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TWO CASES OF ABDOMINAL SECTION.
669
province has become decidedly more unhealthy from malaria. production. Still there is something over and above this in A kind of epidemic wave passed over the tract from north the climate of India that we do not understand. An exactly to south-west, involving in its course the district of Midna- similar combination exists in the West Indies, though the pore. The result of the invasion is that the inhabitants now disease is not so frequent there (in the proportion of 1 to 4). Dr. Budd’s now obsolete theory of the dependence of bear the impress of the noxious influence in a marked degree, in the shape of enlarged spleens, anaemia, bowel complaints, tropical abscess upon dysentery only requires a passing and cachexia generally. Dispensary records also show an notice. It is unsupported by clinical observation, statistics, increase in admissions for liver abscess coincident with the and post-mortem examinations. Dysentery being a disease increased prevalence of fever. While civil surgeon at caused by similar conditions of climate, very frequently Midnapore, I treated there, in the three years 1882-84, no complicates liver abscess, and a very serious complicaless than twenty-one cases, all in natives. Local practi- tion it is, but there is no causal relation between the tioners informed me that in former times the disease was two. Their concurrence in the same individual is a pure coincidence. It is important to remember that the signs practically unknown. In Europeans the greatest liability occurs between the and symptoms even of the hepatitis that precedes it, and ages of twenty and forty-five. Abscess has never yet been of the abscess itself, are apt to be ill marked and insidious; met with in any person, native or European, below fifteen, they often escape notice, or some or all of them may be and it is rare above fifty. In childhood it is absolutely absent. It has been estimated that they are well marked in unknown. Among Europeans men are more liable than 8 per cent. only, while the abscess runs a perfectly latent
in 13 per cent., even in Europeans. Instances are on record where the subjects were engaged in their usual occupations up to the very last. Soldiers have been on full duty up to a few hours of death by the bursting of an abscess internally. In one case an abscess burst while the man was actually on duty. The signs which in a given case of hepatitis lead to suspicion of suppuration are: The enlargement of the liver, which loses its uniform contour and develops more particularly in some one direction so as to form a bulging; localisation of pain and tenderness; pleuritic or peri-hepatitic friction; rigors, chills, sweats, and-most important of all-the temperature. Several apyrexial cases are on record, but I cannot conceive suppuration occurring without the temperature being affected at some time or other. A careful scrutiny of the temperature range, auscultation, and bilateral measurements of the chest are called for. The temperature must be taken every hour, so that a complete reading for the twenty-four hours may be obtained. Subjects of liver abscess are frequently also suffering from malarial fever. A want of periodicity and a resistance to quinine will indicate course
women.
British Army in India, 1883. Admissions per 1000.
Hepatitis. Deaths
per 1000.
Admissions
per cent. of total H,iJmlAR10n!:j.
The disproportion is still more marked as regards abscess itself. In Waring’s 300 cases 9 only were in women, and out of 82 cases reported in various journals 2 only were in women. On the other hand, out of 23 cases in Europeans and Eurasians treated at the Presidency Hospital, Calcutta, as many as 15 were females. The proportion of females to males among the British-born population in India is 1 to 7. I have reason to believe that owing to the exclusive climatic mode of origin in natives there does not exist the same difference in liability of the sexes as in Europeans. Among my 21 cases, mostly dispensary patients, 3 were females; and bearing in mind that the population of females to males attending dispensaries in Bengal is about 1 to 6, this, as far as it goes, does not indicate any very great irregularity. Authorities are agreed that suppurative hepatitis in Europeans in the tropics is mainly due to the effect of climate. But intemperance, over-indulgence in animal and highly spiced foods, and indolence, are spoken of as predisposing causes in the individual; while exposure and chills I am quite disare frequently noted as exciting causes. posed to admit that chill or exposure starts the attack in many instances; this is clearly the mode of origin of many of the reported cases. But have we sufficient evidence of the part the other conditions play in the production of the disease? The great difference in the liability of the two Taces is attributed to the variation in the nature of diet and drink, but it may equally be due to difference in degree of acclimatisation. The great reduction in liver diseases in the army is as likely due to improved sanitary arrangements and protection against climate as to the steadier I am inclined to think that the habits of the men. ’"intemperate" theory, at all events, has been made too much of. An examination of reported cases throws very little light on the subject, because complete histories are so rarely given. It is a significant fact, however, that out of 425 cases of hepatic abscess, including Waring’s 300 and others from the journals, the subjects were said to be intemperate in 50 instances only. Whatever influence personal habits may have, the fact remains that, quite independently of any of them, when an inhabitant of temperate climates - goes to reside in the tropics, there is a tendency for his
liver to become disorganised, though fortunately this in a relatively small proportion only. This to the dark races as well. Natives of mountain applies in regions India, on taking up their abode in the steamy plains of Bengal, are said to become liable to hepatic abscess. Change of climate affects hill cattle in the same way. Imported horses suffer to a large extent; the death-rate from hepatitis among troop horses in India amounts to 2 per 1000
hepatic origin.
