usual incision was made about 4 inches long below the umbilicus. The main cyst was adherent to the abdominal wall in front and was accidentally punctured, and a considerable amount of fluid escaped, some into the peritoneal cavity. The large cyst was found to be connected with the left ovary, but the ovary on the right side was also found to have several small cysts connected with it, the largest about the size of an orange. It was therefore removed. The pedicles were secured with thick sterilized silk ligatures. The abdominal wall was closed with silkworm gut sutures after the manner recommended by Treves, that is, the suture passed through all the structures of the abdominal wall. The peritoneal cavit}', I I should say, was first thoroughly washed out with sterilized hot water. The patient was allowed nothing but hot water for 24 hours, with the exception of an injection of strychnine shortly after the operation as the pulse was low and the extremities cold, patient suffering a cjood deal from shock, OO and an injection of morphia subcutaneously in the evening as she was very restless and fretful. In the evening her temperature rose to 101? F., but the next morning it was normal; 100 6 was the highest temperature recorded after this on the second and third day. The stitches were removed on the 17th November, and with the exception of great weaknes she was all right. She was unfortunately very fretful and greatly retarded her convalescence by refusing food, dragging at her bandages. However she was discharged on 13th January lookino- very well and much stouter 1 than she was on admission. Case No. 2.?The main point of interest connected with this case turns on thefact thatslie was admitted again in July with a ventral hernia, and in very indifferent health, so that I could not operate on her until the 21st August. The operation was not as easy as I expected. The wall had given way a little on the left of the cicatrix which was part of the right wall of the sac. The peritoneum appeared to have become adherent to the skin and to have completely excluded the muscular layers of the abdominal wall. In trying to separate the cicatricial tissue I opened the peritoneum. Having done so, I separated it on both sides of the cicatrix, sewed it up with a continuous suture of fine catgut and dropped it. I then got the muscular layer, and 1 was surprised to find to what a distance the muscle on either side had retracted back; and to prevent anything getting between them again, I sutured the posterior layer of fascia, then the muscle, then the anterior layer of the sheath, then the skin. The external wire sutures were removed on the 31st; the buried ligatures consisting of chronic gut and silkworm gut were left in. The superficial wound took a long time to heal, but there were no serious symptoms; the highest -|
?
?
,
?
% J|lii[i[oi[ of Hospital fraqtiqt. ABDOMINAL SURGERY BY J. C.
AT
RAIPUR&
POYNDER, M.R.C.S., L.R.G.P, MAJOR,
I.M.S.,
Central Provinces.
Cases of Ovariotomy. was adCase No. 1.? Mai Kortin, age 35, 10th on tumour mitted for treatment of ovarian and November. The woman was in fair health, She the diagnosis prevented nothing special. The was operated upon on the loth November.
?
THE INDIAN MEDICAL GAZETTE.
20S
recorded was on the evening of the 101'6. The woman, as before, greatly retarded her recovery by her fretfulness and restlessness, but she was finally discharged on Sth November 1897, and I have heard nothing of her since, so I hope that she has had no ; further trouble of any sort. The question arises, whether the single suture I is sufficient to form a good union or rather a I union in every case which will bear the strain it is called upon to bear by the females of this country. They lift heavy weights and carry them on their heads, causing great strain on the abdominal muscles. 1 had another case previously in which there was very distinct tendency to ventral hernia after about a year. A patient returned to show herself twice after operation; perhaps the cicatrix has not given way any more, or perhaps the female died during the famine, as she belonged to the Bilaspur district where the mortality was very high and the distress very severe during the famine year. Her case was reported in the Indian Medical Gazette of August 1896. I have not seen her since her second visit, so I am not sure whether a regular hernia developed or not. It appears to me that there is much more risk of folding different structures over each other when a single line of suture is used, and the resulting cicatrix is more liable to give way. This untoward result is, I think, less likely to happen if each separate plane is brought together by a line of The operation takes longer, however, sutures. and I must admit that in some of my other cases I have obtained very good results. Still, with equal care, the results in the two cases mentioned were not so good, and the operation described for the ventral hernia clearly showed that the peritoneum and skin were more or less fused together to the complete exclusion of the muscle; and I think, for the future, in the labouring classes, when the condition of the patient will admit it, I shall give the necessary time to suture the different layers separately. Case No. 3.?Milapa, age 50, admitted 31st October 189G. Ordinary cyst. Patient rather thin and not very ctrong. Received quinine, iron and strychnia mixture and was well fed until the i 12th No\ embei. when the abdomen was piepared for operation as usual, and she was operated upon. The operation was very simple; the cyst was free from adhesions and had a low? fairly thin pedicle, which was tied between ligatures and dropped into the cavity after being washed with a little sterilized water and gently dried with a clean sponge. There was no bleedinrr or escape of fluid into the cavity and so the
temperature
operation,
toneum was not
rature, 102'4?
