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A case of fatal peritoneal Hæmorrhage complicating artificial pneumoperitoneum
I64
ME1)ICAL M E M O R A N 1 ) U M
A Case of Fatal Peritoneal H emorrhage Complicating Artificial Pneumoperitoneum Be V. C O T T O N
CORNWALL
AND W. H. P A T R I D G E
From Fazakerle~ Sanatorium, Liverpool 8o far as we have been able to discover by consulting Banyai [I], Index Medicus and Tuberculosis Index [~], a case of fatal peritoneal haemorrhage occurring during the treatment of pulmonary tuberculosis by artificial prmumoperitoneum has not heel1 recorded, It therefore seems desirable to report the following case, The patient, a male. aged 38, [it's(: came under OtLr cm'e in i9,1,3 as an out-patient who attenMecl for refills lbr a right artifichtl/)xtetn:rl.othorax, l.[c had previously had a left artilMal pnettlll.()thorax which obliterated in I!139 and disease iu the left lung appeared to 1)c quiescc, nt, In I94.4 he was admitted to this sanatorium because of reactivation of the left-sided disc:ase and an attempt was made to re-induce the Ieff artilMal pneumothorax. The right skte h.ad then reexpanded except R)r a small apical space con. taining an etlb.sion in which tubc:rde Imeilli were demonstrated. Following repeated washcmts with Azoehloramide T the space obliterated; On ~7,5.46 an artificial pnmmtoperitonmun was induced and contimted tmtil his death. The diaphragm became raised to the 3rd rib anteriorly on both sides, but sputum remailmd positive and both radiological and clinical signs of a left upper zone cavity persisted. Air was given with a Chandler refill needle and a Maxwell A,P. box through a puncture in the abdominal wall I½ in. below the left subcostal margin and external to the rectus abdominis and~ after the first few fills, no anaesthetic was used. On i7.9.46 the patient was put on a piaster bed as he had developed tuberculous disease of his 9th and Ioth dorsal vertebrae. On 2o,9.46 he was given a refill of I,ooo c.c, of air l~sing our usual technique and the Iinal manometer readings were q- 14 -}-17. He made no complaint at the time and seemed as usual when seen two hours later. Later in the day lie vomited undigested tbod twice,, but otherwise made no complaints. He vomited twice the. following morni~lg and at I'2.3o p.m., he was collapsed and vomithtg copiottsly. A tentatiw: diagnosis of acute dilatation o1' the stomach was then ma(:[e and he was removed li'om the piaster bed and given coraminc injections and glucose
saline. As his vomiting then ceased a stomach tul)e was not passed. His condition, however, steadily deteriorated and his respirations hecame quick and shallow, Death occurred at 4.~5 p,m. A post-mortem examination was made by Dr C, A, St. Hill, Pathologist to the Royal Southern Hospital, wire reported as follows: ...... Chart: 1,eft pleltra: grossly thickened .and fihroscd ¢wer the aptx, lhc ph.m':tl caw y is ahnost cml~l)letely obliterated by ¢h:ns~: old ~dlu;sions, Right ph:nra: ch',nse, adhesim~s are present C:Slmcially ~wer tim apex whm'e there is an nld intral)lmu,al eavhy Inntnded by ch'nse lihrmts tissue wails and emttaining a li th; nccr()tic tissue, OutsMe the parietal l)lem'a mid extending li'om the 6th to loth dorsal w:rtel)r;u; is a large al)scess Sl)aCc: cxtmtding ii'cm), the Imdies o1"the vcrtcl)rae to) the angh; ol? tlm ribs. This abscess is lilh:d with milky i)us m~d derived li'om tttl)ermtlmts lcslml hi" the lmdieS of 9th and Ioth I),, which arc c:roded to within ~ in, c)l'the spimtl cord, Iatngs are l)mh~ collal)sed very consldcral)ly ])y [he p Icltnl,olleritc)ueltm lip lo ,.all'(:[[utersl)acc on hoth sides. The left hmg apex shows a ml)erculous cavity about I~ iu, in diameter. Otherwise the lungs appear healthy. Abdomen: Peritoneal cavity contained a huge mass of blood clot with much sanguineous fluid. The clot extends down the let~: side of the abdomen 5'om spleen to pelvis. In tt.le left epigastric region of the abdominal wall is a recent needle puncture, Beneath this there is a small extravasation of Mood into the tissues of the greater omentum apparently derived from a small vein, whilst adherent to the surface of the omentum in this region is a small mass of fibrinous clot. Over the dome ot" the liver is a small collection of distended vessels lint there is no adherent clot in this imlghbmtrhood mid no evidence that the bleeding originated here. Olher organs: Liver, spleen, kidneys, show extensive amyloid i~t[iltration. Brain: Normal. Cause o/'dealh: [¥ritm).eal hacmorrhage, probably ti'om punctured omental vessel. Since this death t)cctu'rc:d, anotll.er case occurred in our series in whh:h tit(:; symptoms suggc, st intrapcrit(mcal hacmorrhag{:, This patient was a ti:male, agc:d '.aS~ with
August i947
TUBERCLE
