TWO CASES OF ABDOMINAL SECTION WITH UNUSUAL COMPLICATIONS.r?Y. F.J. CRAWFORD, M.D., Acting Superintendent, (Sm-crnmcnt
Maternity Ilo-spital,.Madras.
Case No. 1.?Ovarian cystoma; double twist of tlie pedicle; ascites; peiitonitis; adhesions:? M., a married Hindu woman, 35 years of age, with five children, was confined, six months before admission, of her fifth child without difficulty. S)ie nursed the child up to one fortnight ago and ? h-. ad no period daring this time. Menstruation previously as a rule rather free, lasting nine or ten days. She was admitted on Maj7 28th, 1898, with an abdominal tumour, of which her account was meagre and vague like so many of this class of cases. Three months ago she noticed a lump on the lower part of her abdomen, more on the right than the left side. It gradually enlarged without pain or fever, according to her statement and that of her husband. No discharge occurred from the vagina, no constitutional trmbles of any kind were felt by the patient. On admission, she presented all the signs of an ovarian cystoma, the tumour giving a distinct thrill on tapping with the finger. It was irregular, being situated more on the right than the left side, no pain except on pressure, when it was slight ; the greatest girth of the abdomen was 34 inches. There was difficulty of breathing, feeble pulse, anaemia, emaciation and debility, as the result evidently of the adventitious growth occurring in a weakly constitution. There was no anasarca, though the urine was scanty ; ill-defined pains shooting down the legs were complained of, especially at night. The temperature ranged between 98 G and 100'2. Before operation the normal was never reached. On admission, the temperature was 100? F. and the pulse 112 per minute. There was no history of rigors or of severe pain. The abdomen was as large as a seven months' gestation. On vaginal examination, the cervix was found to be small and flush with the vaginal roof, the anterior vaginal wall pushed down somewhat. The uterus was high up and could not be felt by the finger, and it was slightly lengthened. There was no discharge from the passages. The abdomen was slighthT tender on palpation, and there was to the touch a feeling communicated of a certain quantity of fluid there apart from the cystoma. The patient was very weak and ancemic, and evidently not in a fit condition to undergo a serious operation ; so she was kept in hospital and fed carefully. During this period (about six weeks) though the pulse improved and the girth diminished l
o
?
1
l
+
A
.
?
Read before the S. Indian Branch of British Medica1.
sDoiation.
122
THE INDIAN MEDICAL GAZETTE.
[April
1899.
large oozing area wculd have been left if clean removal was done. Whether another halt an hour taken up in this clean removal would have been immediately fatal or not, the remains of the wall left behind were, I think, the cause of cyst quantity fatal result. The total weight of the tumour usual incision the the was made On the 12th July, in the median line below the umbilicus, and the was about 15lbs. During the day the patient peritoneum rapidly come down upon. It was remained low and covered with cold sweat, then found that this membrane was so intimately requiring a lot of brandy. Evening temperature adherent to the anterior wall of the tumour that reached 103?, no vomiting, very little pain, very considerable difficulty was experienced in defin- slight tympanites; flatus passed freely by flatus ing the limits of the latter. These adhesions tube. Nutrient enemata given every four hours. The pulse was quick and weak. The subsequent were present over a large area, and until the hand reached the outer limit of this area all history of the case which extended over a period round, much dissection of the wall of the cyst of eight days was one of septic poisoning. She necessarily took place. The tumour was then died of double pneumonia on July 19th. In this case most of the conditions necessary seen to be greatly degenerated, almost black in and thick it was the production of septic processes existed for the wall softened, colour, and broke into down before layers, operation, a rotten cyst-wall, degenerated readily split up under the gentlest manipulation. After the contents, twisted pedicle, chronic peritonitis, adhesions were dealt with, the tumour was injury to anterior layer of the parietal peritoevacuated in the ordinary way, but difficulty was neum. The admission of the only wanting item, encountered in doing this cleanly on account of namely, the germ was sufficient to precipitate the friability of the cyst wall, the trocar making these processes. This must have occurred either A similar a rough tear on piercing it. difficulty during