- Email: [email protected]
Spontaneous rupture of the spleen complicating labor
SHANNON function patient’s tumor.
:
RUPTURE
OF
SPLEEN
COMPLICATING
with endometrial hyperplasia and repeated only normal full-term pregnancy occurred Histogenesis of the tumor is discussed.
323
LABOR
abortion or miscarriage. after surgical removal
The of the
REFERENCES (1) voigt, w. w.: AM. J. OBST. & GYNEC. 36: 688, 1938. (2) Compton, B. C.: Ibid. 34: 85, 1937. (3) Ragins, 8. B., and Franked, L.: Ibid. 40: 302, 1939. (4) Eastlake, A. C. : Colorado Med. 28: 404, 1931. (5) Gustawsan, Mason, Hays, Wood, (6) Dworsak and Podlesohlca: and D’Amour : AM. J. OBST. & GYNEC. 35: 115,1938. Ztschr. d. ges. Anat. 92: 34, 1930. Arch. f. GynIk. 154: 441, 1933. (7) Fischel, A.: $8h Schiller, W.. . J. Obst. & Gynaec. Brit. Emp. 43: 1135, 1936. (9) Butterworth, * Am. J. Cancer 31: 85, 1937. (10) Robinson, M. R.: Surg. Gynec. Obst. 51: 32l,‘i930. (11) Dockerty, M. B., and MacCarty, W. C. : AM. J. OBST. & GYNEC. 38: 698, 1939.
SPONTANEOUS
(From
T
RUPTURE
OF THE LABOR
SPLEEN
COMPLICATING
WILLIAM F. SHANNON, A.B., M.D., CINCINNATI, the Department of Obstetrics, University of Cincinnati, Medicine and Cincinnati General Hospital)
OHIO College
of
RAUMATIC or spontaneous rupture of the spleen is not an uncommon occurrence in the nonpregnant state. However, rupture of the spleen occurring spontaneously during pregnancy, labor, or the early puerperium is quite unusual, almost rare enough to be called a medical curiosity. Because of this rarity, difficulty in diagnosis, and rapidity of death, most cases are not recognized during life and are discovered only at autopsy. Etiology.-In more than half of the reported cases of splenic rupture complicating pregnancy, there is a definite history of trauma. In the group classified as spontaneous rupture the etiologic factors are still obscure. Certain factors, however, may be considered. Walton1 has stated that splenomegaly accompanied almost every case of spontaneous splenic rupture recorded in the literature. Therefore, it seems that from an etiologie standpoint the question revolves around the cause of the accompanying splenomegaly. From the literature 9 cases of spontaneous splenic rupture were collected. Seven of these showed varying degrees of splenomegaly, and in only 1 case (case of Hubbard) was there a definite pathologic reason, malaria. The question as to whether or not uncomplicated pregnancy might in itself be the cause of physiologic enlargement of the spleen has been entertained by previous writers. Kotschnew and Manenkowa believe that in pregnancy the splenic pulp may proliferate causing enlargement of the organ. De Lees states that the spleen increases somewhat in size during pregnancy. Damesheka points out that the spleen observed after death often gives an erroneous idea of its size, and when it is observed in the human being at operation, the spleen is a much larger organ, varying normally in size from 250 to 350 Gm. On the other hand Barcroft and Steven@ have shown in the dog and other laboratory animals that the size of the exteriorized spleen varies during pregnancy and that it probably reaches its smallest size a few days before labor. They attribute this shrinkage to the need for supplying blood to meet the increased capacity of the vascular bed caused by dilatation of the uterine vessels. Serbin in a recent report comments, “Pregnancy does not cause the spleen to undergo any appreciable hypertrophy, any enlargement is due to pre-existing disease.” Further he adds, I‘ Splenomegaly is sufficiently rare complicating preg nancy to warrant the addition of all observed cases to the literature.” The effect, therefore, of pregnancy as an etiologic factor of splenomegaly in the human still remains a moot question.