By combined statistics the mortality of unrelieved hepatic abscess is found to be about 90 per cent. Death occurs with or without rupture. About one-half of all abscesses that are left alone remain intact. Spontaneous evacuation through the lungs occurs in about 20 per cent., less than half of which recover. Out of 33 cases that recovered spontaneously (Waring’s and others), 16 burst into the lungs, 8 into the intestine, 1 into the stomach, and 2 ended apparently in spontaneous absorption. The extent to which an abscess will develop is surprising. The contents are sometimes to be measured rather by quarts or gallons than by ounces. The whole organ may be converted into a bag of pus. In one case 17 pints were found at the post-mortem examination. I have myself removed as much as 80 oz. at a single operation; while 200 oz., 400 oz., and even 1000 oz. represent the aggregate amounts removed by successive tappings by others. These enormous collections are mostly seen in natives, who are apt to apply for treatment only at too late a stage of the disease. Solitariness is a character of tropical abscesses, but they are often multiple. In Waring’s 300 cases they were solitary in 62 per cent., multiple in 37’8 per cent. Multiplicity is explained by the mode of origin. The disease begins as multiple foci of softening. The foci coalesce as they increase in size. If the areas coalesce into one, a single abscess results; if they combine in groups, the abscesses will be multiple. (To be concluded.)
actually occurs
(Collins) .
What is the particular element or combination of elements in a tropical climate that induces hepatic disease ? It cannot be heat alone; liver abscess is least common in such parts as the Punjab, Central Provinces, &c., where there is greatest heat. Nor is it malaria alone, for the disease is unknown in malarious parts of the temperate regions of the world. The distribution of hepatitis according to district points to a combination of moist heat, dampness of subsoil, and concentration of malaria as the condition most favourable to its
TWO
CASES
OF ABDOMINAL SECTION. BY A. S. UNDERHILL, M.D., M. CH., S.S. CERT. CAMB., SURGEON TO THE GUEST HOSPITAL, DUDLEY.
RECENTLY I have had two cases in which I performed abdominal section, and as these-although fatal-possess points of clinical interest I venture to record them. CASE 1. Rupture of a Tubal Pregnancy.-M. I-, aged twenty-two, married eighteen months, one miscarriage at eighth week, a florid, healthy-looking woman, had catamenia regularly till seven weeks ago, when she was suddenly seized with acute pain in the abdomen, referred chiefly to the region of the right ovary, which continued for about
670
days, leaving her fairly convalescent at the end of two weeks. As she was feeling stronger, she walked for some little distance, but on her return home was again seized with the acute pain over the right ovary, became perten
On rectal examination, directly after its removal, the caudate swelling could still be felt, tense andfirmly adherent, evidently an old heamatocele, which had become partially absorbed, and was now organised. In both
pelvic cavity.