washed
peri-
Highest tempeevening. I forgot to add closed with a single line out.
on the that the wound was of silkworm gut sutures ; it was 99?F. on the 13th and normal on the 14th. Sutures removed on the 19th. The patient was kept in
[June
until she became
hospital looking.
quite
fat and
1899.
healthy
further has been heard about this hope she has had no trouble with the cicatrix, though the wound was only sutured with the one line of silkworm gut sutures. Case No. 4.? Janki, wife of a sepo3r, 2nd Ilegt., was sent to the Main Dispensary bj' Capt. Moore, I.M.S., for treatment on 20th August 1896. She had a rather curious history. Two years ago she had a child; 15 days after her confinement she noticed a small swelling in her abdomen on the right side, which was moveable, and increased steadily, but not very rapidly. She had no return of her menstrual functions until March 1896, and she then onl}' menstruated regularly once. She thinks she became pregnant immediately after this, but there was slight discharge at the end
Nothing
case,
of
so
I
April.
abdomen subsequently increased very and caused her much pain. For the last two months the tumour has been increasing rapidly, so much so, that she has some considerable dyspnoea, continual fever, and much pain in the abdomen. On admission her state of health was very bad, the conjunctiva deeply tinged with bile. Temperature, 99?. Pulse weak Countenai.ee very drawn and haggard; furred; bow els not tongue O OO of open for two days and has only had snatches her the in the last For week, evening, sleep. temperature went up to 100 4. The abdomen was tightly distended, manifestly more on the right side than the left. The measurements were from right anterior superior spine to umbilicus, 10 inches. Ditto on the left side, 8 inches. From spine to umbilicus, right side, 1 foot 7 inches. Ditto on the left side, 1 feet G inches. Fluctuation plainly felt all over the right side; no fluctuation or merely an obscure elastic feeling on the left side and distinct hard maws could be felt on the left side, so that it was clear that there was one large cyst on the right side, and she was probably pregnant. The os was rather low down and slightly patulous; there some was bulging of the right side of the A sound was not passed as she was provagina. bably pregnant. I must admit that I was not quite positive that the woman was pregnant. Mrs. George, the female hospital assistant, informed me that she had distinctly heard the fetal heart on the day after her admission, but neither Capt. Moore nor myself could hear it, and Mrs. George failed to hoar it Her
rapidly
/
again.
'
The condition of the patient was about as bad it could be, but.she was kept quiet with careful light nourishing diet, small doses of stimulants and quinine, and her general condition improved so rapidly that I determined to operate on the 26th, as the distension of her abdomen was very distressing to her.
as
ABDOMINAL SURGERY?POYNDER.
