time; dorsal
decubitus.
235
made and the whole of this straw coloured fluid continued to gush out in a stream from the abdominal cavity. The patient was turned over to the left side to empty the abdomen and then to the right side, until the ovarian tumour came fully into view. During the operation the pulse had to be most carefully watched, and at times it became almost thready, when it was found necessary to administer stimulant mixture. The ovarian tumour was now fully visible, and presented a whitish smooth appearance on the surface, and ou feeling it with both hands it was found to be solid in some places, whilst fluctuating in others; and moreover, it was roughened in the situation where it was solid. On endeavouring to lift it out of the abdominal cavity, it was found strongly adherent on the posterior aspects and also in the region of the
pelvis.
IT. Subjective symptoms. A further incision had to be made upwards Patient feels very weak; appetite is lost; canthe umbilicus to the extent of two through not walk properly; occasionally feels pain in the inches above it, and the strong adhesions to the back and groin ?, is costive as a rule; urine is omentum and intestines were broken scanty.
normal. Pulse at wrist is very weak. Breathing embarrassed.
Temperature
down and dissected
possible. The growth
gradually
as
close to the tumour
as
could, now be lifted out of its bed, and on examination was found to be a cystoDiagnosis.?Ovarian tumour complicated with solid growth. There were three principal lobes ascites. to the growth, one anteriorly of large size, the Treatment previous to operation? second posteriorly and towards the splenic region 1. A good bath. of smaller size, and the third inferiorly within 5 iv. 2. Castor-oil the pelvic cavity and resting 011 the brim of 3 iv. Aquaj Men thro Piperitse pelvis of the smallest size. Numerous smaller statim. The were found attached to these lobes. cysts 3. Ammoniac Carbonatis pr. iv. Rum 5 ii. principal cysts were tapped with the trocar and the dark coloured fluid evacuated. The tumour Aquas ad 5 i. was found attached t. d. s. by a broad pedicle to the Operation.?On the 21st April, after all the left side, a double silk ligature was tied firmly necessary arrangements were made for the opera- round the pedicle ; the clamp was then applied tion at the Female Hospital, and every tiling was above this ligature, and the tumour excised above antisepticised, and due precautions were observ- the clamp. ed to ensure success in the operation, I performThere was a little haimorrhage in the situaed the usual operation of ovariotomy with the tions where the adhesions had formed. Torsion help of my Assistant-Surgeon Sirdar Iiunjit was applied to one or two blood-vessels, and the Singh Sarin, the Female Hospital Assistant Bibi loss of blood was very little. No bleeding Hurkumar, and three compounders, one female occurred from the stump. The whole abdominal cavity was carefully and two male. The woman was placed on the operating table washed out with tepid perchloride of mercury under chloroform; the abdomen was washed care- lotion (I in 5,000) and sponges used to dry the fully with mercury lotion (1 in 5,000) all over, interior of the cavity. There was a little oozing for a time, and after the bladder was_emptied by means of a catheter, and a careful incision was then made in the this had ceased, the lips of the incision were middle line of the abdomen along the linea alba brought into as perfect coaptation as possible, and silver wire sutures, 13 in number, applied. from two inches below the umbilicus to the pubes. Scarcely any bleeding took place at this stage Plorse-hair sutures were placed between the of the operation. The peritoneal tissue and its silver wire sutures, with this difference, however, into view, and a small open- that the silver wires were passed through the came now coverings was made into the peritoneal cavity at the skin and peritoneal tissue ; but the horse-hair ing upper extremity of the incision, when a straw- only through the skin. The sutures were tied from the pubes upwards, and as each suture was coloured fluid squirted out with great force and could not be checked. A further incisiou was applied, the lips of the wound were carefully ...
...
...
...
...
2SG
INDIAN MEDICAL GAZETTE.
washed with mercury lotion and dried before the next suture was tied. No drainage tube was
applied.
once more washed the external surface of the abdomen with tepid mercury lotion, iodoform powder was sprinkled over the line of incision, a piece of lint soaked in mercury lotion was laid along the line of the wound and a thin muslin gauze folded double and steeped in mercury lotion, enveloped the lint covering the whole surfiice of abdomen. A layer of cotton wool prepared with corrosive sublimate was placed over the gauze, and last of sill a broad linen bandage fastened the dressings firmly. The patient was placed comfortably in bed and the following prescribed : 1. Barley water and milk ad libitum. half an hour after the 2. Solid Opium gv. and gr. ^ at bed time. operation 3. Relieve the bladder morning and evening if necessary. The temperature is as recorded in the chart. The patient's pulse was weak after the operation, so 1 ordered rum mixture to be administered every two hours. 22nd April.? No motion; bladder relieved by catheter thrice, but no urine came away each time. Patient is thirsty; pulse very weak; wound dressed. Stop rum. Administer the following :?