operation or during the subsequent occurred later when the edges of the opening dressings, when, by means of a glass drain, The tumour was serous and blood-stained fluid had to be drawn were caught up by forceps. multilocular and the contents colloid. On at- off every four hours for the first two days from tempting to draw out the cyst wall, the omentum the lower part of the peritoneal cavit}\ Without the difficulty I experienced in leaving a perwas seen to be connected with it above and on each side, the whole forming one adherent mass, fectly clean peritoneum I feel sure there would and a large portion of the omentum had conse- have been a different ending to the case. My quently to be removed with the cyst. The four previous ovariotomies had been uncompliperitoneum was inflamed everywhere; it was cated and though one tumour weighed 4Glbs., no thickened and much altered in appearance at untoward symptom arose during their convalesthe site of the adhesions and readily bleeding at cence which was uneventful in all four cases. The pedicle could now be No post-mortem examination was made in this numerous points. examined. It was double twisted and thin and case. Case No. 2.?Pelvic haBmatocnle; pelvic perihad a rotten appearance. One small Wells' on and it rupture into the rectum; fajcal fistula controlled tonitis; this, removing forceps easily only slight oozing occurred from some connec- after operation: M., cvt. 25, married 10 years, tive tissue round the pedicle. The patient was two children living, no abort:ons, six years since now in a very low state, the pulse which should last confinement, had previously been in hospital improve during this operation, remained feeble, under treatment for dysmenorrhea which exthe skin had a cold, clammy perspiration, and tended over a period of six years, menstruation brandy was required. There was in fact fear of regular, fi ee, but accompanied with severe pain the patient not reaching the ward at all, so the especially at the commencement. Retroversion operation was rapidly finished after the peri- was then diagnosed and a pessary relieved the toneal cavity was sponged out, not a trace of symptoms. Subsequently after having a painthe cyst contents being left behind. At the site less period, she left hospital on May 7, 1898, where the tumour adhered, the peritoneum was having been ten days under treatment. On May oozing freely; no bleeding points could be 26, she was re-admitted and gave the following secured, so firm pressure was kept up and a account of herself for the interval. She remained glass drain placed with its end in Douglas' pouch. well for ten days, and then felt, one afternoon, During the operation, which lasted exactly one a severe pain in the abdomen for which a native hour, about one pint of blood-stained peritoneal midwife forcibly applied massage. The same fluid was removed. Though the peritoneum was night she suffered from fever, with acute abdoseen to be implicated, some of the rotten wall of minal pain, fits of shivering, and faintness. the cyst had to be left adherent on account of These symptoms continued and four days before the low condition of the patient. Though the admission to hospital, the pain became more C3*st wall itself did not bleed, the peritoneum acute still and was accompanied with vomiting when it was separated, oozed freely and a very at intervals. On May 25, she brought up two
the temperature chart showed evening rises and morning falls, and the general condiThe urine, however, tion remained feeble. under treatment, became almost normal in
slightly,
April
1899.J
ABDOMINAL SECTION COMPLICATIONS?CRAWFORD.
123
brought away by the irrigator. After many round worms. She came to on May 26, hospital clots were removed, the examining finger on laving had an injection of morphine a few its way to the posterior wall was felt to nours before. On admission she had acute making pain, pass through an opening with well-defined edges; especially above the pubes, where an indistinct this was the opening into the rectum, and at once tumour-like swelling was easily felt, reaching fecal odour was perceived. The opening admitted to about two inches below the umbilicus. It easily the top of the index finger. The patient was situated more on the right side, was hard was now 0 ie touch and very low, and as sufficient cause was distender. The pulse was acutely covered for the production of all the symptoms, Uw to the minute, small and thready. Temfurther exploration of the pelvic organs was perature 102?F., patient very restless, constantabandoned. The clots were removed as far as y ossmg her arms and legs about in bed. She could be, the cavity made thoroughly clean with i
Maternity Ilo-spital,.Madras.