Junk
209
'
had formed, and the only indication that something was wrong was that the fresh un ted tissues at the lower end of the wound distinctly some multilocular cyst, to break down and became slightly very large began compressing and to severely cysts reaching up purulent. There was no offensive smell, and I the size of the cyst there the spleen. Beyond the about operation. believed that the woman had become infected no great difficulty was with through the uterus after the abortion. In this, foetus a contain to The uterus was found I believe, L was entirel}7 wrong, as I was allowed and it was distinctly its head towards the os, to make a I it is, partial post-mortem examination Though elongated and oval in shape. ot the parts that had been operated upon, and on the subject works the of in some think, stated on the I on a small abscess came wound, is opening distinctly that the cavity of the uterus behind the pubes, between the peritoneum towards just foetus the globular and the headtheof of and the muscular wall. pains complained the thorax. Possibly There was very slight serous effusion in the the and patulous were leading towards abortion, lower part of the pelvis, but neither the uterus idea. this favours condition of the os rather well, but in peritoneum nor intestines showed any marked Patient bore the operation fairly Pulse was congestion such as would probably accompany 138. the evening rose to 102 8 ; pulse peritonitis or metritis. of strychnia septic a dose had I think that the bandage becoming wetted distinct!}' weak, and she injection. with subcutaneously, and later on a morphiashe urine must have permitted the passage of did not but This quieted her to some extent, 5 septic germs to very lowest portion of the wound aborted foetus about which was found not quite healed, but perfectly sleep. At 7 a.m., she dropped months old, after which the temperature healthy looking when the stitches were removed. She liad a douche of warm permangato normal. In removing the lowest stitch, I think, some of naturmoved nate of potash lotion. The bowels these germs had been dragged into, and infected comfortable. much more the course of the suture, ally, and the patient was she as resulting in the formaIn the afternoon a catheter was passed, tion if the small abscess found at the post-morthe and had not passed urine for some hours, tem; it contained about two drachms of unhealthy some bladder was found to be distended slightly; sanious pus rather offensive but not ver}7 markedmine was drawn off She had no subsequent ly so. I think the want of difficulty. She was given :? in the lower and the usual inciThe abdomen was cleansed, a on the right was tumour sion was made; the of the smaller
_
Ext.
Ergota Liq.
...
...
..
3ss.
mv.
Liq Strychnia jii ?Aqua enema nutrient to contract, uterus the To help Temperature was was given later in the day. it rose to 99. when normal until the evening, normal. Patient had passed ..
...
29th.?Temperature
...
...
some milk and was fairly very good night, took binder had got soaked flannel The comfortable. Patient went with urineand was changed to-day. between on very fairly. Temperature varying and normal and 99'4. Bowels were fairly regular, and well, she took her nourishment well, slept would she there seemed to be every hope that 2nd The stitches were removed on the recover. whole the the after operation; September, 7 days of the wound had healed except a small piece Here the about ? inch long at the lower part. beneath structures but the a little, skin gaped On the to have healed completely. appeared of rise distinct temperature in 5th, there was a of the day it the middle in and the morning, on the is not shown This went up to 103. and temperaevening chart, as on the morning after this the temperature tures were shown, but show the regular septichart attached began to rises and falls. cemia type of chart?rapid dressed, the The wound was most carefully done that uterus washed out, and everything of the operacourse The of. could be thought but no tion wound was most carefully examined, which felt be could local thickening or hardness that a stitcli abscess would lead one to a
suppose
vitality
part
of the wound was an indication of the mischief underneath, and 1 might with propriety have opened down to see whether I could Hud anything. The abscess was not very clearly circumscribed and was situated on rather loose areolar tissue; consequently there was not that hardness or sense of resistance which generally clearly indicates the formation of a local abscess, and in the absence of these I felt hardly justified in reopening the wound, as it seemed quite probable that the woman had become infected through the uterus. I hope I may not have cause to do so, but in a similar case with a much unhealthy piece of wound, 1 shall certainly open it freely. Another very important question also arises here?should I have been justified in producing abortion to begin with ??and I am inclined to think it would have been the wiser course. Cases of ovariotomy have been reported in which the operation has been successful, and the mother has gone on to the full term. Hindoos are proud of a large family, and would, as a rule, I think, choose to undergo considerable risk rather than abort. I, therefore, determined to operate and try to save the child. On the other hand, the woman was not in the best of health, even though she made such progress during the time she was in hospital before operation. Had she aborted first and recovered, which there is no particular reason to suppose she
The Indian Medical
Gazette,
June 1899.