Having
?
R
Sp. Ammonia) Aqua: ad
avomat.
m. xx.
51.
To be taken every third hour. Barley water and milk ad libitum.
23rd April.?Pulse lias improved ; passed a Patient says she pint of urine voluntarily. feels better. No feeling of distension of abdomen ; is thirsty. Continue treatment as before. Opium gr. ? and evening. morning O O 24th April.?No motion ; passes urine. Pulse is better, 80 per minute ; no pains or tenderness of abdomen ; thirst is less. Removed two silver wire sutures over hypogastrium. Resin plaster applied as support. Dressed as usual. Treatment continued. 2oth April.?Pulse is quick, full and compressible, 84 beats per minute. Complains of pain in the epigastrium; 110 thirst. Removed silver wire sutures throughout. Resin plaster
used as support. Dressed continued as before. R
26th up to 9
Glycerine
5i.
Inject
usual.
Treatment
per rectum.
April.?Doing well; had three motions p.m. Complains of slight pains in epi-
gastrium : 110 tenderness 88 per minute, pretty full says she is better and
can
left side. No thirst. Add two eggs to milk.
or
as
on pressure. Pulse and strong. Patient turn over to the right Treatment continued.
[Aug.
1891.
April.?No motion ; slight pain in abdopulse is somewhat weak. Dressed as Treatment before. Iiealed by first intention. 21th
men;
continued.
April.?No motion ; passes urine volunslight pain in abdomen ; pulse is weak.
28th
tarily
;
Dressed as usual Treatment continued.
Qtiinife Sulpliatis
R
Acid
Sulpliurici
hair
;
sutures
gr.
dil.
m.
29th
morning
and
April.?Had
1|. ii.
5i.
Aqua) To be taken
removed.
evening.
a
motion
last
evening;
80 per minute ; feels hungry, she says, and wants to eat bread. Tongue moist
pulse improved,
and cleaning rapidly ; allowed to sit up for 15 minutes. Treatment continued as before. Stop quinine mixture. Ordered? Ferri et Quinize Citratis
3.'.s.
Aquae
jxii.
ji.
Sago
t. d. s. after food.
and milk allowed.
30th April.?Temperature normal ; pulse normal; tongue moist and clean. Feels hungry; passed no motion this morning; complains of weakness only. Treatment continued. Wound
dressed with iodoform after washing surface of abdomen with mercury lotion. 1 May.?Patient cheerful; had one motion last evening. Doing well in every respect. Treatment continued. 2nd May.?Patient convalescent; allowed to sit up for a couple of hours. Diet improved?Dal, rice. 3rd May.?Patient doing well ; sits up and is quite cheerful. Treatment continued. Diet improved and increased. 4th May.?Rapid improvement; allowed to sit up and walk a little. Diet to be improved daily ; bread and dal allowed. 9th May.?Patient perfectly well ; has put on flesh ; looks cheerful, laughs, talks, and walks about freely. Discharged cured. Remarks.?In the above case the prognosis did not seem highly favourable owing to patient's weak condition and her pulse which was Being anxious very feeble, almost thready. to be operated on and her life being a burden to her, the operation was undertaken with every attention to details regarding cleanliness, etc. The haemorrhage during the operation was very slight indeed, and it was only when breaking down and dissecting the adhesions of intestines and omentum to the tumour that bleeding did occur, but not to any great extent. The abdominal cavity was thoroughly and effectually washed out, and it was not till I was sure that every bleeding point was secure, and that the pedicle of the tumour was iu safe
Aug.
1891.]