extensive bilateral pulmonary tuberculosis and ? tuberculous enteritis, L.A.P. attempted ~5.7.46. P.P. induced i6.7.46. Left phrenic nerve crush ~8.iI.46. P.P. refill 29.II.46, and screening showed slight paradoxical movement. I,ooo c.c. air given. She was seen by one of us (V. C. C.) 30. i 1.46 complaining of severe abdominal pain which had started the night before. The abdomen felt tense so a refill needle was put in and although the reading was onIy + 7 air was allowed to escape and pressures left at +5. The foot of the bed was raised. She was seen again at midnight and looked extremely ill, T.97, P.I3o, with a history of persistent vomiting. She was too ill to move about but it was thought that there was dullness in the left flank. The tbot of the bed was lowered and she was put into Fowler's position,. An attempt at intravenous transfusion failed and she was put o n to a glucose saline drip and cor'.uninc lbur-]murly. She remained extremely ill tbr the next five clays and had symptoms of peritoneal irritatkm, but the condition gradually improved, She showed definite shifting,
z65
dullness i n abdomen as soon as she was well enough to move her position.
Discussion Although the evidence is not conclusive the cause ofhaemorrhage in Case i was p r o b a b l y the puncture of an omental vein at the time of the refill. We do not think that the position on the plaster bed could make puncture of viscera or intraperitoneal vessels more likely. In a series of I29 cases (3,616 refills) these are the only two with symptoms suggesting intraperitoneal haemorrhage and we feel, w h i l e the risk is remote, the possibility of this complication should be borne in mind. Our thanks are due m Dr O. F. Thomas, Medical Superintendent, lbr permission to publish thesecases. References [I] Baayal, A. L. (19,t,6)I'neumoperitoneumTreatment, St. Louis. , [)] TuberculosisIndex (i946) Vol. I, *'4.
Reviews T U B E R C U L O S I S IN T H E BANTU, B. A. I)ormer and F. J. Wiles. South Aft'lean Medical Journal. May '25, I946, Vol. xx, No. re, PP' ~6,2-5, I'he student of the epidemiology of tuberculosis will find here thcts of unusual interest. The Bantu comprise two-thirds of the population of the Union of South Ai~ica, and number some four and a half million persons. They live under three different environments: (i) In native reserves; (ii) on European farms; and (iii) employed industrially in towns. Information for present study is quite lacking concerning the group living on farms. But the other two groups present entirely different reactions to tuberculosis. On a Reserve the Bantu is 'accustomed to an easy, lazy existence--a loafer's paradise~where a bare minimum of work is performed, and most of this by women and children. There are the games, the beer-drinks, and the long chats about nothing. The family unit is the kraal, and the different kraals are at a considerable distance from each other, so that social contact is limited. The members of a family crowd together to sleep, but the daytime is spent in the open-air. The food is simple and monotonous, but, except in time of drought, is adequate. These pastoral people are living in tune with an environment to which they have been accustomed for centuries.' Tuberculosis occurs on the Reserves, but it is chronic or European in type. When the Bantu moves to industry in towns, he changes to hear3;, sustalned physical work for eight or ten hours a
day. 'The unaccustomed exertion causes fatigue, thereby lowering his resistance to infection which spreads easily in his crowded living quarters.' Under these circumstances tuberculosis is widespread, but the great majority of the cases are of an acute, rapidly fatal type. Here can be no question of racial susceptibility to account for two types of tuberculosis occurring in the same race in the same country with environment the only variant. The Bantu mortality in towns from tuberculosis has doubled since 1938 and is now placed at 779 per ioo, ooo which is more than 2o times the European mortality. Most of the cases when recognized, at their own desire, are repatriated and so are lost to death returns; thus out of 986 cases, repatriations were 869, only leaving i 17 to account for I I6 deaths! The mortality, though difficult to estimate accurateIy, among the Bantus employed at the Witwatersrand mines is undoubtedly lower than among other industrlally employed Bantus; but they are medically examined before engagement and during their working time, as well as being placed on proper diet scales and well housed. Indeed, all the evidence presented is against the fatalistic fetish of racial susceptibility, 'and in favour of careful supervision of the Bantu employed industrially. Unless such care is exerted this source of cheap labour may be destroyed. Food on an adequate scale should be provided, otherwise the Bantu sends his wages home or wastes them rather than using them to buy enough calories for his working needs.