ABDOMINAL ABDOMINAL SURGERY AT RA1PUR. SURGERY AT RAIPUR. RECORD RECORD OF OF
AND RESPIRATION. PULSE AND RESPIRATION. TEMPERATURE, TEMPERATURE, PULSE
210
THE INDIAN MEDICAL GAZETTE.
would not have done, she would probably have been in better health and reduced the chance of her getting septicemia, as the uterine discharges greatly increase the chances of producing septic contamination. The reduction in the size of the uterus would have considerably relieved the tension of her abdomen and the dyspnoea owing to pressure on the diaphragm ; and the subsequent abortion, which was very likely to occur, certainly increased the general shock and depression after the operation ; though it did appear to have an}' immediate detrimental effect, it must have added to the strain on the
1899.
was 101 '4; in the evening, it was-104, when she had a cold sponging, and it fell to 100, after which she slept well. There was a good deal of sanguineous discharge from the vagina, O O requiring frequent syringing with Condy's fluid to keep her clean. On the 28th, as her temperature had again gone up to 104, she had a subcutaneous injection of 5 in. creasote in 5 in. olive oil. This was followed in two hours by most copious perspiration, and a drop in the temperaIt produced, however, in addition, ture to 1)8. most dangerous symptoms of collapse, the pulse became weak and thready, and the patient was barely conscious. However, she pulled round after an rather injection, and the temperature began to go up again. It was kept fairly in check by sponging, and from this time she began to improve, and the temperature became normal the 2Gth, and she was discharged after a on month on the 24th November, quite stout and hardly recognizable as the thin worn-out creature who had been admitted. The main point of interest about her case was whether the purgative had caused the mischief; it seemed very much like it; and it is well to postpone a purgative until later; if required, an enema 011I37 should be given. Another point of interest is the powerful effect produced by the subcutaneous injection It appears to be a very valuable of creasote. remedy, but requires to be used with great care owing to the depression which may follow its
pevature
'
o
system.
The time of operation after abortion is in the hands of the operator, but the time the uterus will take to get rid of its contents is not under control, and probably will take place, as this one did, not long after the operation. Taking all these facts into consideration, 1 think I should feel inclined to produce abortion
a similar case. It may appear very easy in theory to diagnose pregnancy in a case like this, but I may say quite certainly that it isn't. I know of one or two cases in which mistakes have been made I have by some of the highest authorities, and with tumour an ovarian secondary myself seen cysts inside it, tightly distended, which gave an exceedingly good illustration of what a child's head feels like in utero, when felt through the abdominal wall. Captain Moore, I.M.S, was kind enough to give me his valuable assistance at the time of the operation, and subsequently saw the patient frequently and with some difficulty obtained the permission of the patient's husband to enable us to examine thq wound, by which I was able to find out where the mischief had probably originated?a of information for future most valuable
[Junk
in
j
use.
Case No. G.?Remootoo Kaotin, age about 45, admitted 011 2nd August 1897 with ovarian tuHealth indifferent. Was put on quinine, mour. tonics and extra food until the 18th.
18til, Operation.?Nothing abnormal; a very large cyst was removed in the usual manner. I11 this case the peritoneum was washed out with
piece hot sterilized water and sewed up with a line guidance. continuous Ghose catgut suture, the muscles and fascia Chunder gave Assistant-Surgeon Gopal wire ; chloroform and took the greatest interest in with silkworm gut and the skin with on the 100? recorded evening the case during the long and anxious time highest temperature and after which elasped between the operation and death of operation, the next morning 99?, normal. A small twisted wire drain of the patient when we were trying all we could that it was the wound at the operation. This into was our I:Ie was put think of to pull patient through. 011 the 22nd. removed was Mudhu Assistant ably assisted by Hospital stitches were removed on the external The Mrs. Hosand Female the Dass Soudan George, had not united in places, but skin The of 31st. our in charge Dufferin Ward. pital Assistant this was adherent to the underlying tissue. is a case chart. to Attached temperature Case No.
