EDEN
HOSPITAL,
CALCUTTA.
Abdominal Surgery 1888-89.
during the year
By Surgeon-Major C. H. Joubert, M.B., F.R.C.S.,
Offtj.
Obstetric
Physician.
The following is a brief account of all the cases in which abdominal section was performed by me during the period I officiated as Obstetric Physician at the Calcutta Medical College, from 1888 to December 1889.
April
Ovariotomy.?Eight completed operations,
of successful and one fatal. One other operation had to be abandoned on account of the universal nature of the adhesions. The patient was temporarily relieved, but left hospital subsequently in a moribuud condition. The following table gives the chief points in connection with these nine cases, and includes one case of removal of a parovarian cyst which
which
seven
were
terminated fatally
OVARIOTOMY CASES, Eden a
Hospital,
? ?
Date of No. operation.
a2
Adhesions.
27-4-89.
M. 3
4-8-88.
M. 0
Numerous Numerous
nr. 4
Adhesions universal, oper-
21-12-88.. 35
posteriorly
ation abandoned.
Ovary
removed.
Notes
:?
Calcutta, from April 1888
Amount of fluid contents and weight of
14oz. lost in hos
Result.
100?
pital.
Recovery
Death 6 hours after operationLeft hospital Moribund 3 weeks later.
to
December 1889.
Duration of
Name.
Horeo
..
liholiu
..
Rhabutfcy
disease.
Hindoo
3or 4 months. 9 months. 9 months
May
Dr. JOUBERT'S ABDOMINAL OPERATIONS.
1890.]
OVARIOTOMY CASES, Eden a
No.
Hospital,
Ovary removed.
Adhesions.
operation.
Amount of fixed contents and weight of
22-1-89.. 40
19-3-89..
1889.?(Continued.)
sac.
u
J
M. 1
M. 1
Race.
Name.
Result.
?.8
4
1888 to December
April
~
Date of
'S
Calcutta, from
131
None.
Parovarian cyst in folds of broad
Slight parietal in front and dense vascular site of former
one
ligament.
R
..
at
9Goz.
103?4-
5oz.
Death
on
5th
Jaun
Mahomedan
Matagini
Hindoo
day from haemorrhage. 13 pin ts lib. 13 oz.
10G?
Recovery
..
Omental, firm
15-7-89..
W.3
26-7-89..
M. 4
Very extensive to thickened omentum. Moderate, but very thick..
9-10-S9..
M. 4
None.
30-11-89..
M. 0
R. cyst, upper, none L. cyst, adherent to las's pouch.
or
1? 21 pints lib. lOoz. 27 pints lib. 7oz, 15 pints lOlbs. 8oz. ?
101?4-
9
years,
tapped year
ago. 2 years.
Bhagobu ti.
10?t>'
Jones
..
J 9 pints
Eurasian
(hospl.nurse)
11 year.
100?4-
Nussibun Mahomedan
3
100?2"
Hannah
Ntivc Christian.
10
Eurasian
3
moderate.
Doug-
8
was
tapping.
W. 0
disease.
3
M 4"
a
3-5-S9...
Duration of
101?-4?
Hilton
..
(hospl. nurse)
years. years.
years.
The following additional details may be mentioned in connection with nine of the above
lar.
cases:?
nurse,
Case No. 3.?Patient very cachectic, abdomen greatly distended measuring41i inches in circumference at umbilicus and 20| inches from ensifovni cartilage to pubes, uterus pushed so far down that the cervix was almost at the vaginal orifice, pressure symptoms very marked. It was found impossible to get into the abdominal cavity owing The to the dense parietal anterior adhesions. most anterior cyst was therefore tapped through the abdominal incision, and a considerable amount of fluid contents removed. The tumour was multilocular and the universal nature of the adhesions became very apparent after the partial collapse of the distended abdomen. T'ie patient obtained only temporary relief and left hospital about six weeks later in a moribund condition. Case No. 4.?Patient much emaciated with marked cachexia. Circumference of abdomen at greatest part 31 inches. The cyst was found to be a unilocular parovarian cyst developed in the folds of the right broad ligament. It was removed by shelling it out of its peritoneal investment without much difficulty. A Staffordshire knot was applied and the redundant peritoneum included cut There was too away. much tension however on the ligature which became loose, and slow though moderate haemorrhage occurred,the patient dying on the fifth day. This result would, probably, not have occurred had a chain ligature of several loops been used instead of Ji single knot. The broad ligament was widely separated by the tumour.
Hospital till a few days before the operation and resumed them after convalescence. Case No. 8.?Patient much emaciated and very cachectic. Circumference of abdomen at umbilicus 44? inches. Eusiform to pubes 23? inches. She was placed on the operating table on the 25th June, but her condition became so bad when under chloroform that the operation Her condition, however, was not undertaken. improved so much after a mouth in hospital, that the operation was again undertaken on the 27th July, aud successfully accomplished. The cyst was very large, the solid portion of it, after the evacuation of numerous secondary cysts, weigh-
Case No. 5.?The only adhesion which gave any trouble was a very dense vascular one at the site of a former tapping, a proof of the inadvisability of tapping ovarian cysts. Case No. 7.?The omentum adherent to the tumour was greatly thickened and very vascu-
Several large pieces of this thickened cutoff. The patient was a hospital who continued her duties at the General
omentum were
ing 10?lbs.
This case Case No. 10.?A hospital nurse. The patient had one of great interest. been under observation for many months since she first complained of a tumour. On account of the irregular outline of the abdominal tumour, its hardness aud other points, the diagnosis between cystic ovarian disease aud uterine myoma was difficult. The notes of an examination on October 10th, 1889,are as follows: Sound enters 3^ inches. Body of the uterus lies in front of the tumour and to the right; cervix pushed up against the back of the pubes. Uterus cannot be separated from the tumour, but the sound seems somewhat movable was
?
by against its lower surface. Douglas's pouch filled tumour has increased by an elastic mass. The two months and interferes in size during the past It is smooth in outmicturition. with greatly
line and more elastic than formerly, feeling more like a cyst than a solid tumour. There is a smaller separate mass to the left, noted prewhich is somewhat movable.
viously,
separately
recommended to undergo an exploratory operation to clear up the diagnosis between Patient
THE INDIAN MEDICAL GAZETTE.