SHANNON
:
RUPTURE
OF
SPLEEN
COMPLICATING
LABOR
325
Fluids were forced and the temperature dropped below normal at normalities. 8 P.M. The blood pressure at this time was 120/80, pulse 85 and regular. commenced to have A few minutes after midnight, Jan. 30, 1940 the patient Rectal examination revealed a soft mass presenting, regular uterine contract,ions. presumably a breech. Fetal heart had not been heard since early afternoon. At 1:46 A.M. the cord prolapsed, but since no pulsation was felt, and the fetal heart had not been heard for several hours, interference was not contemplated. About five minutes later the patient delivered a stillborn white male, weighing 2,069 Gm. Pituitrin was given, and the placenta was expressed intact with more than normal bleeding. Patient continued to bleed in spite of intravenous ergot and uterine The cervix was examined but no lacerations were found. The uterus massage. Since the patient showed was immediately packed through a tubular packer. signs of mild shock, 750 cc. of glucose and saline were given, followed later by a She rallied rapidly and left the table in good transfusion of 500 C.C. of whole blood. condition; blood pressure 13O/SO. Fluids were started and another At 3 A.M. the patient again went into shock. 500 C.C. of blood were given. Blood pressure 84/4R, uterus was well contracted, and there was no discernible bleeding through the pack. The shock deepened and the patient did not rally. She complained only of numbness of the lower extremities. At 6 A.M. the patient was still in shock and showed signs of early pulmonary edema. About the same time slight abdominal distention was noted accompanied by lividity of the lower half of the body. Oxygen therapy was started and respiratory stimulants given. Death occurred at IO:50 A.K Post-mortem Kxomination.-(Dr. Abraham Fink, Department of Pathology, Cincinnati General Hospital.) rlnatwmic Diagnosis: Rupture of the spleen vvith hemorrhage into the peritoneal cavity. Focal hemorrhages into the lower lobe of the right lung, mesentery, fundus of the stomach, and colon. Gross Descripfion: The autopsy was performed four hours post mortem. The abdominal cavity contained 600 C.C. of dark red fluid blood. The peritoneum was smooth, glistening, and pearly pink. In the upper right quadrant there was a thin fibrinous deposit on the under surface of the diaphragm and on the spleen. The organs were in their normal relationship and the large, firm uterus was intact and extended Nuperiorly to 2 cm. below the level of the umbilicus. The heart, aorta, and lungs appeared normal except for scattered areas of hemorrhage, varying from 0.5 to 1.5 cm. in diameter in the right lower lobe of the lung. In the substance of the left diaphragm there was a circular area of hemorrhage 1 cm. in diameter. The large, soft, opalescent red spleen weighed 625 Gm., and was covered with smooth glistening capsule. At the notch of the anterior border of the spIeen there was a shallow groove extending along the diaphragmatic surface. About the midpoint of this groove there was a ragged, linear break in the capsule, measuring 1.5 cm. in length and 0.3 cm. in width. This extended for a depth of 1.2 cm. into the parenchyma of the organ. There were a few light, fibrinous strands lying on the surface of the spleen but not adherent to it, except in the region of the break. Sectioning revealed a dark, pultaceous spIenic tissue. The dark, reddish brown liver weighed 2,050 Gm. On section the tissue was brown, firm, and dripped blood. The gall bladder and pancreas were normal. The mesentery of the small intestines contained several circular areas of Several circular areas hemorrhage which varied from 0.5 cm. to 1.5 cm. in diameter. of hemorrhage 0.5 cm. to 2.0 cm. in diameter were present in the wall of the fundus of the stomach and colon. The uterus was large, The kidneys, ovaries, and oviducts were apparently normal. firmly contracted and measured 21 cm. by 5.3 cm. The walls were firm and pink, were intact, and measured 4 cm. in thickness. The rervical OS was patulous but not lacerated. The endometrium was shaggy and dark red, and the fundus was covered by grayish stringy material.
Mic:roscopic
f)iac/nosis.--Acute
focal hemorrhage in the lungs postpartum uterus.
pas~lit’
an11
vorlgest.iori
rTOlll:a~~h
: toxic.
01
liii.
Itepnlt,si+
luring,
li\,‘r.
