RETENTION VAGINA
:
OF
MENSES
OPERATION
:
FROM
ABSENCE
PERITONITIS
:
OF
DEATH.
By G. C. Roy, m.d., f.r.c.s.
Soudaminey, aged 18 years, and by appearance about the came to the hospital foi out-door treatment on 20th July, suffering from an excruciating pain in the abdomen, to which Her sister she was giving expression in loud cries and sobs. stated that for the last 4 years she had felt the periodic pain without any show of menstrual flux. This pain used to come and go off at regular periods, but for the last 2 months it was It used more or less constant and of an excruciating nature. made her life to come paroxysmally every half hour, and perfectly miserable. On examination the uterus was found enlarged an inch above the pubis regular in contour, but very painful. Per rectum a smooth globular tumour was felt filling up Douglas's pouch. The urethra was in natural position and the external genitals well formed. Below the urethra was the vagina which terminated in a cul de sac half an inch beyond the opening, from which no uterus could be felt. The breasts and altogether the signs of puberty were were undeveloped, backward in development. Plainly it was a case of imperfect vagina, and the agony the girl was suffering from called In ordinary course the best time to for immediate relief. choose for operation is the interval between the menstrual period when the parts are quiescent and not in an excitable state. But here no sucli period of rest was observed, and the necessity for relief was urgent. The bladder having been emptied, an incision was made in the median line in the site of the vagina, when about a dram of pus was let out No canal was felt but a dense layer of impermeable tissue. same,
1
'
'
^
:
,
?;
THE INDIAN MEDICAL GAZETTE,
252
With one finger in the rectum the incision was carried when with persistent dilatation with the finger, the uterus A big sized was reached, but no cervix or os was felt. trocar was then thrust into the organ and the cavity was a of thick treacly blood flowed out of reached. About pint used. On withdrawing the the canula, and no pressure was was found too small for permanent drainage. the trocar opening was and on it director the A introduced, opening was enlarged with a probe-pointed bistoury and dilated with the finger, which reached a big cavity lined with smooth lining membrane. A dose of opium was administered. There was some discharge throughout the day of a thinner consistence. The pain was relieved, and the patient passed a comfortable day, but it was aggravated at night. Next morning she was in agony. She complained of paroxysmal pain in the lower part of abdomen extending down to the thigh. Opium gr. i. was given every 6 hours, and an opium injection ordered. She had fever in the course of the day, and although opium gave some relief, she was never free from pain afterwards. Next day, 22nd, she was much in the same state, with great thirst, restlessness, low temperature, nausea, sickness, and weak pulse, symptoms indicating peritonitis, probably from rupture of Fallopian tube and extravasation of blood. She was kept under the influence of opium and brandy and diffusible stimulants, with warm application over the abdomen were prescribed, but she sank on the night of the 23rd, i.e. the 4th day after operation. Simple as the operation may appear it is not without its elements of danger, which consists in over distension of the uterus with accumulated blood, dilatation of Fallopian tubes, formation of a sanguineous cyst and intra-peritoneal rupture. The cases of retention from imperforate hymen are not so danthose from absence of as in as the arising vagina, gerous former, the vaginal canal participates in the enlargement, and the Fallopian tubes are the last to suffer. Besides, from the very nature of the case, the operation is a much simpler one and the result very hopeful, whereas even if the patient survives the immediate effect of operation in the other variety, she has at best a miserable existence in view. For nothing can keep patent the artificial opening, which must Besides if impregnation inevitably cicatrize and contract. takes place, delivery per vias naturales is simply impossible. If left irt statu quo, the patient is likely to die in the end, either from escape of blood into the peritoneum, or rupture of Fallopian tube, or suppuration set up in the pelvic fascia around the In the present case the obstruction remained too long uterus. unrelieved, and the continuous pain the patient suffered from for two months before death, indicated the mischief which had been set on foot, of which the suppuration in the mouth of the vagina was a minor one. In the absence of post-mortem examination the existence of any deep-seated suppuration in the pelvis would remain a matter of conjecture, but the sudden supervention of peritonitis after operation, left no doubt as to the immediate cause of death.
deeper,
Two
of suppuration in the knee joint treated with antiseptic opening: recovery. A Mahomedan, aged about 35 years, attended as an out-patient for acute synovitis. The knee was very much swollen and tense, attended with a good deal of constitutional disturbance. A few leeches were applied, lead and opium lotions were ordered, and a saline and hyoscyamus mixture was given internally. The pain became worse, and the skin on the inner side of the knee became inflamed and brawny. As the fever persisted and the paiii was attended with jerking of the limb, deepseated inflammation of the joint was suspected and suppuration. The symptoms becoming urgent, and as the spray was unfortunately out of order the first day, the swelling was aspirated and about
cases
an ounce
of grumous pus
was
withdrawn.
