% Jflirror of goKjjital ?ractitc.

RUPTURED EXTRA UTERINE PREGNAN-

/ CY. 5-6 MONTHS. LAPAROTOMY.

DELAYED CHLOROFORM POISONING

RECOVERY.

By C. C. BARKY,

LIEUT.-COL., I.M.S.,

Superintendent, Civil General Hospital, Rangoon.

.Name of patient Mali 0, age 30, sex female, caste or class Burmese, occupation bazaar seller, result cured, date of admission 23rd September, 1913, date of discharge 6th November, 1913.

History.?Married for 15 years, number of preg- nancies, nil; number of children nil; number ot miscarriages, nil; date of last confinement, nil ; date of last miscarriage, nil; date of last men- struation, three da^s ago. Slight blood-stained discharge still present.

Previous history.?Three and-a-lialf months

ago she felt pain in the left iliac region, which lasted for nearly a month. The pain was severe but unaccompanied by faintness or nausea.

When the pain came on she noticed a swelling in the left iliac fossa, which has since steadily increased in size, though she has been free from

pain up to 10 days ago. The pain that then came on has got steadily worse, and is now very acute and the swelling very tender. Has been

regular in her menstruation, the last period occurred 3 days ago. Has never had any profuse vaginal hjemorrhage. Has no reason to think she is pregnant.

Menstrual history.?Age at first menstruation 17 years, regularity once in 4 weeks, quite regular ; duration 3 days, amount in no way excessive, pain none.

Inter-menstrual discharge.?Character none. Functional disturbance of bladder.?Has pain

and difficulty in passing water. Rectum has pain on defsecation.

Physical Examination.

General appearance.?Well nourished, but looks anxious and ill. The breasts are enlarged and

the glandular tissue appears to be hypertrophied. No milk in breasts.

Temperature 100? F. Abdomen.?There is a large, prominent, glo-

bular and smooth swelling of indistinct outline, rising out of the pelvis and extending upwards in the left flank as high as the 10th rib, and from

there across the abdomen to the right as far as

the umbilicus. The swelling appears to fill the

whole pelvis, is fixed and very tender. Per vaginam.?The swelling fills nearly the

whole of the pelvic cavity, extending low down and obliterating the pouch of Douglas. The uterus

can be made out slightly enlarged and pushed well over to the right side of the pelvis. The

swelling is fixed, but elastic and gives the impres- sion of semi-solid cyst. The abdomen is generally distended and signs

of commencing general peritonitis are present. Alimentary system.?Tongue coated and some-

what dry, appetite nil, vomiting none, condition of bowels constipated, liver of normal size ; not

tender.

Circulatory system.?Pulse full and regular, 108 per minute, heart normal.

Respiratory system.?Breathing somewhat hur- ried, chiefly thoracic, lungs normal.

Urinary system.?Urine quantity, colour straw, special gravity 1014, albumen nil, reaction acid

but not markedly so, sugar nil. 22nd September 1913. Chloroform. Median

Laparotomy.?Incision about 7 inches long. The whole of the anterior aspect of the tumour was

covered by congested and blood infiltrated omentum with greatly dilated veins. The omentum which was firmly adherent to the front of the

tumour was removed, exposing a smooth walled cyst of a dark red colour. The pelvis was also seen to contain about 10 ounces of fresh blood.

On examining the relations of the cyst, a small

tear was found at the lower and left side of the

tumour, from which blood clot was exuding. The

upper and right side of the cyst was smooth and free, the lower and left part widely adherent to

the left side of the pelvis and to the uterus which was incorporated into the front of the cyst wall. The rectum and pelvic colon was also incorporated into the posterior wall of the cyst. On introducing a finger through the rent in the lower part of the left side of the cyst, the wall which was as rotten as a wet blotting paper tore widely, exposing a large cavity full of blood clot and a placenta which was lying on the posterior and left wall of the cyst. The placenta which was extensively thrombosed

was rapidly stripped off and removed, and with it a 5-6 months' foetus. There was very free

hemorrhage from a large vein which from its

position was thought to be the internaliliac vein

greatly dilated. The bleeding was controlled by several long clips, but it was found impossible to

RUPTURED EXTRA UTERINE PREGNANCY. 5-6 MONTHS.