:IIIII
neplirswii:
;iu,l
splwn wimlt!i~
Microscopic lkscription : Sections of the spleen showc~l xiuu~oids iuarketlly ~iilat~wl In snnt6’ :,l“‘:ii and engorged with erythrocytrs and l)(ll~rttorphonu~~l~?:ir I~~u~~o~~ytes. the walls of the sinusoids were disintrgraletl with the i’orrnation ol’ lsf~ds in i lit’ rplenic tissue. Some of these (.ontaine~l llinkish. granula I’ 17~11ctrixl. probably lokerl blood. while others c~~mtainrtl chiefly 11ryi 11rl.I(dytos. The nm@n3 of 111~ ltw:rk iI! tli
The liver showed nrarked dilatation ~rf the central vttins a1111 sinusoids. ln some of the latter thrrfn were no recognizabh ret1 ~~11s hut only N granular fluid like that l’ht~ wits of th,b liver i~ortls w6~w niarkedl> tkscrihetl in pools in The splem. granular with vacuolization of their @oplasru. The kidneys showed swelling of tl~ ~?llS of tllr coTlrllllrtwl tuhulw :,h well ah pronounced granularity of their cytoplasm. The uterus presented ulceration of the endometrium with a moderate polymorphonuclear infilt,ration of the surface. ‘I’he blood sinuses w t’r~ large anal c~ollap~ed. The muscle fibers were hypertrophied. Sections of the bone marrow revrale~l no abnormality. ‘l’lle heart, aorta, arterie suprarennls. pamrear, breast, ovary, amI gall hladdrr :tppraro
Tn all, I_ o’) cases including the present relmrt, have bee11 recorded in the literuture. In addition, 6 cases of rupture of an aneurysm of the splenic artery complicating pregnancy were found (Smith, Wessenbe,rg, Lundwall, Mayer, Remmelt,’ and Rohleria). All the cases of splenic~ rupture occurred in white women, and these, with the exception of one, were’ multiparas. Due to a lack of sufficient information, the exact time in gestat,inu at which thi. * accident occurred was not definitely known in the entire group. Twenty of these cases give some information as to the time of occurrence in pregnancy. Of these,, 12 occurred after viability, 7 early in pregnancy, and I in the immediate puerperiurn. Of the cases whil*h happened late in pregnancy 5 oc~urrcrl during labor, besides the present ease (Kotschnew, Simpson, McMerrimey, Sonrmer and v. Hoch). In the last three cases mentioned, signs referable to subrapsular rupture of the spleen were present days before the actual onset of labor. Ten rxses out of 22 came to surgery. Of these 8 recovered after splenectomy. One case
.\I:\RS
1. ;\ case of spontaneous rupture of thrl spleen complicating labor is reported. It is believed to be the first case recorded in the American literature. 2. Twenty-one cases of splenic, rupture complicating pregnancy, labor? and the puerperium have been collected from the literature. 3. Due to difficulty in diagnosis and rapidity of death, spontaneous splenic rupture complicating labor may be an unrecognized cause, albeit a minor one, of fatal obstetric shock.
LE
VINE
AND
WOLF:
DIFFICULT
LABOR
DUE
TO AMORPHOUS
MONSTER
327
REFERENCES (2) Kotschnew, M. S., and (1) Walton, A. J. : Brit. M. J. 22: 1496, 1928-1929. f. GynKk. 49: 3106: 1930. (3) De Lee, J. B.: PrinManenkow, P. W. : Zentralbl. Philadelphia, W. B. Saunders Co., Chapt. ciples and Practices of Obstetrics, (5) Barcroft, T’. J., 4, p. 108. (4) Dameshek, W.: Arch. Int. Med. 47: 968, 1931. and Stevens, J. G. : J. Physiol. 66: 32, 1928. (6) Kehrer, E.: Zentralbl. f. Gyniik. 45: 941, 1921. (7) Strettwn, J. L.: Brit. M. J. 1: 901, 1926. (8) Bolder, E.: Bull. Sot. d’Obst. et de Gynec. d’Paris 21: 141, 1932. (9) Smith, A. H. D., Morrison, W. J., and Bladder, A. F.: Lancet 1: 694, 1933. (10) Burnett, E. C., and McMerrimey, W. H. : Brit. M. J. 1: 1122, 1935. (11) Sommer (Berlin): Ztschr. f. Geburtsh. u. GynLk. 116: 107, 1932. (12) 21. Hoch, Iz.: Deutsche med. Wchnschr. (14) 64: 48, 1938. (13) Bolder, E.: Bull. Sot. d ‘obst. et de gym%. 22: 707, 1933. Serbin, W. B.: AM. J. OBST. & GYNEC. 34: 486, 1937.
DIFFICULT I.
LE
VINE,
LABOR 1\!.n.,
DUE .4ND
I.
TO AMORPHOUS J.
WOLF,
M.D.,
MONSTER
PIZTERSON,
N. J.
AMORPHUS is a form of essential monster born with a sepaCARDIACUS rate homologous twin or triplet, which is usually normal and on which it depends for its imperfect development in the uterus. Only 8 cases of amorphous monster have been reported in the American literature since 1882.1 Most of the reports We have been prompted to report this have appeared in the German literature. case because of its rarity and the difficulty it presented in delivery.