5.?Parbati Soubrarin,
an
elderly
very thin and haggard, age about 45, 189G. was admitted on 9th October She was kept under treatment to improve her went general health until the 20th. Temperature but after 4 hours dropped operation, up to 102'8, to normal by 12 midnight and continued between normal and 99'4, until the 23rd, when she comand desire to plained of a feeling of fulness a mild saline she was given accordingly evacuate; This was followed by three rather aperient. free stools, and at 1 p.m., on the 24th, her ternwoman,
This occurred through making the stitches tight. I think it is of the greatest importance that the edges of the skin are approximated accurately without being tilted either way, it is To my very difficult to accomplish this always. mind the wound looks very nicely adjusted, and it is not until the stitches are removed that it is found a little tilt was given slightly, rolling the A little careful edges away at one or other edge. the time spent on this to attention point repays more much heals skin the as quickly. it, o
too
(To be continued.)
o
?
?
,
?
% J|lii[i[oi[ of Hospital fraqtiqt. ABDOMINAL SURGERY BY J. C.
AT
RAIPUR&
POYNDER, M.R.C.S., L.R.G.P, MAJOR,
I.M.S.,
Central Provinces.
Cases of Ovariotomy. was adCase No. 1.? Mai Kortin, age 35, 10th on tumour mitted for treatment of ovarian and November. The woman was in fair health, She the diagnosis prevented nothing special. The was operated upon on the loth November.
?
THE INDIAN MEDICAL GAZETTE.
20S
recorded was on the evening of the 101'6. The woman, as before, greatly retarded her recovery by her fretfulness and restlessness, but she was finally discharged on Sth November 1897, and I have heard nothing of her since, so I hope that she has had no ; further trouble of any sort. The question arises, whether the single suture I is sufficient to form a good union or rather a I union in every case which will bear the strain it is called upon to bear by the females of this country. They lift heavy weights and carry them on their heads, causing great strain on the abdominal muscles. 1 had another case previously in which there was very distinct tendency to ventral hernia after about a year. A patient returned to show herself twice after operation; perhaps the cicatrix has not given way any more, or perhaps the female died during the famine, as she belonged to the Bilaspur district where the mortality was very high and the distress very severe during the famine year. Her case was reported in the Indian Medical Gazette of August 1896. I have not seen her since her second visit, so I am not sure whether a regular hernia developed or not. It appears to me that there is much more risk of folding different structures over each other when a single line of suture is used, and the resulting cicatrix is more liable to give way. This untoward result is, I think, less likely to happen if each separate plane is brought together by a line of The operation takes longer, however, sutures. and I must admit that in some of my other cases I have obtained very good results. Still, with equal care, the results in the two cases mentioned were not so good, and the operation described for the ventral hernia clearly showed that the peritoneum and skin were more or less fused together to the complete exclusion of the muscle; and I think, for the future, in the labouring classes, when the condition of the patient will admit it, I shall give the necessary time to suture the different layers separately. Case No. 3.?Milapa, age 50, admitted 31st October 189G. Ordinary cyst. Patient rather thin and not very ctrong. Received quinine, iron and strychnia mixture and was well fed until the i 12th No\ embei. when the abdomen was piepared for operation as usual, and she was operated upon. The operation was very simple; the cyst was free from adhesions and had a low? fairly thin pedicle, which was tied between ligatures and dropped into the cavity after being washed with a little sterilized water and gently dried with a clean sponge. There was no bleedinrr or escape of fluid into the cavity and so the
temperature
operation,
toneum was not
rature, 102'4?
washed
peri-
Highest tempeevening. I forgot to add closed with a single line out.
on the that the wound was of silkworm gut sutures ; it was 99?F. on the 13th and normal on the 14th. Sutures removed on the 19th. The patient was kept in
[June
until she became
hospital looking.