Case No. 1.?Ovarian cystoma; double twist of tlie pedicle; ascites; peiitonitis; adhesions:? M., a married Hindu woman, 35 years of age, with five children, was confined, six months before admission, of her fifth child without difficulty. S)ie nursed the child up to one fortnight ago and ? h-. ad no period daring this time. Menstruation previously as a rule rather free, lasting nine or ten days. She was admitted on Maj7 28th, 1898, with an abdominal tumour, of which her account was meagre and vague like so many of this class of cases. Three months ago she noticed a lump on the lower part of her abdomen, more on the right than the left side. It gradually enlarged without pain or fever, according to her statement and that of her husband. No discharge occurred from the vagina, no constitutional trmbles of any kind were felt by the patient. On admission, she presented all the signs of an ovarian cystoma, the tumour giving a distinct thrill on tapping with the finger. It was irregular, being situated more on the right than the left side, no pain except on pressure, when it was slight ; the greatest girth of the abdomen was 34 inches. There was difficulty of breathing, feeble pulse, anaemia, emaciation and debility, as the result evidently of the adventitious growth occurring in a weakly constitution. There was no anasarca, though the urine was scanty ; ill-defined pains shooting down the legs were complained of, especially at night. The temperature ranged between 98 G and 100'2. Before operation the normal was never reached. On admission, the temperature was 100? F. and the pulse 112 per minute. There was no history of rigors or of severe pain. The abdomen was as large as a seven months' gestation. On vaginal examination, the cervix was found to be small and flush with the vaginal roof, the anterior vaginal wall pushed down somewhat. The uterus was high up and could not be felt by the finger, and it was slightly lengthened. There was no discharge from the passages. The abdomen was slighthT tender on palpation, and there was to the touch a feeling communicated of a certain quantity of fluid there apart from the cystoma. The patient was very weak and ancemic, and evidently not in a fit condition to undergo a serious operation ; so she was kept in hospital and fed carefully. During this period (about six weeks) though the pulse improved and the girth diminished l
o
?
1
l
+
A
.
?
Read before the S. Indian Branch of British Medica1.
sDoiation.
122
THE INDIAN MEDICAL GAZETTE.
[April
1899.
large oozing area wculd have been left if clean removal was done. Whether another halt an hour taken up in this clean removal would have been immediately fatal or not, the remains of the wall left behind were, I think, the cause of cyst quantity fatal result. The total weight of the tumour usual incision the the was made On the 12th July, in the median line below the umbilicus, and the was about 15lbs. During the day the patient peritoneum rapidly come down upon. It was remained low and covered with cold sweat, then found that this membrane was so intimately requiring a lot of brandy. Evening temperature adherent to the anterior wall of the tumour that reached 103?, no vomiting, very little pain, very considerable difficulty was experienced in defin- slight tympanites; flatus passed freely by flatus ing the limits of the latter. These adhesions tube. Nutrient enemata given every four hours. The pulse was quick and weak. The subsequent were present over a large area, and until the hand reached the outer limit of this area all history of the case which extended over a period round, much dissection of the wall of the cyst of eight days was one of septic poisoning. She necessarily took place. The tumour was then died of double pneumonia on July 19th. In this case most of the conditions necessary seen to be greatly degenerated, almost black in and thick it was the production of septic processes existed for the wall softened, colour, and broke into down before layers, operation, a rotten cyst-wall, degenerated readily split up under the gentlest manipulation. After the contents, twisted pedicle, chronic peritonitis, adhesions were dealt with, the tumour was injury to anterior layer of the parietal peritoevacuated in the ordinary way, but difficulty was neum. The admission of the only wanting item, encountered in doing this cleanly on account of namely, the germ was sufficient to precipitate the friability of the cyst wall, the trocar making these processes. This must have occurred either A similar a rough tear on piercing it. difficulty during operation or during the subsequent occurred later when the