A
CASE
REPORT
Mrs. M. P., aged 37 years, gravida ii, had her last menstrual period on Dec. 7, 1938. Quickening was felt April 21, 1939 and her estimated confinement was Sept. 19, 1939. Her family history was negative. Four sisters and one brother were living and well. There was no history of multiple births, or the birth of monsters in her family to the best of her knowledge. Her past history was negative. Her menses began at the age of fifteen, occurring every twenty-eight days, and lasting five days with moderate flow and slight pain. She had been married four years. Her husband’s health was good, and they had one child aged 2.5 years. Her previous delivery was normal and she had had no miscarriages. The patient received routine prenatal care. Her abdomen seemed large during pregnancy but a multiple pregnancy was not diagnosed. Only one fetal heart was heard. No extra fetal mass was palpable in the abdomen. Prior to the delivery the uterus measured about six inches above the umbilicus. The patient was admitted to the Barnert Hospital, Sept. 13, 1939, at 1:30 A.M. Her pains were irregular and by 9:00 A.M. were recurring regularly with moderate severity. At 1:20 P.M. she was delivered of a live female infant weighing 41h pounds which presented by the breech but was delivered without difficulty. Following the birth of the baby, a mass was palpable in the abdomen, delivery of which was awaited about an hour. When this failed to occur, one ampoule of pituitrin was divided into three doses and each part was given at ten-minute intervals without effect. The patient was anesthetized and an intrauterine examination was made. A smooth rounded mass was felt which had an opening suggesting a mouth. This was grasped and delivery was attempted but was unsuccessful. Delivery was finally accomplished by making lateral incisions into the mass and placing the hooked ends of an obstetric forceps into each side. The monster was extracted in this way. A single placenta followed. A normal amount of bleeding followed, and there were no lacerations. The mother was given sulfanilamide for a few days and recovery was uneventful. The baby was weak, nursed poorly, had facial twitching and nystagmus but left the hospital in fairly good condition on Sept. 24, 1939.
:
RUPTURE
OF
SPLEEN
COMPLICATING
with endometrial hyperplasia and repeated only normal full-term pregnancy occurred Histogenesis of the tumor is discussed.
323
LABOR
abortion or miscarriage. after surgical removal
The of the
REFERENCES (1) voigt, w. w.: AM. J. OBST. & GYNEC. 36: 688, 1938. (2) Compton, B. C.: Ibid. 34: 85, 1937. (3) Ragins, 8. B., and Franked, L.: Ibid. 40: 302, 1939. (4) Eastlake, A. C. : Colorado Med. 28: 404, 1931. (5) Gustawsan, Mason, Hays, Wood, (6) Dworsak and Podlesohlca: and D’Amour : AM. J. OBST. & GYNEC. 35: 115,1938. Ztschr. d. ges. Anat. 92: 34, 1930. Arch. f. GynIk. 154: 441, 1933. (7) Fischel, A.: $8h Schiller, W.. . J. Obst. & Gynaec. Brit. Emp. 43: 1135, 1936. (9) Butterworth, * Am. J. Cancer 31: 85, 1937. (10) Robinson, M. R.: Surg. Gynec. Obst. 51: 32l,‘i930. (11) Dockerty, M. B., and MacCarty, W. C. : AM. J. OBST. & GYNEC. 38: 698, 1939.
SPONTANEOUS
(From
T
RUPTURE
OF THE LABOR
SPLEEN
COMPLICATING
WILLIAM F. SHANNON, A.B., M.D., CINCINNATI, the Department of Obstetrics, University of Cincinnati, Medicine and Cincinnati General Hospital)
OHIO College
of
RAUMATIC or spontaneous rupture of the spleen is not an uncommon occurrence in the nonpregnant state. However, rupture of the spleen occurring spontaneously during pregnancy, labor, or the early puerperium is quite unusual, almost rare enough to be called a medical curiosity. Because of this rarity, difficulty in diagnosis, and rapidity of death, most cases are not recognized during life and are discovered only at autopsy. Etiology.-In more than half of the reported cases of splenic rupture complicating pregnancy, there is a definite history of trauma. In the group classified as spontaneous rupture the etiologic factors are still obscure. Certain factors, however, may be considered. Walton1 has stated that splenomegaly accompanied almost every case of spontaneous splenic rupture recorded in the literature. Therefore, it seems that from an etiologie standpoint the question revolves around the cause of the accompanying splenomegaly. From the literature 9 cases of spontaneous splenic rupture were collected. Seven of these showed varying degrees of splenomegaly, and in only 1 case (case of Hubbard) was there a definite pathologic reason, malaria. The question as to whether or not uncomplicated pregnancy might in itself be the cause of physiologic enlargement of the spleen has been entertained by previous writers. Kotschnew and Manenkowa believe that in pregnancy the splenic pulp may proliferate causing enlargement of the organ. De Lees states that the spleen increases somewhat in size during pregnancy. Damesheka points out that the spleen observed after death often gives an erroneous idea of its size, and when it is observed in the human being at operation, the spleen is a much larger organ, varying normally in size from 250 to 350 Gm. On the other hand Barcroft and Steven@ have shown in the dog and other laboratory animals that the size of the exteriorized spleen varies during pregnancy and that it probably reaches its smallest size a few days before labor. They attribute this shrinkage to the need for supplying blood to meet the increased capacity of the vascular bed caused by dilatation of the uterine vessels. Serbin in a recent report comments, “Pregnancy does not cause the spleen to undergo any appreciable hypertrophy, any enlargement is due to pre-existing disease.” Further he adds, I‘ Splenomegaly is sufficiently rare complicating preg nancy to warrant the addition of all observed cases to the literature.” The effect, therefore, of pregnancy as an etiologic factor of splenomegaly in the human still remains a moot question.