The relief
was
marked, although there was continual oozing of matter through the opening made by the needle. The next day a director was passed through the opening and the skin laid open upward and downward to the extent of i_^ inches. It was found that the external cavity of suppuration did not communicate It contained some coagulated blood, which was with the joint. turned out and the joint was put on a Macintyre splint and The inflammation and outer swelling subsided, poulticed. but the synovial swelling remained. All went on well for 6 days, and the wound was granulating, when one night the patient perceived an unusual gush of fluid through the opening. In fact a communication had formed with the cavity not
so
[September, 1883.
of the joint, and the synovial fluid made its escape by the rupture in the wall of the sac. The oily nature of the fluid, with the emptying and collapse of the synovial swelling on pressure, left For three days the wound was enno doubt on that point. veloped in carbolised cotton and kept at rest, but the recurrence of pain, high fever and the puriform nature of the discharge called for interference. Fortunately the spray was at hand, and under it a counter opening was made in the outer side of the joint and The joint was washed a drainage tube was passed through. out with carbolic lotion and the wound dressed antiseptically. In a week more all the pain subsided, the swelling, discharge, and fever disappeared, and the patient was looking cheerful. The tube was removed, and the patient made a good recovery, with the joint perfectly movable, but stiff from long disuse. The 2nd case was that of a boy who was attending the hospital at the same time for acute synovitis. His right kneejoint was first very much swollen and inflamed, attenced with fever. After 8 or 10 days' treatment he was no better, and getting worn out with constitutional disturbance, when I aspirated the joint and gave exi' to 4 or 5 ounces of puriform fluid. The pain continued for 2 days more, but with lead and opium lotion externally and Pot. iodid. internally, the boy recovered without further accumulation of fluid. There was some thickening of the bone left, but no pain when he was last seen in the dispensary. Both these cases are triumphs of antiseptic surgery, which in former years would have necessitated amputation or excision.
:
OF
MENSES
OPERATION
:
FROM
ABSENCE
PERITONITIS
:
OF
DEATH.
By G. C. Roy, m.d., f.r.c.s.
Soudaminey, aged 18 years, and by appearance about the came to the hospital foi out-door treatment on 20th July, suffering from an excruciating pain in the abdomen, to which Her sister she was giving expression in loud cries and sobs. stated that for the last 4 years she had felt the periodic pain without any show of menstrual flux. This pain used to come and go off at regular periods, but for the last 2 months it was It used more or less constant and of an excruciating nature. made her life to come paroxysmally every half hour, and perfectly miserable. On examination the uterus was found enlarged an inch above the pubis regular in contour, but very painful. Per rectum a smooth globular tumour was felt filling up Douglas's pouch. The urethra was in natural position and the external genitals well formed. Below the urethra was the vagina which terminated in a cul de sac half an inch beyond the opening, from which no uterus could be felt. The breasts and altogether the signs of puberty were were undeveloped, backward in development. Plainly it was a case of imperfect vagina, and the agony the girl was suffering from called In ordinary course the best time to for immediate relief. choose for operation is the interval between the menstrual period when the parts are quiescent and not in an excitable state. But here no sucli period of rest was observed, and the necessity for relief was urgent. The bladder having been emptied, an incision was made in the median line in the site of the vagina, when about a dram of pus was let out No canal was felt but a dense layer of impermeable tissue. same,
1
'
'
^
:
,
?;
THE INDIAN MEDICAL GAZETTE,
252
With one finger in the rectum the incision was carried when with persistent dilatation with the finger, the uterus A big sized was reached, but no cervix or os was felt. trocar was then thrust into the organ and the cavity was a of thick treacly blood flowed out of reached. About pint used. On withdrawing the the canula, and no pressure was was found too small for permanent drainage. the trocar opening was and on it director the A introduced, opening was enlarged with a probe-pointed bistoury and dilated with the finger, which reached a big cavity lined with smooth lining membrane. A dose of opium was administered. There was some discharge throughout the day of a thinner consistence. The pain was relieved, and the patient passed a comfortable day, but it was aggravated at night. Next morning she was in agony. She complained of paroxysmal pain in the lower part of abdomen extending down to the thigh. Opium gr. i. was given every 6 hours, and an opium injection ordered. She had fever in the course of the day, and although opium gave some relief, she was never free from pain afterwards. Next