fectly blanched, staggered to a sofa, and was profoundly instances the Fallopian tubes were intact. I thoroughly collapsed for about twelve hours; from this condition she washed out the pelvic cavity with warm water; and as very slowly recovered, and still referred all her pain to the haemorrhage was very slight, I did not resort to drainage. right side of the lower abdomen. On vaginal examination She passed a fair night, but never completely rallied from I found the os and cervix uteri cedematous and very tender, the shock, and died twenty-eight hours after the operation. No post-mortem examination was allowed, but I examined but unlike what is usually found in commencing pregnancy, the uterus was fixed and deflected to the right; posteriorly the wound, and found that there had been no bleeding; the there was a tender semi-solid mass; abdominal percussion- stumps of the appendices were healthy-looking, and, as far as far as could be ascertained on account of the tenderness as I could ascertain, there was no appreciable cause for her -gave a duller note than normal from the groin to the death except exhaustion. Had she consented to the operaumbilicus on both sides. Her condition during the next tion when it was first proposed, I feel assured that her life twelve days was very unsatisfactory. She had a recurrence would have been saved. I have twice operated on moreof peritonitis, and suffered most distressing pain. Her seemingly unpromising cases with favourable results, but pulse was never under 140, and her temperature averaged this patient was of a depressed, nervous temperament, 103° F. Neither herself nor relatives would consent to any and greatly dreaded the operation, making her on this operative interference. On the fourteenth day her symptoms account a very unfavourable subject. The case was of became aggravated, and as she would evidently sink before interest on account of its diagnostic difficulties, as the many hours elapsed, permission was given for abdominal swelling was in shape, position, and history typical of what section. is usually found with pyosalpinx. On opening the abdomen in the mesial line about a pint Tipton, Staffs. and a half of very dark-coloured serous fluid gushed out. On the right side the uterus was bound down by adhesions and coagula to the brim of the pelvis. The right broad liga- A CASE OF RAPID PLEURAL EFFUSION ment was a mass of coagula, the Fallopian tube being much TREATED BY ANTISEPTIC INCISION. thickened and enlarged; the left broad ligament was encased BY ALBERT WILSON, M.D. in coagula, but it was impossible to recognise the Fallopian ____
at the lower part of the abdomen matted together by inflammatory adhesions. To appearance and touch much of the coagula resembled placental tissue, but nowhere could I find a trace of an embryo. I removed as much of the coagula as possible without injuring the intestines, thoroughly washed out the cavity with warm water, and inserted a glass drainage-tube into the pelvis. She rallied well from the operation and suffered little pain. On the eighth day, however, she died, obstinate constipation and vomiting being the predominant
tube; the intestines
were
symptoms.
In my opinion the patient had a right tubal pregnancy; the first attack of peritonitis killed the ovum, which burst after the exertion of walking, and so caused the hsematocele. If at this time consent had been obtained for the operation her chances of recovery would have been more promising; but on the fourteenth day fresh bleeding took place and handicapped the operation, from which she had not sufficient strength to rally. Under similar circumstances I should not hesitate to advise an early operation, as I think I might promise a fair relief from pain and a probably favourable result. CASE 2. Cystic Degeneration of both Ovaries mitk an old Haematocele.-M. C-, aged forty-two, married, with six children, nine months ago was attended by a midwife, who delivered her after a very severe labour. Some weeks after-
wards, not feeling strong and suffering great bearing-down pains and pain in defecation, she consulted a medical man,
and was treated by rest in the recumbent position and tonic medicine, but not feeling much better she was admitted under
my
care
into the Guest
Hospital.
I found the uterus retro-
flexed, but fairly movable on the sound. Posteriorly, in Douglas’s pouch, there was a tense swelling, somewhat caudate in shape and very painful on pressure. Per rectum it was more defined ; over both ovarian regions there was considerable tenderness, so much so that it was impossible
to ascertain their condition. She could not walk or stand without much bearing-down pain, and she had occasional attacks of obstinate vomiting; the temperature was normal. Permission to explore the abdominal cavity could not be obtained; I therefore treated her with morphia suppositories and mild aperients, keeping her entirely in bed, considering that hers was a case of pyosalpinx-very full-coming on after delivery. As she did not obtain the relief she anticipated, she left the hospital at the expiration of three weeks, but returned after two months, during which time she had had no cessation from pain, and had lost 121b. in weight. As the patient was now quite unable to do anything, and was evidently becoming worse, after consultation I performed abdominal section, and found the right ovary considerably enlarged and full of cysts; the left ovary was also in a state of cystic degeneration, and bound down firmly in a small cyst the recto-vaginal cul-de-sac. On
which
removing it,
was
adherent burst, its contents
being
lost in the