A
MIRROR OF HOSPITAL PRACTICE.
that I ventured to suture the line of incision with silver wire. In two of my previous cases of ovarian tumour operated on in this hospital, I inserted a glass drainage tube at the lower extremity of the incision ; but I regret to say that the procedure seemed to me to be disastrous, for suppuration occurred along the track of the glass tube and kept up for some considerable time. In the case in point there was no drainage tube applied, the -result being that the wound healed by first intention and not a drop of pus came away, nor was there any indication in the temperature to open out the sutures to evacuate pus. I am firmly of opinion that, having used antiseptic means and irrigated the abdominal cavity thoroughly and wiped it dry with, clean sponges and having arrested bleeding at every point, it is perfectly safe, nay better to apply your sutures without the insertion of a drainage t^ibe. Should rise of temperature, pain and tenderness of abdomen with any other peculiar features point to accumulation of pus, then it is easy enough to open out the stitches at lower part of abdomen and let the pus out. The case in point did remarkably well throughout and made a most rapid and excellent recovery, and there was no untoward symptoms of any kind. The tumour weighed 9lbs. and the ascitic fluid drawn away measured 25 pints. I have to offer my thanks to Assistant-Surgeon Sirdar Runjit Singh for the careful notes of the case and to Female Hospital'Assistant Bibi Htirkumar for her undivided attention in nursing the patient.
custody
237
no
Family history.?Patient is a widow, was supported by her husband twelve years ago when
alive; but since his death she has no particular occupation; her son supports her. Has luid six children, three are now alive, married and well,
% Jflivvor of gospitat fnaciue. A CASE OF OVARIAN
TUMOUR; OPERA-
TION?RECOVERY. By Surgeon G. H. FINK, i.m.s., Civil Surgeon, Bijnor.
Bhuiiya, aged 50 years, Hindu female, was admitted into the Female Hospital, Bijuor, 011 the 20th April 1891, for ovarian tumour.
the rest are dead. She has once given birth to twins (females), who only lived two mouths. Has only had one abortion. No members of her family, as far as she can recollect, have suffered from a similar disease as she has at the present time. Past slate of health.?Has always enjoyed good health, and luis had no uterine troubles before. Menstruation was very regular, and then stopped as a natural consequence of age. She does not recollect the exact date of the change in life. Present illness.?About three or four years ago, she began to feel a growth springing from the left inguinal region, which appeared to be solid in character and gradually it extended upwards in the abdominal region. She did not pay any particular attention to this at first, as it caused her no inconvenience beyond pressure The period of slow growth on the abdomen. occupied seme years ; but within the last four months it has taken on rapid action, and has given rise to very great inconvenience. Gradual weakness and loss of appetite have also set in within these last four months, and occasional severe pains in the back and groin have come on with harassed breathing and great exhaustion after walking a few paces, which act is performed with great difficulty. Present state of health? I. Objective symptoms. The patient is a thin, spare-looking woman, with a suffering anxious countenance; prominent cheek bones, hollow cheeks, sunken sockets, angles of mouth drawn down, and wrinkles present all over the face, particularly round the eyes and mouth. The skin covering the abdomen is tightly stretched, feels thin and smooth. Two superficial veins are enlarged, and the umbilicus is pouched out. The abdomen is enormously enlarged, very much bulged out in the umbilical and hypogastric regions, but also bulged at the sides towards the flanks. The measurements are as follows:? 38 inches. (a) Over the umbilicus 34 (b) One inch below umbilicus ,, (c) Three inches above umbilicus 37 ? The general appearance of the patient is thin and half-starved, with the ovarian features very marked.
Aug.
FINK'S CASE OF OVARIAN TUMOUR.
1891.]
Reveals a large swelling of the Palpation abdominal cavity generally, and by deep pressure of both hands over the abdomen, a tumour within this large swelling, extending above the ?
umbilicus and on either side of the umbilicus for four or five inches, and a roughness over the surface of a lobular character is present. Percussion?Denotes dulness below and resonance above the umbilicus, with presence of the percussion wave, denoting fluid as being present in appreciable quantity. Dulness is most marked towards the left side of abdomen. The vagina is shortened in length and the os uteri pushed downwards. A tumour can be felt pressing on the left side and above, by rectal examination ; on passing the catheter a very little urine coines away. Micturition has been difficult for some time; dorsal
decubitus.
235
made and the whole of this straw coloured fluid continued to gush out in a stream from the abdominal cavity. The patient was turned over to the left side to empty the abdomen and then to the right side, until the ovarian tumour came fully into view. During the operation the pulse had to be most carefully watched, and at times it became almost thready, when it was found necessary to administer stimulant mixture. The ovarian tumour was now fully visible, and presented a whitish smooth appearance on the surface, and ou feeling it with both hands it was found to be solid in some places, whilst fluctuating in others; and moreover, it was roughened in the situation where it was solid. On endeavouring to lift it out of the abdominal cavity, it was found strongly adherent on the posterior aspects and also in the region of the
pelvis.