ME1)ICAL M E M O R A N 1 ) U M
A Case of Fatal Peritoneal H emorrhage Complicating Artificial Pneumoperitoneum Be V. C O T T O N
CORNWALL
AND W. H. P A T R I D G E
From Fazakerle~ Sanatorium, Liverpool 8o far as we have been able to discover by consulting Banyai [I], Index Medicus and Tuberculosis Index [~], a case of fatal peritoneal haemorrhage occurring during the treatment of pulmonary tuberculosis by artificial prmumoperitoneum has not heel1 recorded, It therefore seems desirable to report the following case, The patient, a male. aged 38, [it's(: came under OtLr cm'e in i9,1,3 as an out-patient who attenMecl for refills lbr a right artifichtl/)xtetn:rl.othorax, l.[c had previously had a left artilMal pnettlll.()thorax which obliterated in I!139 and disease iu the left lung appeared to 1)c quiescc, nt, In I94.4 he was admitted to this sanatorium because of reactivation of the left-sided disc:ase and an attempt was made to re-induce the Ieff artilMal pneumothorax. The right skte h.ad then reexpanded except R)r a small apical space con. taining an etlb.sion in which tubc:rde Imeilli were demonstrated. Following repeated washcmts with Azoehloramide T the space obliterated; On ~7,5.46 an artificial pnmmtoperitonmun was induced and contimted tmtil his death. The diaphragm became raised to the 3rd rib anteriorly on both sides, but sputum remailmd positive and both radiological and clinical signs of a left upper zone cavity persisted. Air was given with a Chandler refill needle and a Maxwell A,P. box through a puncture in the abdominal wall I½ in. below the left subcostal margin and external to the rectus abdominis and~ after the first few fills, no anaesthetic was used. On i7.9.46 the patient was put on a piaster bed as he had developed tuberculous disease of his 9th and Ioth dorsal vertebrae. On 2o,9.46 he was given a refill of I,ooo c.c, of air l~sing our usual technique and the Iinal manometer readings were q- 14 -}-17. He made no complaint at the time and seemed as usual when seen two hours later. Later in the day lie vomited undigested tbod twice,, but otherwise made no complaints. He vomited twice the. following morni~lg and at I'2.3o p.m., he was collapsed and vomithtg copiottsly. A tentatiw: diagnosis of acute dilatation o1' the stomach was then ma(:[e and he was removed li'om the piaster bed and given coraminc injections and glucose
saline. As his vomiting then ceased a stomach tul)e was not passed. His condition, however, steadily deteriorated and his respirations hecame quick and shallow, Death occurred at 4.~5 p,m. A post-mortem examination was made by Dr C, A, St. Hill, Pathologist to the Royal Southern Hospital, wire reported as follows: ...... Chart: 1,eft pleltra: grossly thickened .and fihroscd ¢wer the aptx, lhc ph.m':tl caw y is ahnost cml~l)letely obliterated by ¢h:ns~: old ~dlu;sions, Right ph:nra: ch',nse, adhesim~s are present C:Slmcially ~wer tim apex whm'e there is an nld intral)lmu,al eavhy Inntnded by ch'nse lihrmts tissue wails and emttaining a li th; nccr()tic tissue, OutsMe the parietal l)lem'a mid extending li'om the 6th to loth dorsal w:rtel)r;u; is a large al)scess Sl)aCc: cxtmtding ii'cm), the Imdies o1"the vcrtcl)rae to) the angh; ol? tlm ribs. This abscess is lilh:d with milky i)us m~d derived li'om tttl)ermtlmts lcslml hi" the lmdieS of 9th and Ioth I),, which arc c:roded to within ~ in, c)l'the spimtl cord, Iatngs are l)mh~ collal)sed very consldcral)ly ])y [he p Icltnl,olleritc)ueltm lip lo ,.all'(:[[utersl)acc on hoth sides. The left hmg apex shows a ml)erculous cavity about I~ iu, in diameter. Otherwise the lungs appear healthy. Abdomen: Peritoneal cavity contained a huge mass of blood clot with much sanguineous fluid. The clot extends down the let~: side of the abdomen 5'om spleen to pelvis. In tt.le left epigastric region of the abdominal wall is a recent needle puncture, Beneath this there is a small extravasation of Mood into the tissues of the greater omentum apparently derived from a small vein, whilst adherent to the surface of the omentum in this region is a small mass of fibrinous clot. Over the dome ot" the liver is a small collection of distended vessels lint there is no adherent clot in this imlghbmtrhood mid no evidence that the bleeding originated here. Olher organs: Liver, spleen, kidneys, show extensive amyloid i~t[iltration. Brain: Normal. Cause o/'dealh: [¥ritm).eal hacmorrhage, probably ti'om punctured omental vessel. Since this death t)cctu'rc:d, anotll.er case occurred in our series in whh:h tit(:; symptoms suggc, st intrapcrit(mcal hacmorrhag{:, This patient was a ti:male, agc:d '.aS~ with
August i947
TUBERCLE