quite
fat and
1899.
healthy
further has been heard about this hope she has had no trouble with the cicatrix, though the wound was only sutured with the one line of silkworm gut sutures. Case No. 4.? Janki, wife of a sepo3r, 2nd Ilegt., was sent to the Main Dispensary bj' Capt. Moore, I.M.S., for treatment on 20th August 1896. She had a rather curious history. Two years ago she had a child; 15 days after her confinement she noticed a small swelling in her abdomen on the right side, which was moveable, and increased steadily, but not very rapidly. She had no return of her menstrual functions until March 1896, and she then onl}' menstruated regularly once. She thinks she became pregnant immediately after this, but there was slight discharge at the end
Nothing
case,
of
so
I
April.
abdomen subsequently increased very and caused her much pain. For the last two months the tumour has been increasing rapidly, so much so, that she has some considerable dyspnoea, continual fever, and much pain in the abdomen. On admission her state of health was very bad, the conjunctiva deeply tinged with bile. Temperature, 99?. Pulse weak Countenai.ee very drawn and haggard; furred; bow els not tongue O OO of open for two days and has only had snatches her the in the last For week, evening, sleep. temperature went up to 100 4. The abdomen was tightly distended, manifestly more on the right side than the left. The measurements were from right anterior superior spine to umbilicus, 10 inches. Ditto on the left side, 8 inches. From spine to umbilicus, right side, 1 foot 7 inches. Ditto on the left side, 1 feet G inches. Fluctuation plainly felt all over the right side; no fluctuation or merely an obscure elastic feeling on the left side and distinct hard maws could be felt on the left side, so that it was clear that there was one large cyst on the right side, and she was probably pregnant. The os was rather low down and slightly patulous; there some was bulging of the right side of the A sound was not passed as she was provagina. bably pregnant. I must admit that I was not quite positive that the woman was pregnant. Mrs. George, the female hospital assistant, informed me that she had distinctly heard the fetal heart on the day after her admission, but neither Capt. Moore nor myself could hear it, and Mrs. George failed to hoar it Her
rapidly
/
again.
'
The condition of the patient was about as bad it could be, but.she was kept quiet with careful light nourishing diet, small doses of stimulants and quinine, and her general condition improved so rapidly that I determined to operate on the 26th, as the distension of her abdomen was very distressing to her.
as
ABDOMINAL SURGERY?POYNDER.
Junk
209
'
had formed, and the only indication that something was wrong was that the fresh un ted tissues at the lower end of the wound distinctly some multilocular cyst, to break down and became slightly very large began compressing and to severely cysts reaching up purulent. There was no offensive smell, and I the size of the cyst there the spleen. Beyond the about operation. believed that the woman had become infected no great difficulty was with through the uterus after the abortion. In this, foetus a contain to The uterus was found I believe, L was entirel}7 wrong, as I was allowed and it was distinctly its head towards the os, to make a I it is, partial post-mortem examination Though elongated and oval in shape. ot the parts that had been operated upon, and on the subject works the of in some think, stated on the I on a small abscess came wound, is opening distinctly that the cavity of the uterus behind the pubes, between the peritoneum towards just foetus the globular and the headtheof of and the muscular wall. pains complained the thorax. Possibly There was very slight serous effusion in the the and patulous were leading towards abortion, lower part of the pelvis, but neither the uterus idea. this favours condition of the os rather well, but in peritoneum nor intestines showed any marked Patient bore the operation fairly Pulse was congestion such as would probably accompany 138. the evening rose to 102 8 ; pulse peritonitis or metritis. of strychnia septic a dose had I think that the bandage becoming wetted distinct!}' weak, and she injection. with subcutaneously, and later on a morphiashe urine must have permitted the passage of did not but This quieted her to some extent, 5 septic germs to very lowest portion of the wound aborted foetus about which was found not quite healed, but perfectly sleep. At 7 a.m., she dropped months old, after which the temperature healthy looking when the stitches were removed. She liad a douche of warm permangato normal. In removing the lowest stitch, I think, some of naturmoved nate of potash lotion. The bowels these germs had been dragged into, and infected comfortable. much more the course of the suture, ally, and the patient was she as resulting in the formaIn the afternoon a catheter was passed, tion if the small abscess found at the post-morthe and had not passed urine for some hours, tem; it contained about two drachms of unhealthy some bladder was found to be distended slightly; sanious pus rather offensive but not ver}7 markedmine was drawn off She had no subsequent ly so. I think the want of difficulty. She was given :? in the lower and the usual inciThe abdomen was cleansed, a on the right was tumour sion was made; the of the smaller
_
Ext.