LAPAROTOMY. DELAYED CHLOROFORM POISONING?

RECOVERY.

Bv Lieut-Col. C. C. BaRRY, i.m.s.,

Superintendent, Civil General Hospital, Rangoon.

DATES OF

OBSERVATION. 22 23 24 25 26 27 28 29 30

DAY OF DIS.

Cent. Fahr. TIME

M.E M.E M.E M.E M.E M.E M.E ME ME M. E M E M.E

42 107 150

106 140

41

105 130

40 104120

103? IIP

39 102 100

o I- <: s-* 0_LS O I

J

I

o o

*

> ?

<f> 7~r $ '

? !

101 90

38 loo ao

99 70

37 NORMAL

z 98 ? 25 m

V 97

Pulse.

Resp.

Bowels.

96/ /loo

82, 82

24/ /26

24

26

24

24

20 /

/22

URINE

'Sp. Gr. Reaction,

Albumen. Acetone.

Bile.

1014 015 1014 1016 IOI6 1015 1014 1015

ACID ACID NEUTRAL NEUTRAL NEUTRAL ALKELINE

NIL NIL NIL NIL NIL

NIL NIL NIL NIL NIL NIL

PRESENT PRESENT PRESENT PRESENT NIL

PULSE

TEMPERATURE

PULSE

TEMPERATURE

Sept., 1914.] DELAYED CHLOROFORM POISONING. 353

pass any ligatures owing to the depth of the bleed- ing point and the rotten state of the tissues which were extensively infiltrated with blood, nor for

this reason could the ovarian artery or vein be

identified and safely ligatured. No attempt could be made to remove the cyst wall owing to its

intimate relations to the rectum, pelvic colon and uterus. The cyst wall was therefore sewn to the lower part of the abdominal wound, the cyst cavity being plugged with gauze and the artery clips left in position. The upper part of the

abdominal wound was closed in the usual manner.

The patient was considerably collapsed from loss of blood, but on the whole stood the operation well. Intravenous saline infusion was not given as owing to the rotten state of the cyst wall and

the infiltrated condition of the surrounding parts there was considerable doubt if all the bleeding points had been secured. The foetus was quite fresh and evidently had been living to within a

short time before the operation, though the head was much flattened owing to pressure from the

surrounding parts. It was a well formed male, 5-G months' growth.

Subsequent History.?23rd /September 1913.? Patient rallied quickly after operation and has slept fairly well. Is now quite comfortable. Artery clips removed from abdomen.

24tlx September 1913.?Patient doing well, is cheerful and bright, no pain, gauze plug removed from abdomen and cyst cavity lightly replugged with aseptic gauze.

25th September 1913. 8 a.m.?Patient seems drowsy this morning and keeps her eyes closed. The eyelids and face are slightly puffy. The conjunctiva slighly jaundiced, temperature normal, pulse 110, urine ap. gr. 1014, reaction very acid. No albumen, acetone, sugar or bile present.

3 p.m. Patient very restless throwing herself about in bed, screaming and grinding her teeth. Jaundice has

markedly increased. 2Gth September 1913.?Patient became unconscious in

early hours of the morning and is now in a state of coma. (Edema of face has increased and oedema is

present in hands and feet. Urine Gr. 1014, bile present. No sugar albumen, or acetone present. Reaction

markedly acid. Motions light coloured but seem to contain fair amount of bile.

27th September 1913 & 28th September 1913.? Patient remained in a state of complete coma and could not be roused, marked jaundice present of conjunctiva and other mucous membranes. Urine as above neutral in reaction.

29th September 1913.?Patient less comatose, opens her eyes when spoken to, but does not speak. Jaundice less marked. CEdema as above. Urine neutral in reaction.