132
cystic or fibroid disease; an experienced colleague, whose opinion I had the advantage of having being in favour of the diagnosis of fibroid. Examined agaiu ou the 28tli Novemtlie notes were as follows:?Left cul-de-sac obliterated. Sound enters 3^ inches, the point at fundus appears to be 1^ inches away from the anterior surface of the larger tumour, showing that, if growing from the uterine body, it must be from the lower part of the posterior wall. The separate mass on the left side has considerably increased since last examination. The abdomen was opened on the 30th November 1889, and two large independent ovarian cysts were found, in contact with but not adherent to each other. The right cyst was of the size of an adult head, and Avas the uppermost. The left cyst was somewhat smaller and crowded into the pelvis. The right cyst was removed with comparative ease, although the left cyst had also to be tapped before the right one could be drawn out of the abdomen and the pedicle secured, for it bulged up from the pelvis into the incision as soon as the right cyst collapsed. The left cyst was adherent in Douglas's pouch and opened up the folds of the left broad ligament. Considerable difficulty was experienced iu securing a safe pedicle. Both cysts were the left multilocular, containing a large amount of papillomatous masses; the right some few papillomatous granulations on its inner surface. The unusual size of the uterus in a multiparous woman was due to the left cyst being of the papillomatous variety. Keith's drainage tubes were used in all cases where there was any fear of oozing from torn
ber,
adhesions. Morphia or after operation was hardly ministration of hot water
opium as a sedative ever given. The ad-
drink was found obstiuate controlling vomiting. Glycerine enemata were very successfully administered to procure the first action of the bowels after operation. The sutures for the incision were of silkworm gut. abdominal Carbolic lotion was used for the hands, instruments and sponges, but the spray was not employed in any case. All the ovarian cysts were as a
very useful iu
multilocular.
Removal
of
the Uterine
Appendages.
^
1890
suffered from epileptiform fits for some years and had been certified as insane in 1887, though sent
to any asylum. The fits becoming frequent since the last confinement and renderding her life a burden and a danger, oophornot
more
and agreed to. The fits of an hysteric epileptiform type. Pelvic examination gave negative evidence, the ovaries appearing only tender, not enlarged. On operating double pyosalpinx was found. The right ovary was nearly double the size of the left, but contained a recently ruptured Graafian follicle, apparently of under Botli ovaries appeared 24 hours' standing. healthy. The patient menstruated on 27th April, the discharge lasting for nine days, but not in May or June. Operation on 4th July She made a perfect recovery from the 1889. " operation.thatHad one "fit only on 8th of July, date till her discharge from Hosbut from July, complained of constant pital, on 25th headache, was restless at night, often shouting and screaming, but felt well enough to leave mentioned. She was, however, on the date back to Hospital six weeks after the brought operation in an unconscious condition, and died in about thirty-six hours. At the post mortem examination, extensive purulent meningitis of the base of the brain was found. The double must have developed after the conception of the child born in August 1888, but there was no history of any acute subsequent inflammatory attack. Case No. 3.?European, 4-para, aged 42. Had suffered for about three years from profuse menorrhagia, incapacitating her from her work Had spent months in hospital with as a nurse. The uterus was unibut temporary relief. formly enlarged, os patulous, sound entering 3| inches, fundus in hollow of sacrum, cavity empty, but enlarged. Anterior wall normal thickness, posterior wall considerably thickened. Diagnosis, small interstitial fibroid of posterior wall. Operatiou on 5th April 1889. Both ovaries and tubes removed. A small thin-walled cyst of the right ovary ruptured during removal. Posterior wall of uterus felt very thick. Both ectomy seen in
was
proposed hospital were
pyosalpinx
ovaries cirrhosed.
There
was a
bloody discharge
vagina the fourth and fifth days after operatiou, and again on the twenty-seventh day. Patient seen again on 3rd February 1890, ten " months after operation. Lost a " spoonful of blood in June and July .last, none since. No pains or monthly disturbance of any kind. Headaches and hysterical fits, frequent previously, have disappeared since operation. Has gained flesh and strength, is employed now as well and strong, a hospital nurse, feels and contemplates matrimony. from the
Case 1.?Patient a Hindoo, 1-para, aged 40. Large uterine fibroid. Menstruation very profuse for last four years. The right ovary and three inches of a distended Fallopian tube and the left ovary were removed. The left tube was too closely applied to the large fibroid mass for safe removal. The patient made a perfect recovery and left hospital much dissatisfied at the non-removal of her tumour. Lost sight of. Case No. 2.?European, 4-para, aged 25. Youngest child born in Eden Hospital in August Normal labour and convalescence. Had 1888.
[May
on
perfectly
Pelvic
Case
Noticed
tumours
No. a
simulating
1.?Hindoo,
lump
in
the
ovarian cysts.
2-para. aged
right iliac fossa
40. about
May
Dr. JOUBERT'S ABDOMINAL OPERATIONS.
1890.]
Menstruation normal. On admislarge abdominal tumour was found, un-
2 years ago.
sion
a
on the right side, reaching symmetrical, 4 inches below
pelvis
to
able from side to
side,
ensiform cartilage,
not from below
from
mov-
upwards,
indistinct fluctuation. Circumference of ahdomen at most prominent part 33 inches. Uterus lying below and to left of tumour, but not separable from it. Sound enters 2| inches. Diagnosis, multilocular right ovarian tumour.
abdomen (28th May 1888), the to be sessile on a very broad base, extending from the brim of the pelvis, right side, to the right false ribs, and very broad also from before backwards. It was so semifluctuating to the touch that the presence of fluid with much solid matter seemed certain. The peritoneum was somewhat movable over the deeper surface of the tumour. The colour was pinkish and there were no adhesions. The uterus aud the appendages of both sides were found to be quite healthy and unconnected with the tumour. Owing to the^ enormous size of the base and the apparent impossibility of securing was not a safe pedicle, the operation proceeded with. The patient suffered severely from shock aud died on the third day without obvious cause. The post mortem examination showed the tumour to be quite solid aud composed entirely of pure white fibrous tissue and to have grown from the subperitoneal connective tissue of the right side of the abdominal wall and pelvis. It weighed 15lbs. It might have been removed by shelling it out of its peritoneal capsule, but the operation would surely have been fatal to a patient who succumbed to a mere exploratory incision. There was slight peritonitis but no septic condiOn
opening the
tumour
was
found
tions.