Ergota Liq.
...
...
..
3ss.
mv.
Liq Strychnia jii ?Aqua enema nutrient to contract, uterus the To help Temperature was was given later in the day. it rose to 99. when normal until the evening, normal. Patient had passed ..
...
29th.?Temperature
...
...
some milk and was fairly very good night, took binder had got soaked flannel The comfortable. Patient went with urineand was changed to-day. between on very fairly. Temperature varying and normal and 99'4. Bowels were fairly regular, and well, she took her nourishment well, slept would she there seemed to be every hope that 2nd The stitches were removed on the recover. whole the the after operation; September, 7 days of the wound had healed except a small piece Here the about ? inch long at the lower part. beneath structures but the a little, skin gaped On the to have healed completely. appeared of rise distinct temperature in 5th, there was a of the day it the middle in and the morning, on the is not shown This went up to 103. and temperaevening chart, as on the morning after this the temperature tures were shown, but show the regular septichart attached began to rises and falls. cemia type of chart?rapid dressed, the The wound was most carefully done that uterus washed out, and everything of the operacourse The of. could be thought but no tion wound was most carefully examined, which felt be could local thickening or hardness that a stitcli abscess would lead one to a
suppose
vitality
part
of the wound was an indication of the mischief underneath, and 1 might with propriety have opened down to see whether I could Hud anything. The abscess was not very clearly circumscribed and was situated on rather loose areolar tissue; consequently there was not that hardness or sense of resistance which generally clearly indicates the formation of a local abscess, and in the absence of these I felt hardly justified in reopening the wound, as it seemed quite probable that the woman had become infected through the uterus. I hope I may not have cause to do so, but in a similar case with a much unhealthy piece of wound, 1 shall certainly open it freely. Another very important question also arises here?should I have been justified in producing abortion to begin with ??and I am inclined to think it would have been the wiser course. Cases of ovariotomy have been reported in which the operation has been successful, and the mother has gone on to the full term. Hindoos are proud of a large family, and would, as a rule, I think, choose to undergo considerable risk rather than abort. I, therefore, determined to operate and try to save the child. On the other hand, the woman was not in the best of health, even though she made such progress during the time she was in hospital before operation. Had she aborted first and recovered, which there is no particular reason to suppose she
The Indian Medical
Gazette,
June 1899.
ABDOMINAL ABDOMINAL SURGERY AT RA1PUR. SURGERY AT RAIPUR. RECORD RECORD OF OF
AND RESPIRATION. PULSE AND RESPIRATION. TEMPERATURE, TEMPERATURE, PULSE
210
THE INDIAN MEDICAL GAZETTE.
would not have done, she would probably have been in better health and reduced the chance of her getting septicemia, as the uterine discharges greatly increase the chances of producing septic contamination. The reduction in the size of the uterus would have considerably relieved the tension of her abdomen and the dyspnoea owing to pressure on the diaphragm ; and the subsequent abortion, which was very likely to occur, certainly increased the general shock and depression after the operation ; though it did appear to have an}' immediate detrimental effect, it must have added to the strain on the
1899.