30th September 1913.?Patient much better, quite conscious and speaks readily. Jaundice much marked, oedema of hands and feet present as before, urine as

above except reaction is neutral, and no bile is present. ls? October 1913.?Patient quite bright, has no

recollection of the last few, days. Jaundice disappearing, oedema much less. Urine alkaline. 2nd October 1913.?CEdema has disappeared, slight

jaundice present, doing well. Urine alkaline. 6th October 1913 ?Jaundice has disappeared. Urine

normal, neutral in reaction. Patient doing well and gaining strength.

6th November 1913.?The patient has made a good recovery and is tit for discharge from hospital. The sac containing the extra uterine foetation has become

obliterated and the abdominal wound has firmly healed. Whether she will develop a ventral hernia is doubtful. The surgical after-treatment of this patient gave no trouble, though there was some sloughing of the edges of the extra uterine sac where it had been sewn to the lower part of the laparotomy incision. The sac cavity was irrigated twice daily with tr, of

iodine solution and kept loosely packed with gauze.

The case appears to be of considerable interest both from the primary disease for which the

patient was admitted and on account of the

secondary symptoms occurring some 2j days after the operation and which I can only attribute to delayed chloroform poisoning.

As regards the primary disease, it would seem this was a case of tubal pregnancy that had

ruptured into the broad ligament some months previously. The ovum had continued to grow between the layers of the broad ligament strip- ping the peritoneum off the pelvic wall as high as the brim of the pelvis and forming a pedun- culated tumour attached to the pelvis by a broad base. In growing, the rectum and uterus had become incorporated into the sac wall and the omentum had become firmly adherent over its anterior surface. Eventually the cyst wall had

ruptured causing acute abdominal pain and effusion of blood into the abdominal cavity.

It seems probable from some cause haemor-

rhage had taken place into the cyst cavity from the placenta and so had determined the

rupture of the cyst, since the cyst cavity was greatly distended with blood clot and the vessels of the placenta itself markedly thrombosed.

The symptoms.?Possible causation and patho- logy of delayed chloroform poisoning have been so ably discussed by Munro and White in the Octo- ber 1913 number of Indian Medical Gazette

that any further comment is superfluous, but as this patient recovered it would be well perhaps to give a short summary of the symptoms she presented. The patient rapidly rallied from the severe

operation she had undergone, had a normal tem- perature for 48 hours and was exceptionally bright and well. There was no abdominal dis-

tension and practically no pain; in short, she seemed on the road to rapid recovery. The first

symptom noticed was drowsiness, with slight jaundice and slight cedema of the eyelids. Twelve hours later the patient was restless and

noisy with a rapid pulse and a quickly rising temperature, the jaundice had also markedly increased. In eight hours more the patient was

deeply comatose, remained so for 3 days and then

gradually recovered consciousness. The coma

was profound, the evacuations were passed un-

consciously and all medicine and nourishment

had to be given by a nasal tube. The jaun- dice at first sight became well marked and

bile appeared in the urine, it gradually faded

away.

354 THE INDIAN MEDICAL GAZETTE. [Sept., 1914.

The temperature and pulse rate is given in the accompanying chart; both rose rapidly and then more slowly declined. The urine was examined before the operation

and was apparently normal; it was examined

daily from the time drowsiness was first noticed; it never contained any acetone, but was

markedly acid. Subsequent examinations dis- closed no abnormal acidity, though the alkalies were stopped. No albumen or sugar was ever found in the

urine which appeared to be passed in normal

quantities, though no accurate measurements

could be taken as the patient when comatose

passed her evacuations unconsciously. Previous to the onset of the symptoms the urine had been passed daily in normal quantity.

There was never any vomiting. The treatment consisted of drachm doses of sodse bicarb, every hour, given every hour for the first 24 hours, 4 hours for 48 hours, and finally every 6 hours till the urine became alkaline and remained so. How far this treatment acted in obtaining the

patient's recovery I am unable to say, but I have no doubt the unremitting care and attention the patient received from the nursing staff and the Sub-Assistant Surgeon in sub-charge of the ward was the chief factor.