is of interest, as it shows the advanincision made during the early stage of pleural effusion before it had become a case of empyema, In fact,. the effusion was so large and so rapid, and the dyspnoea and cardiac depression were so great, that the case would never have reached the stage of empyema if prompt operative treatment had been delayed. The patient, Mrs. B--, aged thirty-five, was first seen by me on March 3rd, 1886. She complained of breathlessness and increased cough, and she had been ill nearly a week. There had been no rigors ; the pulse was 140, small and weak; the expectoration was mucous, slightly rusty; respiration 40; temperature under the tongue 102°. 6o. examining the chest, the left base was dull on percussion. The front of the chest was normal in all respects. Auscultation : At the right base there were moist dies and crepitations ; at the left base there were no respiratory sounds audible; vocal resonance was increased over the right base, whilst it was oegophonic over the left base; vocal fremitus was increased over the right base; but absent over the left. The absence of vocal fremitus decided the diagnosis as. pleurisy and pneumonia. March 4th.-The dulness is higher posteriorly, and in the axillary line there is also dulness in front from the left side when she sits up. The first sound, which is weak, is loudest behind the sternum. Temperature 101° ; pulse 140; respiration 46. 5th.-General condition worse and increased effusion. Absolute dulness at and below the third rib in front, and from a line parallel with the fourth dorsal vertebra behind. The right chest is normal, except for cardiac dulness over the fourth right costal cartilage. The apex of the heart is now almost under the right mamma. There is a total absence of respiratory sounds all over the left chest, both back and front, except above and just below the clavicle. (Egophony is well marked at the angle of the left scapula, the vocal resonance is altered in front, vocal fremitus is absent on the left side, and there are moist sounds over the right base. Temperature 101’; respiration 48; pulse 140. The pulse tracing shows a very small wave, due to the feeble cardiac impulse and the contracted arteries. Operative treatment was now imperative. Being a disciple of Lister, 1 did not feel justified in opening this large cavity without the spray, as it was a small foul room, and the impure air entering the pleural cavity would be very dangerous and certain to cause suppuration. Further, to wash out the cavity, which I had allowed to become septic, would be an unnecessary labour for me, and a needless and rather dangerous entertainment for the patient. I preferred prevention to cure. I made an incision between the seventh and eighth ribs posteriorly to the axillary line. Clearserurapoured forth in abundance; more than five pints were THE
tage of
following case an
province has become decidedly more unhealthy from malaria. production. Still there is something over and above this in A kind of epidemic wave passed over the tract from north the climate of India that we do not understand. An exactly to south-west, involving in its course the district of Midna- similar combination exists in the West Indies, though the pore. The result of the invasion is that the inhabitants now disease is not so frequent there (in the proportion of 1 to 4). Dr. Budd’s now obsolete theory of the dependence of bear the impress of the noxious influence in a marked degree, in the shape of enlarged spleens, anaemia, bowel complaints, tropical abscess upon dysentery only requires a passing and cachexia generally. Dispensary records also show an notice. It is unsupported by clinical observation, statistics, increase in admissions for liver abscess coincident with the and post-mortem examinations. Dysentery being a disease increased prevalence of fever. While civil surgeon at caused by similar conditions of climate, very frequently Midnapore, I treated there, in the three years 1882-84, no complicates liver abscess, and a very serious complicaless than twenty-one cases, all in natives. Local practi- tion it is, but there is no causal relation between the tioners informed me that in former times the disease was two. Their concurrence in the same individual is a pure coincidence. It is important to remember that the signs practically unknown. In Europeans the greatest liability occurs between the and symptoms even of the hepatitis that precedes it, and ages of twenty and forty-five. Abscess has never yet been of the abscess itself, are apt to be ill marked and insidious; met with in any person, native or European, below fifteen, they often escape notice, or some or all of them may be and it is rare above fifty. In childhood it is absolutely absent. It has been estimated that they are well marked in unknown. Among Europeans men are more liable than 8 per cent. only, while the abscess runs a perfectly latent
in 13 per cent., even in Europeans. Instances are on record where the subjects were engaged in their usual occupations up to the very last. Soldiers have been on full duty up to a few hours of death by the bursting of an abscess internally. In one case an abscess burst while the man was actually on duty. The signs which in a given case of hepatitis lead to suspicion of suppuration are: The enlargement of the liver, which loses its uniform contour and develops more particularly in some one direction so as to form a bulging; localisation of pain and tenderness; pleuritic or peri-hepatitic friction; rigors, chills, sweats, and-most important of all-the temperature. Several apyrexial cases are on record, but I cannot conceive suppuration occurring without the temperature being affected at some time or other. A careful scrutiny of the temperature range, auscultation, and bilateral measurements of the chest are called for. The temperature must be taken every hour, so that a complete reading for the twenty-four hours may be obtained. Subjects of liver abscess are frequently also suffering from malarial fever. A want of periodicity and a resistance to quinine will indicate course
women.