Case No. 2.?Hindoo, 5-para, aged 42.', Noticed small tumour on the right side of the lower abdomen 15 years previously, the growth of which to present size has been gradual. On admission, (6th Nov. 1889) a tumour reaching from pelvis to within 2 inches of ensiform was found. Circumference at umbilicus 35^ inches. Outline irregular. Uterus pushed up to the left almost above pelvis. Sound enters inches, but introduced with difficulty aud causing much pain. The operation on 4t,h November 1889 revealed
a
tumour differing from an ordinary ovarian cyst. The peritoneal layer covering it was thick and could be moved over the deeper layer of the surface. The tumour felt as resilient as a cyst, but as a mass was more flaccid. There were no adhesious. The uterus and left ovary were felt under the tumour. The base was very broad,
a
extending from the uterus to the brim of the pelvis on the right side. The round liga-
false
ment and
Fallopiau
tube
(right)
were
seen
the tumour, and it was clearly in the folds of the right broad ligament. As it was apparently removable, the trocar was used to
stretched
over
133
demonstrate the presence or absence of fluid, of which there was none. The mass was then got out of the abdomen through an enlarged incision and thetumour shelled out of its peritonealinvestment, a ligature being applied at the base in the depths of the broad ligament, and the mass cut away. There was but little loss of blood. The extreme ends of the rent in the peritoneal capsule were brought together by silk sutures, and the central part stitched to the lower part of the abdominal wound, a drainage tube being left in the cavity in the broad ligament. The tumour weighed 20lbs. and was composed of pure white fibrous tissue, with a few small cysts in places. No muscular fibres or ovarian tissue was found in any part of it. It had apparently developed from the connective tissue in the folds of the broad ligament. The patient died at 6 a. m. on the 11th November, the third day after the operation. There was considerable oozing of blood through the drainage tube, but no great amount in all. A postmortem examination showed absence of peritonitis, no blood in the general peritoneal cavity, the edges and sides of the sac united to the abdominal -walls and intestines and its cavity quite shut off. But there was a large amount of blood clot in the sac, not septic. The right ovary and tube were found on the posterior wall of the sac, quite healthy and not connected with the tumour. Death was due to a moderate amount of haemorrhage into the sac, the patient being depressed by the severity of the operation.
Ectopic gestation. 1.?Eurasian, multipara, aged
Cases of Case No.
37.
Menstruated regularly previous to and in May 1888. On 13th July 1888, while still in bed in the early morning, was seized with sudden pain in the abdomen. Admitted into hospital at 2 P. M. in marked collapse, T. 97, P. 136. Lyiug her right side, the abdomen was dull as far of dependas the median line, with some bulging ent side. Puncture with a fine aspirator needle shewed the presence of effused blood in the abdomeu. The vaginal cul-de-sacs were clear, the cervix uteri was firm, the os admitted the tip of the sound entered 2| inches, ana show-
on
finger,
ed mi empty uterus retroverted. Diagnosis, ruptured tubal pregnancy. The patieut was removed to the operating room section peras soou as possible and abdominal The abdomeu was full or blood and formed. but much escapclots, 80 ozs. were measured tube was found Fallopian The right ed besides. piece of chorionic strucruptured and a small the rent. No foetus was of out ture hanging found, and the tube appeared to have been distended to the size of a large bean. The ruptured tube was tied and removed, but the patient died before the operation was completed from the enormous previous haemorrhage. The case 18
134
THE INDIAN MEDICAL GAZETTE.
TMay 1890.
showed what enormous loss of blood could take turiug through the placenta with a small aspirator place from the rupture of a tubal pregnancy of, trocar. On withdrawing the needle, the opening gaped, broke down and profuse haemorrprobably, only six or seven weeks' date. Case No. 2. Eurasian, 1-para, age 32. Only hage occurred, but the cyst collapsed and a free pregnancy eleven years previously. Menstruat- part above the placenta came slightly into view. was seized with forceps and incised. ed September 1888, not subsequently. On 24th This December 1888, while playing tennis, had a sud- The amniotic cavity Avas full of blood, but a
pain iu abdomen, felt very faint, and had to go to bed. A lump was noticed in the right lower abdomen next day by the Civil Surgeon of Roorden
kee. Went about as usual from the 26th December to the 2nd January 1889, going to a dance on the 31st December. Same symptoms again, only more severe, on 2nd and 4th January, followed by recovery in three or four days. On 14tli January passed a membranous cast of the interior of uterus, with blood discharge, thought to be a miscarriage. On 20th January same symptons of pain and collap'se. Rallied again and was sent to Calcutta, being admitted into Eden Hospital on 31st January 1889. A large hard mass was found occupying the lower right side, extending to one inch beyond the median line to the left and to one finger's breadth above the umbilicus. The mass extended backwards towards the spine and seemed to be several inches thick. It was fixed below and movable above. The body of the uterus merged into a firm hard mass in the right cul-de-sac. Cervix not displaced, sound entered 3^ inches; an empty uterus, inclined somewhat to the left. No stethoscopic signs of pregnancy.
Diagnosis, ectopic pregnancy of over four months, with partial ruptures and haemorrhages on 24th December 2nd, 4th and 20th January.