IT. Subjective symptoms. A further incision had to be made upwards Patient feels very weak; appetite is lost; canthe umbilicus to the extent of two through not walk properly; occasionally feels pain in the inches above it, and the strong adhesions to the back and groin ?, is costive as a rule; urine is omentum and intestines were broken scanty.
normal. Pulse at wrist is very weak. Breathing embarrassed.
Temperature
down and dissected
possible. The growth
gradually
as
close to the tumour
as
could, now be lifted out of its bed, and on examination was found to be a cystoDiagnosis.?Ovarian tumour complicated with solid growth. There were three principal lobes ascites. to the growth, one anteriorly of large size, the Treatment previous to operation? second posteriorly and towards the splenic region 1. A good bath. of smaller size, and the third inferiorly within 5 iv. 2. Castor-oil the pelvic cavity and resting 011 the brim of 3 iv. Aquaj Men thro Piperitse pelvis of the smallest size. Numerous smaller statim. The were found attached to these lobes. cysts 3. Ammoniac Carbonatis pr. iv. Rum 5 ii. principal cysts were tapped with the trocar and the dark coloured fluid evacuated. The tumour Aquas ad 5 i. was found attached t. d. s. by a broad pedicle to the Operation.?On the 21st April, after all the left side, a double silk ligature was tied firmly necessary arrangements were made for the opera- round the pedicle ; the clamp was then applied tion at the Female Hospital, and every tiling was above this ligature, and the tumour excised above antisepticised, and due precautions were observ- the clamp. ed to ensure success in the operation, I performThere was a little haimorrhage in the situaed the usual operation of ovariotomy with the tions where the adhesions had formed. Torsion help of my Assistant-Surgeon Sirdar Iiunjit was applied to one or two blood-vessels, and the Singh Sarin, the Female Hospital Assistant Bibi loss of blood was very little. No bleeding Hurkumar, and three compounders, one female occurred from the stump. The whole abdominal cavity was carefully and two male. The woman was placed on the operating table washed out with tepid perchloride of mercury under chloroform; the abdomen was washed care- lotion (I in 5,000) and sponges used to dry the fully with mercury lotion (1 in 5,000) all over, interior of the cavity. There was a little oozing for a time, and after the bladder was_emptied by means of a catheter, and a careful incision was then made in the this had ceased, the lips of the incision were middle line of the abdomen along the linea alba brought into as perfect coaptation as possible, and silver wire sutures, 13 in number, applied. from two inches below the umbilicus to the pubes. Scarcely any bleeding took place at this stage Plorse-hair sutures were placed between the of the operation. The peritoneal tissue and its silver wire sutures, with this difference, however, into view, and a small open- that the silver wires were passed through the came now coverings was made into the peritoneal cavity at the skin and peritoneal tissue ; but the horse-hair ing upper extremity of the incision, when a straw- only through the skin. The sutures were tied from the pubes upwards, and as each suture was coloured fluid squirted out with great force and could not be checked. A further incisiou was applied, the lips of the wound were carefully ...
...
...
...
...
2SG
INDIAN MEDICAL GAZETTE.
washed with mercury lotion and dried before the next suture was tied. No drainage tube was
applied.
once more washed the external surface of the abdomen with tepid mercury lotion, iodoform powder was sprinkled over the line of incision, a piece of lint soaked in mercury lotion was laid along the line of the wound and a thin muslin gauze folded double and steeped in mercury lotion, enveloped the lint covering the whole surfiice of abdomen. A layer of cotton wool prepared with corrosive sublimate was placed over the gauze, and last of sill a broad linen bandage fastened the dressings firmly. The patient was placed comfortably in bed and the following prescribed : 1. Barley water and milk ad libitum. half an hour after the 2. Solid Opium gv. and gr. ^ at bed time. operation 3. Relieve the bladder morning and evening if necessary. The temperature is as recorded in the chart. The patient's pulse was weak after the operation, so 1 ordered rum mixture to be administered every two hours. 22nd April.? No motion; bladder relieved by catheter thrice, but no urine came away each time. Patient is thirsty; pulse very weak; wound dressed. Stop rum. Administer the following :?
Having
?
R
Sp. Ammonia) Aqua: ad
avomat.
m. xx.
51.
To be taken every third hour. Barley water and milk ad libitum.