extensive bilateral pulmonary tuberculosis and ? tuberculous enteritis, L.A.P. attempted ~5.7.46. P.P. induced i6.7.46. Left phrenic nerve crush ~8.iI.46. P.P. refill 29.II.46, and screening showed slight paradoxical movement. I,ooo c.c. air given. She was seen by one of us (V. C. C.) 30. i 1.46 complaining of severe abdominal pain which had started the night before. The abdomen felt tense so a refill needle was put in and although the reading was onIy + 7 air was allowed to escape and pressures left at +5. The foot of the bed was raised. She was seen again at midnight and looked extremely ill, T.97, P.I3o, with a history of persistent vomiting. She was too ill to move about but it was thought that there was dullness in the left flank. The tbot of the bed was lowered and she was put into Fowler's position,. An attempt at intravenous transfusion failed and she was put o n to a glucose saline drip and cor'.uninc lbur-]murly. She remained extremely ill tbr the next five clays and had symptoms of peritoneal irritatkm, but the condition gradually improved, She showed definite shifting,
z65
dullness i n abdomen as soon as she was well enough to move her position.
Discussion Although the evidence is not conclusive the cause ofhaemorrhage in Case i was p r o b a b l y the puncture of an omental vein at the time of the refill. We do not think that the position on the plaster bed could make puncture of viscera or intraperitoneal vessels more likely. In a series of I29 cases (3,616 refills) these are the only two with symptoms suggesting intraperitoneal haemorrhage and we feel, w h i l e the risk is remote, the possibility of this complication should be borne in mind. Our thanks are due m Dr O. F. Thomas, Medical Superintendent, lbr permission to publish thesecases. References [I] Baayal, A. L. (19,t,6)I'neumoperitoneumTreatment, St. Louis. , [)] TuberculosisIndex (i946) Vol. I, *'4.
Reviews T U B E R C U L O S I S IN T H E BANTU, B. A. I)ormer and F. J. Wiles. South Aft'lean Medical Journal. May '25, I946, Vol. xx, No. re, PP' ~6,2-5, I'he student of the epidemiology of tuberculosis will find here thcts of unusual interest. The Bantu comprise two-thirds of the population of the Union of South Ai~ica, and number some four and a half million persons. They live under three different environments: (i) In native reserves; (ii) on European farms; and (iii) employed industrially in towns. Information for present study is quite lacking concerning the group living on farms. But the other two groups present entirely different reactions to tuberculosis. On a Reserve the Bantu is 'accustomed to an easy, lazy existence--a loafer's paradise~where a bare minimum of work is performed, and most of this by women and children. There are the games, the beer-drinks, and the long chats about nothing. The family unit is the kraal, and the different kraals are at a considerable distance from each other, so that social contact is limited. The members of a family crowd together to sleep, but the daytime is spent in the open-air. The food is simple and monotonous, but, except in time of drought, is adequate. These pastoral people are living in tune with an environment to which they have been accustomed for centuries.' Tuberculosis occurs on the Reserves, but it is chronic or European in type. When the Bantu moves to industry in towns, he changes to hear3;, sustalned physical work for eight or ten hours a
day. 'The unaccustomed exertion causes fatigue, thereby lowering his resistance to infection which spreads easily in his crowded living quarters.' Under these circumstances tuberculosis is widespread, but the great majority of the cases are of an acute, rapidly fatal type. Here can be no question of racial susceptibility to account for two types of tuberculosis occurring in the same race in the same country with environment the only variant. The Bantu mortality in towns from tuberculosis has doubled since 1938 and is now placed at 779 per ioo, ooo which is more than 2o times the European mortality. Most of the cases when recognized, at their own desire, are repatriated and so are lost to death returns; thus out of 986 cases, repatriations were 869, only leaving i 17 to account for I I6 deaths! The mortality, though difficult to estimate accurateIy, among the Bantus employed at the Witwatersrand mines is undoubtedly lower than among other industrlally employed Bantus; but they are medically examined before engagement and during their working time, as well as being placed on proper diet scales and well housed. Indeed, all the evidence presented is against the fatalistic fetish of racial susceptibility, 'and in favour of careful supervision of the Bantu employed industrially. Unless such care is exerted this source of cheap labour may be destroyed. Food on an adequate scale should be provided, otherwise the Bantu sends his wages home or wastes them rather than using them to buy enough calories for his working needs.