British Army in India, 1883. Admissions per 1000.
Hepatitis. Deaths
per 1000.
Admissions
per cent. of total H,iJmlAR10n!:j.
The disproportion is still more marked as regards abscess itself. In Waring’s 300 cases 9 only were in women, and out of 82 cases reported in various journals 2 only were in women. On the other hand, out of 23 cases in Europeans and Eurasians treated at the Presidency Hospital, Calcutta, as many as 15 were females. The proportion of females to males among the British-born population in India is 1 to 7. I have reason to believe that owing to the exclusive climatic mode of origin in natives there does not exist the same difference in liability of the sexes as in Europeans. Among my 21 cases, mostly dispensary patients, 3 were females; and bearing in mind that the population of females to males attending dispensaries in Bengal is about 1 to 6, this, as far as it goes, does not indicate any very great irregularity. Authorities are agreed that suppurative hepatitis in Europeans in the tropics is mainly due to the effect of climate. But intemperance, over-indulgence in animal and highly spiced foods, and indolence, are spoken of as predisposing causes in the individual; while exposure and chills I am quite disare frequently noted as exciting causes. posed to admit that chill or exposure starts the attack in many instances; this is clearly the mode of origin of many of the reported cases. But have we sufficient evidence of the part the other conditions play in the production of the disease? The great difference in the liability of the two Taces is attributed to the variation in the nature of diet and drink, but it may equally be due to difference in degree of acclimatisation. The great reduction in liver diseases in the army is as likely due to improved sanitary arrangements and protection against climate as to the steadier I am inclined to think that the habits of the men. ’"intemperate" theory, at all events, has been made too much of. An examination of reported cases throws very little light on the subject, because complete histories are so rarely given. It is a significant fact, however, that out of 425 cases of hepatic abscess, including Waring’s 300 and others from the journals, the subjects were said to be intemperate in 50 instances only. Whatever influence personal habits may have, the fact remains that, quite independently of any of them, when an inhabitant of temperate climates - goes to reside in the tropics, there is a tendency for his
liver to become disorganised, though fortunately this in a relatively small proportion only. This to the dark races as well. Natives of mountain applies in regions India, on taking up their abode in the steamy plains of Bengal, are said to become liable to hepatic abscess. Change of climate affects hill cattle in the same way. Imported horses suffer to a large extent; the death-rate from hepatitis among troop horses in India amounts to 2 per 1000
hepatic origin.
By combined statistics the mortality of unrelieved hepatic abscess is found to be about 90 per cent. Death occurs with or without rupture. About one-half of all abscesses that are left alone remain intact. Spontaneous evacuation through the lungs occurs in about 20 per cent., less than half of which recover. Out of 33 cases that recovered spontaneously (Waring’s and others), 16 burst into the lungs, 8 into the intestine, 1 into the stomach, and 2 ended apparently in spontaneous absorption. The extent to which an abscess will develop is surprising. The contents are sometimes to be measured rather by quarts or gallons than by ounces. The whole organ may be converted into a bag of pus. In one case 17 pints were found at the post-mortem examination. I have myself removed as much as 80 oz. at a single operation; while 200 oz., 400 oz., and even 1000 oz. represent the aggregate amounts removed by successive tappings by others. These enormous collections are mostly seen in natives, who are apt to apply for treatment only at too late a stage of the disease. Solitariness is a character of tropical abscesses, but they are often multiple. In Waring’s 300 cases they were solitary in 62 per cent., multiple in 37’8 per cent. Multiplicity is explained by the mode of origin. The disease begins as multiple foci of softening. The foci coalesce as they increase in size. If the areas coalesce into one, a single abscess results; if they combine in groups, the abscesses will be multiple. (To be concluded.)
actually occurs
(Collins) .