23rd April.?Pulse lias improved ; passed a Patient says she pint of urine voluntarily. feels better. No feeling of distension of abdomen ; is thirsty. Continue treatment as before. Opium gr. ? and evening. morning O O 24th April.?No motion ; passes urine. Pulse is better, 80 per minute ; no pains or tenderness of abdomen ; thirst is less. Removed two silver wire sutures over hypogastrium. Resin plaster applied as support. Dressed as usual. Treatment continued. 2oth April.?Pulse is quick, full and compressible, 84 beats per minute. Complains of pain in the epigastrium; 110 thirst. Removed silver wire sutures throughout. Resin plaster
used as support. Dressed continued as before. R
26th up to 9
Glycerine
5i.
Inject
usual.
Treatment
per rectum.
April.?Doing well; had three motions p.m. Complains of slight pains in epi-
gastrium : 110 tenderness 88 per minute, pretty full says she is better and
can
left side. No thirst. Add two eggs to milk.
or
as
on pressure. Pulse and strong. Patient turn over to the right Treatment continued.
[Aug.
1891.
April.?No motion ; slight pain in abdopulse is somewhat weak. Dressed as Treatment before. Iiealed by first intention. 21th
men;
continued.
April.?No motion ; passes urine volunslight pain in abdomen ; pulse is weak.
28th
tarily
;
Dressed as usual Treatment continued.
Qtiinife Sulpliatis
R
Acid
Sulpliurici
hair
;
sutures
gr.
dil.
m.
29th
morning
and
April.?Had
1|. ii.
5i.
Aqua) To be taken
removed.
evening.
a
motion
last
evening;
80 per minute ; feels hungry, she says, and wants to eat bread. Tongue moist
pulse improved,
and cleaning rapidly ; allowed to sit up for 15 minutes. Treatment continued as before. Stop quinine mixture. Ordered? Ferri et Quinize Citratis
3.'.s.
Aquae
jxii.
ji.
Sago
t. d. s. after food.
and milk allowed.
30th April.?Temperature normal ; pulse normal; tongue moist and clean. Feels hungry; passed no motion this morning; complains of weakness only. Treatment continued. Wound
dressed with iodoform after washing surface of abdomen with mercury lotion. 1 May.?Patient cheerful; had one motion last evening. Doing well in every respect. Treatment continued. 2nd May.?Patient convalescent; allowed to sit up for a couple of hours. Diet improved?Dal, rice. 3rd May.?Patient doing well ; sits up and is quite cheerful. Treatment continued. Diet improved and increased. 4th May.?Rapid improvement; allowed to sit up and walk a little. Diet to be improved daily ; bread and dal allowed. 9th May.?Patient perfectly well ; has put on flesh ; looks cheerful, laughs, talks, and walks about freely. Discharged cured. Remarks.?In the above case the prognosis did not seem highly favourable owing to patient's weak condition and her pulse which was Being anxious very feeble, almost thready. to be operated on and her life being a burden to her, the operation was undertaken with every attention to details regarding cleanliness, etc. The haemorrhage during the operation was very slight indeed, and it was only when breaking down and dissecting the adhesions of intestines and omentum to the tumour that bleeding did occur, but not to any great extent. The abdominal cavity was thoroughly and effectually washed out, and it was not till I was sure that every bleeding point was secure, and that the pedicle of the tumour was iu safe
Aug.
1891.]
A
MIRROR OF HOSPITAL PRACTICE.
that I ventured to suture the line of incision with silver wire. In two of my previous cases of ovarian tumour operated on in this hospital, I inserted a glass drainage tube at the lower extremity of the incision ; but I regret to say that the procedure seemed to me to be disastrous, for suppuration occurred along the track of the glass tube and kept up for some considerable time. In the case in point there was no drainage tube applied, the -result being that the wound healed by first intention and not a drop of pus came away, nor was there any indication in the temperature to open out the sutures to evacuate pus. I am firmly of opinion that, having used antiseptic means and irrigated the abdominal cavity thoroughly and wiped it dry with, clean sponges and having arrested bleeding at every point, it is perfectly safe, nay better to apply your sutures without the insertion of a drainage t^ibe. Should rise of temperature, pain and tenderness of abdomen with any other peculiar features point to accumulation of pus, then it is easy enough to open out the stitches at lower part of abdomen and let the pus out. The case in point did remarkably well throughout and made a most rapid and excellent recovery, and there was no untoward symptoms of any kind. The tumour weighed 9lbs. and the ascitic fluid drawn away measured 25 pints. I have to offer my thanks to Assistant-Surgeon Sirdar Runjit Singh for the careful notes of the case and to Female Hospital'Assistant Bibi Htirkumar for her undivided attention in nursing the patient.
custody
237