Operation was decided upon, but unavoidably postponed till 8th February. The abdominal incision exposed a very vascular thickened omentum lying over a solid tumour which extended from the uterus and right iliac fossa below to two or
inches above the umbilicus above, and from beyond the median line to the left, quite into the lumbar region to the right. This solid mass was the placenta, which was situated iu the front and lower part of the gestation cyst and was adherent to the omentum, the most unfortuuate situation possible for the success of an operation. Free haemorrhage occurred on making any attempt to find the free edge of the placenta, so as to get at the cyst wall and remove the foetus. The abdominal incision was enlarged upwards and downwards, but it only disclosed more and more of a huge placenta capping and covering everywhere the rest of the cyst. The
adherent omeutum, which the parts behind, was then the placenta, the
to prevented access off and stripped up
hfemorrhage being fairly
controlled by means of sponges. But the placental tissue was so friable that it broke dowu under slight pressure. In order possibly to be able to define the cyst wall beyond the placenta, the liquor amnii was then drawn off by puuc-
in detected the foetus lying under covering placenta, and across the lumbar vertebrae. It was hooked up and brought out with difficulty, showing no signs of life, and being The cutbeween seven and eight inches long. edges of the cyst were sutured to the upper part of the abdominal incision, and as there was no further bleeding, the pelvic and abdominal cavities were sponged out and the wound closed with two drainage tubes in it?one leading into the amniotic sac, and the other into the pelvis?the umbilical cord being left hanging out by the side of the amniotic tube. The patient,however, was moribund from the great loss of blood and died on being removed to bed. The enormous difficulties of the operation were due to the unfortunate situation of the placenta, as the foetus could not be reached except by disturbing the attachments of the placenta. But for this the operation presented every chance of success. No post mortem examination was permitted, but the gestation was probably of the tubo-
finger passed the
ovarian variety.
Exploratory
Incisions.
Besides the previously noted cases of exploration in the case of fibrous tumour of the right side of the pelvis, there were the following :? Hindoo, multipara, age 25.? Case No. 1. Menstruation absent for one year, gave a history of a swelling in the left flank, which gradually extended upwards during the past year. Had suffered from fever years ago. Great emaciation. Circumference of abdomen 43^- iuches. Uterus small, freely movable in pelvis under an appa-
Pelvis not encroached upon. walls very tense, but the outline of The tumour was indistinctly made out. a was between ascites alone and ascites diagnosis complicated with ovarian tumour. An incision large enough to admit the little finger was made in the usual situation, and after a large quantity of ascitic fluid had escaped the pelvis was explored, and the uterus and appendages found to be quite healthy, but a very large spleen reaching from the pelvis .to the ribs was found. On this date, 13th July 1889, the amount of The patient refluid evacuated was 448 oz.
rent
tumour.
Abdominal
covered
as
from
an
ordinary
tapping.
She
times subsequently, again tapped 2,508 oz. of fluid in all being drawn off. Diswas
seven
charged from hospital relieved. Case iVo. 2.?An
European boy after
of 5 years.
obstruction of
Chronic peritonitis bowels. No pus was found, but general
the
recent
May
Dr. HEHIR ON SALOL IN CHOLERA.
1890.]
adhesions and an inflammatory mass in the right iliac fossa surrounding the ccecum. The peritoneal cavity was washed out with water. The patient quite recovered from the operation but sank from exhaustion five days later.
Kolpo-hysterectomy,
cancer
of uterus.?Euro-
pean, 6-para, aged 37. Menstruation regular, till a year ago, since when severe floodings with fainting fits. Was told six months previous to admission, on 12th September 1889, that she had a tumour outside the womb. On admission the fundus uteri was felt in Douglas's poucli not enlarged : cul-de-sacs clear and no apparent implication of the vagina: cervix greatly hypertrophied into an irregular lobular mass. The growth was very vascular, but not broken down in any place, though very irregular on the surface. The external os could not be found on account of the free bleeding, when attempts were made to pass the sound. The mass involving the cervix was removed ou the 1st October 1889, by means of the wire It quite filled the upper part of ecraseur. the vagina and precluded the possibility of total removal of the uterus, without its previous removal. The wire cut well above the disease on the right side, but on the left the disease was found to have involved a little of the vaginal wall and a little diseased tissue was left. There was very little haemorrhage and the patient did very well. The weight of the mass removed was 12|oz. On account of the evident presence of disease still remaining on the left side of the stump of the cervix, it was determined to remove the whole of the uterus, and this was done on the 8th October 1889. The uterus was freed in front and behind without much difficulty, and the broad ligament on each side secured by a Gregg Smith's clamp. In order, however, to include the diseased bit of vagina on the left side, the left clamp was applied somewhat obliquely, and this brought the top of the clamp too near to the left corner of the uterus, as proved by after-results. The uterus was then cut away and removed. At first the clamp appeared to act perfectly, but in about two minutes violent arterial haemorrhage occurred evidently due to some large vessel having the left slipped through clamp. It was quite to reach the impossible bleeding vessel in the divided broad ligament, high up in the pelvis, and fatal haemorrhage appeared imminent, but immediate pressure on the abdominal aorta at once. Pr essure stopped the hemorrhage an half for hour, when it was was kept up
relaxed,
moving
and the
the
dressing applied.
patient,
free arterial
But
on
haemorrhage
recurred. Pressure was resumed and for four hours, when as there was no kept up oozing seen it was was cautiously relaxed. The at once
135
patient was kept on the operating table for sixteen hours and then removed to the ward. The vessel which slipped through the clamp must have been much bruised, so that pressure evidently allowed an efficient clot to form. No further bleeding occurred. The patient had to be kept fully under the influence of morphia and chloral, owing to great restlessness, and for fear of her movements disturbing the clamps and the clot. The dressings were quite sweet when changed on the 10th, 48 hours after the operation, and but for the continued restlessness of the patient, necessitating the continuance of sedatives, all appeared to be going on well. Highest temperature, 100'6. The clamps were removed ou the 11th or 70 hours after the operation. The ends were free from clots, but smelt slightly offensive. Sedatives omitted. But the same day at 5 P.M., the temperature rose to 105*2? and symptoms of peritonitis became marked, the patient being very restless and unconscious. The unfavorable symptoms became more marked on the 12th, the vaginal discharge being offensive and the temperature rising at once to 106*6?. Death ocNo curred at 3 a.m. on the 13th October. P. M. examination permitted. The trouble with the left clamp aud the absolute necessity of avoiding any traction on it prevented the upper part of the wouud being drawn down so as to bring peritoneal surfaces into contact, and so shut off the vaginal canal from the pelvic cavity. In spite of the strictest antiseptic precautions, the pelvic peritoneum became infected by septic material from the wound aud fatal peritonitis enclosed resulted.
vaginal
HOSPITAL,
CALCUTTA.