What is the particular element or combination of elements in a tropical climate that induces hepatic disease ? It cannot be heat alone; liver abscess is least common in such parts as the Punjab, Central Provinces, &c., where there is greatest heat. Nor is it malaria alone, for the disease is unknown in malarious parts of the temperate regions of the world. The distribution of hepatitis according to district points to a combination of moist heat, dampness of subsoil, and concentration of malaria as the condition most favourable to its
TWO
CASES
OF ABDOMINAL SECTION. BY A. S. UNDERHILL, M.D., M. CH., S.S. CERT. CAMB., SURGEON TO THE GUEST HOSPITAL, DUDLEY.
RECENTLY I have had two cases in which I performed abdominal section, and as these-although fatal-possess points of clinical interest I venture to record them. CASE 1. Rupture of a Tubal Pregnancy.-M. I-, aged twenty-two, married eighteen months, one miscarriage at eighth week, a florid, healthy-looking woman, had catamenia regularly till seven weeks ago, when she was suddenly seized with acute pain in the abdomen, referred chiefly to the region of the right ovary, which continued for about
670
days, leaving her fairly convalescent at the end of two weeks. As she was feeling stronger, she walked for some little distance, but on her return home was again seized with the acute pain over the right ovary, became perten
On rectal examination, directly after its removal, the caudate swelling could still be felt, tense andfirmly adherent, evidently an old heamatocele, which had become partially absorbed, and was now organised. In both
pelvic cavity.
fectly blanched, staggered to a sofa, and was profoundly instances the Fallopian tubes were intact. I thoroughly collapsed for about twelve hours; from this condition she washed out the pelvic cavity with warm water; and as very slowly recovered, and still referred all her pain to the haemorrhage was very slight, I did not resort to drainage. right side of the lower abdomen. On vaginal examination She passed a fair night, but never completely rallied from I found the os and cervix uteri cedematous and very tender, the shock, and died twenty-eight hours after the operation. No post-mortem examination was allowed, but I examined but unlike what is usually found in commencing pregnancy, the uterus was fixed and deflected to the right; posteriorly the wound, and found that there had been no bleeding; the there was a tender semi-solid mass; abdominal percussion- stumps of the appendices were healthy-looking, and, as far as far as could be ascertained on account of the tenderness as I could ascertain, there was no appreciable cause for her -gave a duller note than normal from the groin to the death except exhaustion. Had she consented to the operaumbilicus on both sides. Her condition during the next tion when it was first proposed, I feel assured that her life twelve days was very unsatisfactory. She had a recurrence would have been saved. I have twice operated on moreof peritonitis, and suffered most distressing pain. Her seemingly unpromising cases with favourable results, but pulse was never under 140, and her temperature averaged this patient was of a depressed, nervous temperament, 103° F. Neither herself nor relatives would consent to any and greatly dreaded the operation, making her on this operative interference. On the fourteenth day her symptoms account a very unfavourable subject. The case was of became aggravated, and as she would evidently sink before interest on account of its diagnostic difficulties, as the many hours elapsed, permission was given for abdominal swelling was in shape, position, and history typical of what section. is usually found with pyosalpinx. On opening the abdomen in the mesial line about a pint Tipton, Staffs. and a half of very dark-coloured serous fluid gushed out. On the right side the uterus was bound down by adhesions and coagula to the brim of the pelvis. The right broad liga- A CASE OF RAPID PLEURAL EFFUSION ment was a mass of coagula, the Fallopian tube being much TREATED BY ANTISEPTIC INCISION. thickened and enlarged; the left broad ligament was encased BY ALBERT WILSON, M.D. in coagula, but it was impossible to recognise the Fallopian ____
at the lower part of the abdomen matted together by inflammatory adhesions. To appearance and touch much of the coagula resembled placental tissue, but nowhere could I find a trace of an embryo. I removed as much of the coagula as possible without injuring the intestines, thoroughly washed out the cavity with warm water, and inserted a glass drainage-tube into the pelvis. She rallied well from the operation and suffered little pain. On the eighth day, however, she died, obstinate constipation and vomiting being the predominant
tube; the intestines
were
symptoms.