was 101 '4; in the evening, it was-104, when she had a cold sponging, and it fell to 100, after which she slept well. There was a good deal of sanguineous discharge from the vagina, O O requiring frequent syringing with Condy's fluid to keep her clean. On the 28th, as her temperature had again gone up to 104, she had a subcutaneous injection of 5 in. creasote in 5 in. olive oil. This was followed in two hours by most copious perspiration, and a drop in the temperaIt produced, however, in addition, ture to 1)8. most dangerous symptoms of collapse, the pulse became weak and thready, and the patient was barely conscious. However, she pulled round after an rather injection, and the temperature began to go up again. It was kept fairly in check by sponging, and from this time she began to improve, and the temperature became normal the 2Gth, and she was discharged after a on month on the 24th November, quite stout and hardly recognizable as the thin worn-out creature who had been admitted. The main point of interest about her case was whether the purgative had caused the mischief; it seemed very much like it; and it is well to postpone a purgative until later; if required, an enema 011I37 should be given. Another point of interest is the powerful effect produced by the subcutaneous injection It appears to be a very valuable of creasote. remedy, but requires to be used with great care owing to the depression which may follow its
pevature
'
o
system.
The time of operation after abortion is in the hands of the operator, but the time the uterus will take to get rid of its contents is not under control, and probably will take place, as this one did, not long after the operation. Taking all these facts into consideration, 1 think I should feel inclined to produce abortion
a similar case. It may appear very easy in theory to diagnose pregnancy in a case like this, but I may say quite certainly that it isn't. I know of one or two cases in which mistakes have been made I have by some of the highest authorities, and with tumour an ovarian secondary myself seen cysts inside it, tightly distended, which gave an exceedingly good illustration of what a child's head feels like in utero, when felt through the abdominal wall. Captain Moore, I.M.S, was kind enough to give me his valuable assistance at the time of the operation, and subsequently saw the patient frequently and with some difficulty obtained the permission of the patient's husband to enable us to examine thq wound, by which I was able to find out where the mischief had probably originated?a of information for future most valuable
[Junk
in
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use.
Case No. G.?Remootoo Kaotin, age about 45, admitted 011 2nd August 1897 with ovarian tuHealth indifferent. Was put on quinine, mour. tonics and extra food until the 18th.
18til, Operation.?Nothing abnormal; a very large cyst was removed in the usual manner. I11 this case the peritoneum was washed out with
piece hot sterilized water and sewed up with a line guidance. continuous Ghose catgut suture, the muscles and fascia Chunder gave Assistant-Surgeon Gopal wire ; chloroform and took the greatest interest in with silkworm gut and the skin with on the 100? recorded evening the case during the long and anxious time highest temperature and after which elasped between the operation and death of operation, the next morning 99?, normal. A small twisted wire drain of the patient when we were trying all we could that it was the wound at the operation. This into was our I:Ie was put think of to pull patient through. 011 the 22nd. removed was Mudhu Assistant ably assisted by Hospital stitches were removed on the external The Mrs. Hosand Female the Dass Soudan George, had not united in places, but skin The of 31st. our in charge Dufferin Ward. pital Assistant this was adherent to the underlying tissue. is a case chart. to Attached temperature Case No.
5.?Parbati Soubrarin,
an
elderly
very thin and haggard, age about 45, 189G. was admitted on 9th October She was kept under treatment to improve her went general health until the 20th. Temperature but after 4 hours dropped operation, up to 102'8, to normal by 12 midnight and continued between normal and 99'4, until the 23rd, when she comand desire to plained of a feeling of fulness a mild saline she was given accordingly evacuate; This was followed by three rather aperient. free stools, and at 1 p.m., on the 24th, her ternwoman,
This occurred through making the stitches tight. I think it is of the greatest importance that the edges of the skin are approximated accurately without being tilted either way, it is To my very difficult to accomplish this always. mind the wound looks very nicely adjusted, and it is not until the stitches are removed that it is found a little tilt was given slightly, rolling the A little careful edges away at one or other edge. the time spent on this to attention point repays more much heals skin the as quickly. it, o
too
(To be continued.)
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