Abdominal Surgery 1888-89.
during the year
By Surgeon-Major C. H. Joubert, M.B., F.R.C.S.,
Offtj.
Obstetric
Physician.
The following is a brief account of all the cases in which abdominal section was performed by me during the period I officiated as Obstetric Physician at the Calcutta Medical College, from 1888 to December 1889.
April
Ovariotomy.?Eight completed operations,
of successful and one fatal. One other operation had to be abandoned on account of the universal nature of the adhesions. The patient was temporarily relieved, but left hospital subsequently in a moribuud condition. The following table gives the chief points in connection with these nine cases, and includes one case of removal of a parovarian cyst which
which
seven
were
terminated fatally
OVARIOTOMY CASES, Eden a
Hospital,
? ?
Date of No. operation.
a2
Adhesions.
27-4-89.
M. 3
4-8-88.
M. 0
Numerous Numerous
nr. 4
Adhesions universal, oper-
21-12-88.. 35
posteriorly
ation abandoned.
Ovary
removed.
Notes
:?
Calcutta, from April 1888
Amount of fluid contents and weight of
14oz. lost in hos
Result.
100?
pital.
Recovery
Death 6 hours after operationLeft hospital Moribund 3 weeks later.
to
December 1889.
Duration of
Name.
Horeo
..
liholiu
..
Rhabutfcy
disease.
Hindoo
3or 4 months. 9 months. 9 months
May
Dr. JOUBERT'S ABDOMINAL OPERATIONS.
1890.]
OVARIOTOMY CASES, Eden a
No.
Hospital,
Ovary removed.
Adhesions.
operation.
Amount of fixed contents and weight of
22-1-89.. 40
19-3-89..
1889.?(Continued.)
sac.
u
J
M. 1
M. 1
Race.
Name.
Result.
?.8
4
1888 to December
April
~
Date of
'S
Calcutta, from
131
None.
Parovarian cyst in folds of broad
Slight parietal in front and dense vascular site of former
one
ligament.
R
..
at
9Goz.
103?4-
5oz.
Death
on
5th
Jaun
Mahomedan
Matagini
Hindoo
day from haemorrhage. 13 pin ts lib. 13 oz.
10G?
Recovery
..
Omental, firm
15-7-89..
W.3
26-7-89..
M. 4
Very extensive to thickened omentum. Moderate, but very thick..
9-10-S9..
M. 4
None.
30-11-89..
M. 0
R. cyst, upper, none L. cyst, adherent to las's pouch.
or
1? 21 pints lib. lOoz. 27 pints lib. 7oz, 15 pints lOlbs. 8oz. ?
101?4-
9
years,
tapped year
ago. 2 years.
Bhagobu ti.
10?t>'
Jones
..
J 9 pints
Eurasian
(hospl.nurse)
11 year.
100?4-
Nussibun Mahomedan
3
100?2"
Hannah
Ntivc Christian.
10
Eurasian
3
moderate.
Doug-
8
was
tapping.
W. 0
disease.
3
M 4"
a
3-5-S9...
Duration of
101?-4?
Hilton
..
(hospl. nurse)
years. years.
years.
The following additional details may be mentioned in connection with nine of the above
lar.
cases:?
nurse,
Case No. 3.?Patient very cachectic, abdomen greatly distended measuring41i inches in circumference at umbilicus and 20| inches from ensifovni cartilage to pubes, uterus pushed so far down that the cervix was almost at the vaginal orifice, pressure symptoms very marked. It was found impossible to get into the abdominal cavity owing The to the dense parietal anterior adhesions. most anterior cyst was therefore tapped through the abdominal incision, and a considerable amount of fluid contents removed. The tumour was multilocular and the universal nature of the adhesions became very apparent after the partial collapse of the distended abdomen. T'ie patient obtained only temporary relief and left hospital about six weeks later in a moribund condition. Case No. 4.?Patient much emaciated with marked cachexia. Circumference of abdomen at greatest part 31 inches. The cyst was found to be a unilocular parovarian cyst developed in the folds of the right broad ligament. It was removed by shelling it out of its peritoneal investment without much difficulty. A Staffordshire knot was applied and the redundant peritoneum included cut There was too away. much tension however on the ligature which became loose, and slow though moderate haemorrhage occurred,the patient dying on the fifth day. This result would, probably, not have occurred had a chain ligature of several loops been used instead of Ji single knot. The broad ligament was widely separated by the tumour.
Hospital till a few days before the operation and resumed them after convalescence. Case No. 8.?Patient much emaciated and very cachectic. Circumference of abdomen at umbilicus 44? inches. Eusiform to pubes 23? inches. She was placed on the operating table on the 25th June, but her condition became so bad when under chloroform that the operation Her condition, however, was not undertaken. improved so much after a mouth in hospital, that the operation was again undertaken on the 27th July, aud successfully accomplished. The cyst was very large, the solid portion of it, after the evacuation of numerous secondary cysts, weigh-
Case No. 5.?The only adhesion which gave any trouble was a very dense vascular one at the site of a former tapping, a proof of the inadvisability of tapping ovarian cysts. Case No. 7.?The omentum adherent to the tumour was greatly thickened and very vascu-
Several large pieces of this thickened cutoff. The patient was a hospital who continued her duties at the General
omentum were
ing 10?lbs.
This case Case No. 10.?A hospital nurse. The patient had one of great interest. been under observation for many months since she first complained of a tumour. On account of the irregular outline of the abdominal tumour, its hardness aud other points, the diagnosis between cystic ovarian disease aud uterine myoma was difficult. The notes of an examination on October 10th, 1889,are as follows: Sound enters 3^ inches. Body of the uterus lies in front of the tumour and to the right; cervix pushed up against the back of the pubes. Uterus cannot be separated from the tumour, but the sound seems somewhat movable was
?
by against its lower surface. Douglas's pouch filled tumour has increased by an elastic mass. The two months and interferes in size during the past It is smooth in outmicturition. with greatly
line and more elastic than formerly, feeling more like a cyst than a solid tumour. There is a smaller separate mass to the left, noted prewhich is somewhat movable.
viously,
separately
recommended to undergo an exploratory operation to clear up the diagnosis between Patient
THE INDIAN MEDICAL GAZETTE.