In my opinion the patient had a right tubal pregnancy; the first attack of peritonitis killed the ovum, which burst after the exertion of walking, and so caused the hsematocele. If at this time consent had been obtained for the operation her chances of recovery would have been more promising; but on the fourteenth day fresh bleeding took place and handicapped the operation, from which she had not sufficient strength to rally. Under similar circumstances I should not hesitate to advise an early operation, as I think I might promise a fair relief from pain and a probably favourable result. CASE 2. Cystic Degeneration of both Ovaries mitk an old Haematocele.-M. C-, aged forty-two, married, with six children, nine months ago was attended by a midwife, who delivered her after a very severe labour. Some weeks after-
wards, not feeling strong and suffering great bearing-down pains and pain in defecation, she consulted a medical man,
and was treated by rest in the recumbent position and tonic medicine, but not feeling much better she was admitted under
my
care
into the Guest
Hospital.
I found the uterus retro-
flexed, but fairly movable on the sound. Posteriorly, in Douglas’s pouch, there was a tense swelling, somewhat caudate in shape and very painful on pressure. Per rectum it was more defined ; over both ovarian regions there was considerable tenderness, so much so that it was impossible
to ascertain their condition. She could not walk or stand without much bearing-down pain, and she had occasional attacks of obstinate vomiting; the temperature was normal. Permission to explore the abdominal cavity could not be obtained; I therefore treated her with morphia suppositories and mild aperients, keeping her entirely in bed, considering that hers was a case of pyosalpinx-very full-coming on after delivery. As she did not obtain the relief she anticipated, she left the hospital at the expiration of three weeks, but returned after two months, during which time she had had no cessation from pain, and had lost 121b. in weight. As the patient was now quite unable to do anything, and was evidently becoming worse, after consultation I performed abdominal section, and found the right ovary considerably enlarged and full of cysts; the left ovary was also in a state of cystic degeneration, and bound down firmly in a small cyst the recto-vaginal cul-de-sac. On
which
removing it,
was
adherent burst, its contents
being
lost in the
is of interest, as it shows the advanincision made during the early stage of pleural effusion before it had become a case of empyema, In fact,. the effusion was so large and so rapid, and the dyspnoea and cardiac depression were so great, that the case would never have reached the stage of empyema if prompt operative treatment had been delayed. The patient, Mrs. B--, aged thirty-five, was first seen by me on March 3rd, 1886. She complained of breathlessness and increased cough, and she had been ill nearly a week. There had been no rigors ; the pulse was 140, small and weak; the expectoration was mucous, slightly rusty; respiration 40; temperature under the tongue 102°. 6o. examining the chest, the left base was dull on percussion. The front of the chest was normal in all respects. Auscultation : At the right base there were moist dies and crepitations ; at the left base there were no respiratory sounds audible; vocal resonance was increased over the right base, whilst it was oegophonic over the left base; vocal fremitus was increased over the right base; but absent over the left. The absence of vocal fremitus decided the diagnosis as. pleurisy and pneumonia. March 4th.-The dulness is higher posteriorly, and in the axillary line there is also dulness in front from the left side when she sits up. The first sound, which is weak, is loudest behind the sternum. Temperature 101° ; pulse 140; respiration 46. 5th.-General condition worse and increased effusion. Absolute dulness at and below the third rib in front, and from a line parallel with the fourth dorsal vertebra behind. The right chest is normal, except for cardiac dulness over the fourth right costal cartilage. The apex of the heart is now almost under the right mamma. There is a total absence of respiratory sounds all over the left chest, both back and front, except above and just below the clavicle. (Egophony is well marked at the angle of the left scapula, the vocal resonance is altered in front, vocal fremitus is absent on the left side, and there are moist sounds over the right base. Temperature 101’; respiration 48; pulse 140. The pulse tracing shows a very small wave, due to the feeble cardiac impulse and the contracted arteries. Operative treatment was now imperative. Being a disciple of Lister, 1 did not feel justified in opening this large cavity without the spray, as it was a small foul room, and the impure air entering the pleural cavity would be very dangerous and certain to cause suppuration. Further, to wash out the cavity, which I had allowed to become septic, would be an unnecessary labour for me, and a needless and rather dangerous entertainment for the patient. I preferred prevention to cure. I made an incision between the seventh and eighth ribs posteriorly to the axillary line. Clearserurapoured forth in abundance; more than five pints were THE
tage of
following case an