edges of the opening dressings, when, by means of a glass drain, The tumour was serous and blood-stained fluid had to be drawn were caught up by forceps. multilocular and the contents colloid. On at- off every four hours for the first two days from tempting to draw out the cyst wall, the omentum the lower part of the peritoneal cavit}\ Without the difficulty I experienced in leaving a perwas seen to be connected with it above and on each side, the whole forming one adherent mass, fectly clean peritoneum I feel sure there would and a large portion of the omentum had conse- have been a different ending to the case. My quently to be removed with the cyst. The four previous ovariotomies had been uncompliperitoneum was inflamed everywhere; it was cated and though one tumour weighed 4Glbs., no thickened and much altered in appearance at untoward symptom arose during their convalesthe site of the adhesions and readily bleeding at cence which was uneventful in all four cases. The pedicle could now be No post-mortem examination was made in this numerous points. examined. It was double twisted and thin and case. Case No. 2.?Pelvic haBmatocnle; pelvic perihad a rotten appearance. One small Wells' on and it rupture into the rectum; fajcal fistula controlled tonitis; this, removing forceps easily only slight oozing occurred from some connec- after operation: M., cvt. 25, married 10 years, tive tissue round the pedicle. The patient was two children living, no abort:ons, six years since now in a very low state, the pulse which should last confinement, had previously been in hospital improve during this operation, remained feeble, under treatment for dysmenorrhea which exthe skin had a cold, clammy perspiration, and tended over a period of six years, menstruation brandy was required. There was in fact fear of regular, fi ee, but accompanied with severe pain the patient not reaching the ward at all, so the especially at the commencement. Retroversion operation was rapidly finished after the peri- was then diagnosed and a pessary relieved the toneal cavity was sponged out, not a trace of symptoms. Subsequently after having a painthe cyst contents being left behind. At the site less period, she left hospital on May 7, 1898, where the tumour adhered, the peritoneum was having been ten days under treatment. On May oozing freely; no bleeding points could be 26, she was re-admitted and gave the following secured, so firm pressure was kept up and a account of herself for the interval. She remained glass drain placed with its end in Douglas' pouch. well for ten days, and then felt, one afternoon, During the operation, which lasted exactly one a severe pain in the abdomen for which a native hour, about one pint of blood-stained peritoneal midwife forcibly applied massage. The same fluid was removed. Though the peritoneum was night she suffered from fever, with acute abdoseen to be implicated, some of the rotten wall of minal pain, fits of shivering, and faintness. the cyst had to be left adherent on account of These symptoms continued and four days before the low condition of the patient. Though the admission to hospital, the pain became more C3*st wall itself did not bleed, the peritoneum acute still and was accompanied with vomiting when it was separated, oozed freely and a very at intervals. On May 25, she brought up two
the temperature chart showed evening rises and morning falls, and the general condiThe urine, however, tion remained feeble. under treatment, became almost normal in
slightly,
April
1899.J
ABDOMINAL SECTION COMPLICATIONS?CRAWFORD.
123
brought away by the irrigator. After many round worms. She came to on May 26, hospital clots were removed, the examining finger on laving had an injection of morphine a few its way to the posterior wall was felt to nours before. On admission she had acute making pain, pass through an opening with well-defined edges; especially above the pubes, where an indistinct this was the opening into the rectum, and at once tumour-like swelling was easily felt, reaching fecal odour was perceived. The opening admitted to about two inches below the umbilicus. It easily the top of the index finger. The patient was situated more on the right side, was hard was now 0 ie touch and very low, and as sufficient cause was distender. The pulse was acutely covered for the production of all the symptoms, Uw to the minute, small and thready. Temfurther exploration of the pelvic organs was perature 102?F., patient very restless, constantabandoned. The clots were removed as far as y ossmg her arms and legs about in bed. She could be, the cavity made thoroughly clean with i