132
cystic or fibroid disease; an experienced colleague, whose opinion I had the advantage of having being in favour of the diagnosis of fibroid. Examined agaiu ou the 28tli Novemtlie notes were as follows:?Left cul-de-sac obliterated. Sound enters 3^ inches, the point at fundus appears to be 1^ inches away from the anterior surface of the larger tumour, showing that, if growing from the uterine body, it must be from the lower part of the posterior wall. The separate mass on the left side has considerably increased since last examination. The abdomen was opened on the 30th November 1889, and two large independent ovarian cysts were found, in contact with but not adherent to each other. The right cyst was of the size of an adult head, and Avas the uppermost. The left cyst was somewhat smaller and crowded into the pelvis. The right cyst was removed with comparative ease, although the left cyst had also to be tapped before the right one could be drawn out of the abdomen and the pedicle secured, for it bulged up from the pelvis into the incision as soon as the right cyst collapsed. The left cyst was adherent in Douglas's pouch and opened up the folds of the left broad ligament. Considerable difficulty was experienced iu securing a safe pedicle. Both cysts were the left multilocular, containing a large amount of papillomatous masses; the right some few papillomatous granulations on its inner surface. The unusual size of the uterus in a multiparous woman was due to the left cyst being of the papillomatous variety. Keith's drainage tubes were used in all cases where there was any fear of oozing from torn
ber,
adhesions. Morphia or after operation was hardly ministration of hot water
opium as a sedative ever given. The ad-
drink was found obstiuate controlling vomiting. Glycerine enemata were very successfully administered to procure the first action of the bowels after operation. The sutures for the incision were of silkworm gut. abdominal Carbolic lotion was used for the hands, instruments and sponges, but the spray was not employed in any case. All the ovarian cysts were as a
very useful iu
multilocular.
Removal
of
the Uterine
Appendages.
^
1890
suffered from epileptiform fits for some years and had been certified as insane in 1887, though sent
to any asylum. The fits becoming frequent since the last confinement and renderding her life a burden and a danger, oophornot
more
and agreed to. The fits of an hysteric epileptiform type. Pelvic examination gave negative evidence, the ovaries appearing only tender, not enlarged. On operating double pyosalpinx was found. The right ovary was nearly double the size of the left, but contained a recently ruptured Graafian follicle, apparently of under Botli ovaries appeared 24 hours' standing. healthy. The patient menstruated on 27th April, the discharge lasting for nine days, but not in May or June. Operation on 4th July She made a perfect recovery from the 1889. " operation.thatHad one "fit only on 8th of July, date till her discharge from Hosbut from July, complained of constant pital, on 25th headache, was restless at night, often shouting and screaming, but felt well enough to leave mentioned. She was, however, on the date back to Hospital six weeks after the brought operation in an unconscious condition, and died in about thirty-six hours. At the post mortem examination, extensive purulent meningitis of the base of the brain was found. The double must have developed after the conception of the child born in August 1888, but there was no history of any acute subsequent inflammatory attack. Case No. 3.?European, 4-para, aged 42. Had suffered for about three years from profuse menorrhagia, incapacitating her from her work Had spent months in hospital with as a nurse. The uterus was unibut temporary relief. formly enlarged, os patulous, sound entering 3| inches, fundus in hollow of sacrum, cavity empty, but enlarged. Anterior wall normal thickness, posterior wall considerably thickened. Diagnosis, small interstitial fibroid of posterior wall. Operatiou on 5th April 1889. Both ovaries and tubes removed. A small thin-walled cyst of the right ovary ruptured during removal. Posterior wall of uterus felt very thick. Both ectomy seen in
was
proposed hospital were
pyosalpinx
ovaries cirrhosed.
There
was a
bloody discharge
vagina the fourth and fifth days after operatiou, and again on the twenty-seventh day. Patient seen again on 3rd February 1890, ten " months after operation. Lost a " spoonful of blood in June and July .last, none since. No pains or monthly disturbance of any kind. Headaches and hysterical fits, frequent previously, have disappeared since operation. Has gained flesh and strength, is employed now as well and strong, a hospital nurse, feels and contemplates matrimony. from the
Case 1.?Patient a Hindoo, 1-para, aged 40. Large uterine fibroid. Menstruation very profuse for last four years. The right ovary and three inches of a distended Fallopian tube and the left ovary were removed. The left tube was too closely applied to the large fibroid mass for safe removal. The patient made a perfect recovery and left hospital much dissatisfied at the non-removal of her tumour. Lost sight of. Case No. 2.?European, 4-para, aged 25. Youngest child born in Eden Hospital in August Normal labour and convalescence. Had 1888.
[May
on
perfectly
Pelvic
Case
Noticed
tumours
No. a
simulating
1.?Hindoo,
lump
in
the
ovarian cysts.
2-para. aged
right iliac fossa
40. about
May
Dr. JOUBERT'S ABDOMINAL OPERATIONS.
1890.]
Menstruation normal. On admislarge abdominal tumour was found, un-
2 years ago.
sion
a
on the right side, reaching symmetrical, 4 inches below
pelvis
to
able from side to
side,
ensiform cartilage,
not from below
from
mov-
upwards,
indistinct fluctuation. Circumference of ahdomen at most prominent part 33 inches. Uterus lying below and to left of tumour, but not separable from it. Sound enters 2| inches. Diagnosis, multilocular right ovarian tumour.
abdomen (28th May 1888), the to be sessile on a very broad base, extending from the brim of the pelvis, right side, to the right false ribs, and very broad also from before backwards. It was so semifluctuating to the touch that the presence of fluid with much solid matter seemed certain. The peritoneum was somewhat movable over the deeper surface of the tumour. The colour was pinkish and there were no adhesions. The uterus aud the appendages of both sides were found to be quite healthy and unconnected with the tumour. Owing to the^ enormous size of the base and the apparent impossibility of securing was not a safe pedicle, the operation proceeded with. The patient suffered severely from shock aud died on the third day without obvious cause. The post mortem examination showed the tumour to be quite solid aud composed entirely of pure white fibrous tissue and to have grown from the subperitoneal connective tissue of the right side of the abdominal wall and pelvis. It weighed 15lbs. It might have been removed by shelling it out of its peritoneal capsule, but the operation would surely have been fatal to a patient who succumbed to a mere exploratory incision. There was slight peritonitis but no septic condiOn
opening the
tumour
was
found
tions.