day, 22nd, she was much in the same state, with great thirst, restlessness, low temperature, nausea, sickness, and weak pulse, symptoms indicating peritonitis, probably from rupture of Fallopian tube and extravasation of blood. She was kept under the influence of opium and brandy and diffusible stimulants, with warm application over the abdomen were prescribed, but she sank on the night of the 23rd, i.e. the 4th day after operation. Simple as the operation may appear it is not without its elements of danger, which consists in over distension of the uterus with accumulated blood, dilatation of Fallopian tubes, formation of a sanguineous cyst and intra-peritoneal rupture. The cases of retention from imperforate hymen are not so danthose from absence of as in as the arising vagina, gerous former, the vaginal canal participates in the enlargement, and the Fallopian tubes are the last to suffer. Besides, from the very nature of the case, the operation is a much simpler one and the result very hopeful, whereas even if the patient survives the immediate effect of operation in the other variety, she has at best a miserable existence in view. For nothing can keep patent the artificial opening, which must Besides if impregnation inevitably cicatrize and contract. takes place, delivery per vias naturales is simply impossible. If left irt statu quo, the patient is likely to die in the end, either from escape of blood into the peritoneum, or rupture of Fallopian tube, or suppuration set up in the pelvic fascia around the In the present case the obstruction remained too long uterus. unrelieved, and the continuous pain the patient suffered from for two months before death, indicated the mischief which had been set on foot, of which the suppuration in the mouth of the vagina was a minor one. In the absence of post-mortem examination the existence of any deep-seated suppuration in the pelvis would remain a matter of conjecture, but the sudden supervention of peritonitis after operation, left no doubt as to the immediate cause of death.
deeper,
Two
of suppuration in the knee joint treated with antiseptic opening: recovery. A Mahomedan, aged about 35 years, attended as an out-patient for acute synovitis. The knee was very much swollen and tense, attended with a good deal of constitutional disturbance. A few leeches were applied, lead and opium lotions were ordered, and a saline and hyoscyamus mixture was given internally. The pain became worse, and the skin on the inner side of the knee became inflamed and brawny. As the fever persisted and the paiii was attended with jerking of the limb, deepseated inflammation of the joint was suspected and suppuration. The symptoms becoming urgent, and as the spray was unfortunately out of order the first day, the swelling was aspirated and about
cases
an ounce
of grumous pus
was
withdrawn.
The relief
was
marked, although there was continual oozing of matter through the opening made by the needle. The next day a director was passed through the opening and the skin laid open upward and downward to the extent of i_^ inches. It was found that the external cavity of suppuration did not communicate It contained some coagulated blood, which was with the joint. turned out and the joint was put on a Macintyre splint and The inflammation and outer swelling subsided, poulticed. but the synovial swelling remained. All went on well for 6 days, and the wound was granulating, when one night the patient perceived an unusual gush of fluid through the opening. In fact a communication had formed with the cavity not
so
[September, 1883.
of the joint, and the synovial fluid made its escape by the rupture in the wall of the sac. The oily nature of the fluid, with the emptying and collapse of the synovial swelling on pressure, left For three days the wound was enno doubt on that point. veloped in carbolised cotton and kept at rest, but the recurrence of pain, high fever and the puriform nature of the discharge called for interference. Fortunately the spray was at hand, and under it a counter opening was made in the outer side of the joint and The joint was washed a drainage tube was passed through. out with carbolic lotion and the wound dressed antiseptically. In a week more all the pain subsided, the swelling, discharge, and fever disappeared, and the patient was looking cheerful. The tube was removed, and the patient made a good recovery, with the joint perfectly movable, but stiff from long disuse. The 2nd case was that of a boy who was attending the hospital at the same time for acute synovitis. His right kneejoint was first very much swollen and inflamed, attenced with fever. After 8 or 10 days' treatment he was no better, and getting worn out with constitutional disturbance, when I aspirated the joint and gave exi' to 4 or 5 ounces of puriform fluid. The pain continued for 2 days more, but with lead and opium lotion externally and Pot. iodid. internally, the boy recovered without further accumulation of fluid. There was some thickening of the bone left, but no pain when he was last seen in the dispensary. Both these cases are triumphs of antiseptic surgery, which in former years would have necessitated amputation or excision.