Case No. 2.?Hindoo, 5-para, aged 42.', Noticed small tumour on the right side of the lower abdomen 15 years previously, the growth of which to present size has been gradual. On admission, (6th Nov. 1889) a tumour reaching from pelvis to within 2 inches of ensiform was found. Circumference at umbilicus 35^ inches. Outline irregular. Uterus pushed up to the left almost above pelvis. Sound enters inches, but introduced with difficulty aud causing much pain. The operation on 4t,h November 1889 revealed
a
tumour differing from an ordinary ovarian cyst. The peritoneal layer covering it was thick and could be moved over the deeper layer of the surface. The tumour felt as resilient as a cyst, but as a mass was more flaccid. There were no adhesious. The uterus and left ovary were felt under the tumour. The base was very broad,
a
extending from the uterus to the brim of the pelvis on the right side. The round liga-
false
ment and
Fallopiau
tube
(right)
were
seen
the tumour, and it was clearly in the folds of the right broad ligament. As it was apparently removable, the trocar was used to
stretched
over
133
demonstrate the presence or absence of fluid, of which there was none. The mass was then got out of the abdomen through an enlarged incision and thetumour shelled out of its peritonealinvestment, a ligature being applied at the base in the depths of the broad ligament, and the mass cut away. There was but little loss of blood. The extreme ends of the rent in the peritoneal capsule were brought together by silk sutures, and the central part stitched to the lower part of the abdominal wound, a drainage tube being left in the cavity in the broad ligament. The tumour weighed 20lbs. and was composed of pure white fibrous tissue, with a few small cysts in places. No muscular fibres or ovarian tissue was found in any part of it. It had apparently developed from the connective tissue in the folds of the broad ligament. The patient died at 6 a. m. on the 11th November, the third day after the operation. There was considerable oozing of blood through the drainage tube, but no great amount in all. A postmortem examination showed absence of peritonitis, no blood in the general peritoneal cavity, the edges and sides of the sac united to the abdominal -walls and intestines and its cavity quite shut off. But there was a large amount of blood clot in the sac, not septic. The right ovary and tube were found on the posterior wall of the sac, quite healthy and not connected with the tumour. Death was due to a moderate amount of haemorrhage into the sac, the patient being depressed by the severity of the operation.
Ectopic gestation. 1.?Eurasian, multipara, aged
Cases of Case No.
37.
Menstruated regularly previous to and in May 1888. On 13th July 1888, while still in bed in the early morning, was seized with sudden pain in the abdomen. Admitted into hospital at 2 P. M. in marked collapse, T. 97, P. 136. Lyiug her right side, the abdomen was dull as far of dependas the median line, with some bulging ent side. Puncture with a fine aspirator needle shewed the presence of effused blood in the abdomeu. The vaginal cul-de-sacs were clear, the cervix uteri was firm, the os admitted the tip of the sound entered 2| inches, ana show-
on
finger,
ed mi empty uterus retroverted. Diagnosis, ruptured tubal pregnancy. The patieut was removed to the operating room section peras soou as possible and abdominal The abdomeu was full or blood and formed. but much escapclots, 80 ozs. were measured tube was found Fallopian The right ed besides. piece of chorionic strucruptured and a small the rent. No foetus was of out ture hanging found, and the tube appeared to have been distended to the size of a large bean. The ruptured tube was tied and removed, but the patient died before the operation was completed from the enormous previous haemorrhage. The case 18
134
THE INDIAN MEDICAL GAZETTE.
TMay 1890.
showed what enormous loss of blood could take turiug through the placenta with a small aspirator place from the rupture of a tubal pregnancy of, trocar. On withdrawing the needle, the opening gaped, broke down and profuse haemorrprobably, only six or seven weeks' date. Case No. 2. Eurasian, 1-para, age 32. Only hage occurred, but the cyst collapsed and a free pregnancy eleven years previously. Menstruat- part above the placenta came slightly into view. was seized with forceps and incised. ed September 1888, not subsequently. On 24th This December 1888, while playing tennis, had a sud- The amniotic cavity Avas full of blood, but a
pain iu abdomen, felt very faint, and had to go to bed. A lump was noticed in the right lower abdomen next day by the Civil Surgeon of Roorden
kee. Went about as usual from the 26th December to the 2nd January 1889, going to a dance on the 31st December. Same symptoms again, only more severe, on 2nd and 4th January, followed by recovery in three or four days. On 14tli January passed a membranous cast of the interior of uterus, with blood discharge, thought to be a miscarriage. On 20th January same symptons of pain and collap'se. Rallied again and was sent to Calcutta, being admitted into Eden Hospital on 31st January 1889. A large hard mass was found occupying the lower right side, extending to one inch beyond the median line to the left and to one finger's breadth above the umbilicus. The mass extended backwards towards the spine and seemed to be several inches thick. It was fixed below and movable above. The body of the uterus merged into a firm hard mass in the right cul-de-sac. Cervix not displaced, sound entered 3^ inches; an empty uterus, inclined somewhat to the left. No stethoscopic signs of pregnancy.
Diagnosis, ectopic pregnancy of over four months, with partial ruptures and haemorrhages on 24th December 2nd, 4th and 20th January.
Operation was decided upon, but unavoidably postponed till 8th February. The abdominal incision exposed a very vascular thickened omentum lying over a solid tumour which extended from the uterus and right iliac fossa below to two or
inches above the umbilicus above, and from beyond the median line to the left, quite into the lumbar region to the right. This solid mass was the placenta, which was situated iu the front and lower part of the gestation cyst and was adherent to the omentum, the most unfortuuate situation possible for the success of an operation. Free haemorrhage occurred on making any attempt to find the free edge of the placenta, so as to get at the cyst wall and remove the foetus. The abdominal incision was enlarged upwards and downwards, but it only disclosed more and more of a huge placenta capping and covering everywhere the rest of the cyst. The
adherent omeutum, which the parts behind, was then the placenta, the
to prevented access off and stripped up
hfemorrhage being fairly
controlled by means of sponges. But the placental tissue was so friable that it broke dowu under slight pressure. In order possibly to be able to define the cyst wall beyond the placenta, the liquor amnii was then drawn off by puuc-
in detected the foetus lying under covering placenta, and across the lumbar vertebrae. It was hooked up and brought out with difficulty, showing no signs of life, and being The cutbeween seven and eight inches long. edges of the cyst were sutured to the upper part of the abdominal incision, and as there was no further bleeding, the pelvic and abdominal cavities were sponged out and the wound closed with two drainage tubes in it?one leading into the amniotic sac, and the other into the pelvis?the umbilical cord being left hanging out by the side of the amniotic tube. The patient,however, was moribund from the great loss of blood and died on being removed to bed. The enormous difficulties of the operation were due to the unfortunate situation of the placenta, as the foetus could not be reached except by disturbing the attachments of the placenta. But for this the operation presented every chance of success. No post mortem examination was permitted, but the gestation was probably of the tubo-
finger passed the
ovarian variety.
Exploratory
Incisions.
Besides the previously noted cases of exploration in the case of fibrous tumour of the right side of the pelvis, there were the following :? Hindoo, multipara, age 25.? Case No. 1. Menstruation absent for one year, gave a history of a swelling in the left flank, which gradually extended upwards during the past year. Had suffered from fever years ago. Great emaciation. Circumference of abdomen 43^- iuches. Uterus small, freely movable in pelvis under an appa-
Pelvis not encroached upon. walls very tense, but the outline of The tumour was indistinctly made out. a was between ascites alone and ascites diagnosis complicated with ovarian tumour. An incision large enough to admit the little finger was made in the usual situation, and after a large quantity of ascitic fluid had escaped the pelvis was explored, and the uterus and appendages found to be quite healthy, but a very large spleen reaching from the pelvis .to the ribs was found. On this date, 13th July 1889, the amount of The patient refluid evacuated was 448 oz.
rent
tumour.
Abdominal
covered
as
from
an
ordinary
tapping.
She
times subsequently, again tapped 2,508 oz. of fluid in all being drawn off. Diswas
seven
charged from hospital relieved. Case iVo. 2.?An
European boy after
of 5 years.
obstruction of
Chronic peritonitis bowels. No pus was found, but general
the
recent
May
Dr. HEHIR ON SALOL IN CHOLERA.
1890.]
adhesions and an inflammatory mass in the right iliac fossa surrounding the ccecum. The peritoneal cavity was washed out with water. The patient quite recovered from the operation but sank from exhaustion five days later.
Kolpo-hysterectomy,
cancer
of uterus.?Euro-
pean, 6-para, aged 37. Menstruation regular, till a year ago, since when severe floodings with fainting fits. Was told six months previous to admission, on 12th September 1889, that she had a tumour outside the womb. On admission the fundus uteri was felt in Douglas's poucli not enlarged : cul-de-sacs clear and no apparent implication of the vagina: cervix greatly hypertrophied into an irregular lobular mass. The growth was very vascular, but not broken down in any place, though very irregular on the surface. The external os could not be found on account of the free bleeding, when attempts were made to pass the sound. The mass involving the cervix was removed ou the 1st October 1889, by means of the wire It quite filled the upper part of ecraseur. the vagina and precluded the possibility of total removal of the uterus, without its previous removal. The wire cut well above the disease on the right side, but on the left the disease was found to have involved a little of the vaginal wall and a little diseased tissue was left. There was very little haemorrhage and the patient did very well. The weight of the mass removed was 12|oz. On account of the evident presence of disease still remaining on the left side of the stump of the cervix, it was determined to remove the whole of the uterus, and this was done on the 8th October 1889. The uterus was freed in front and behind without much difficulty, and the broad ligament on each side secured by a Gregg Smith's clamp. In order, however, to include the diseased bit of vagina on the left side, the left clamp was applied somewhat obliquely, and this brought the top of the clamp too near to the left corner of the uterus, as proved by after-results. The uterus was then cut away and removed. At first the clamp appeared to act perfectly, but in about two minutes violent arterial haemorrhage occurred evidently due to some large vessel having the left slipped through clamp. It was quite to reach the impossible bleeding vessel in the divided broad ligament, high up in the pelvis, and fatal haemorrhage appeared imminent, but immediate pressure on the abdominal aorta at once. Pr essure stopped the hemorrhage an half for hour, when it was was kept up
relaxed,
moving
and the
the
dressing applied.
patient,
free arterial
But
on
haemorrhage
recurred. Pressure was resumed and for four hours, when as there was no kept up oozing seen it was was cautiously relaxed. The at once
135
patient was kept on the operating table for sixteen hours and then removed to the ward. The vessel which slipped through the clamp must have been much bruised, so that pressure evidently allowed an efficient clot to form. No further bleeding occurred. The patient had to be kept fully under the influence of morphia and chloral, owing to great restlessness, and for fear of her movements disturbing the clamps and the clot. The dressings were quite sweet when changed on the 10th, 48 hours after the operation, and but for the continued restlessness of the patient, necessitating the continuance of sedatives, all appeared to be going on well. Highest temperature, 100'6. The clamps were removed ou the 11th or 70 hours after the operation. The ends were free from clots, but smelt slightly offensive. Sedatives omitted. But the same day at 5 P.M., the temperature rose to 105*2? and symptoms of peritonitis became marked, the patient being very restless and unconscious. The unfavorable symptoms became more marked on the 12th, the vaginal discharge being offensive and the temperature rising at once to 106*6?. Death ocNo curred at 3 a.m. on the 13th October. P. M. examination permitted. The trouble with the left clamp aud the absolute necessity of avoiding any traction on it prevented the upper part of the wouud being drawn down so as to bring peritoneal surfaces into contact, and so shut off the vaginal canal from the pelvic cavity. In spite of the strictest antiseptic precautions, the pelvic peritoneum became infected by septic material from the wound aud fatal peritonitis enclosed resulted.
vaginal