SHANNON
:
RUPTURE
OF
SPLEEN
COMPLICATING
LABOR
325
Fluids were forced and the temperature dropped below normal at normalities. 8 P.M. The blood pressure at this time was 120/80, pulse 85 and regular. commenced to have A few minutes after midnight, Jan. 30, 1940 the patient Rectal examination revealed a soft mass presenting, regular uterine contract,ions. presumably a breech. Fetal heart had not been heard since early afternoon. At 1:46 A.M. the cord prolapsed, but since no pulsation was felt, and the fetal heart had not been heard for several hours, interference was not contemplated. About five minutes later the patient delivered a stillborn white male, weighing 2,069 Gm. Pituitrin was given, and the placenta was expressed intact with more than normal bleeding. Patient continued to bleed in spite of intravenous ergot and uterine The cervix was examined but no lacerations were found. The uterus massage. Since the patient showed was immediately packed through a tubular packer. signs of mild shock, 750 cc. of glucose and saline were given, followed later by a She rallied rapidly and left the table in good transfusion of 500 C.C. of whole blood. condition; blood pressure 13O/SO. Fluids were started and another At 3 A.M. the patient again went into shock. 500 C.C. of blood were given. Blood pressure 84/4R, uterus was well contracted, and there was no discernible bleeding through the pack. The shock deepened and the patient did not rally. She complained only of numbness of the lower extremities. At 6 A.M. the patient was still in shock and showed signs of early pulmonary edema. About the same time slight abdominal distention was noted accompanied by lividity of the lower half of the body. Oxygen therapy was started and respiratory stimulants given. Death occurred at IO:50 A.K Post-mortem Kxomination.-(Dr. Abraham Fink, Department of Pathology, Cincinnati General Hospital.) rlnatwmic Diagnosis: Rupture of the spleen vvith hemorrhage into the peritoneal cavity. Focal hemorrhages into the lower lobe of the right lung, mesentery, fundus of the stomach, and colon. Gross Descripfion: The autopsy was performed four hours post mortem. The abdominal cavity contained 600 C.C. of dark red fluid blood. The peritoneum was smooth, glistening, and pearly pink. In the upper right quadrant there was a thin fibrinous deposit on the under surface of the diaphragm and on the spleen. The organs were in their normal relationship and the large, firm uterus was intact and extended Nuperiorly to 2 cm. below the level of the umbilicus. The heart, aorta, and lungs appeared normal except for scattered areas of hemorrhage, varying from 0.5 to 1.5 cm. in diameter in the right lower lobe of the lung. In the substance of the left diaphragm there was a circular area of hemorrhage 1 cm. in diameter. The large, soft, opalescent red spleen weighed 625 Gm., and was covered with smooth glistening capsule. At the notch of the anterior border of the spIeen there was a shallow groove extending along the diaphragmatic surface. About the midpoint of this groove there was a ragged, linear break in the capsule, measuring 1.5 cm. in length and 0.3 cm. in width. This extended for a depth of 1.2 cm. into the parenchyma of the organ. There were a few light, fibrinous strands lying on the surface of the spleen but not adherent to it, except in the region of the break. Sectioning revealed a dark, pultaceous spIenic tissue. The dark, reddish brown liver weighed 2,050 Gm. On section the tissue was brown, firm, and dripped blood. The gall bladder and pancreas were normal. The mesentery of the small intestines contained several circular areas of Several circular areas hemorrhage which varied from 0.5 cm. to 1.5 cm. in diameter. of hemorrhage 0.5 cm. to 2.0 cm. in diameter were present in the wall of the fundus of the stomach and colon. The uterus was large, The kidneys, ovaries, and oviducts were apparently normal. firmly contracted and measured 21 cm. by 5.3 cm. The walls were firm and pink, were intact, and measured 4 cm. in thickness. The rervical OS was patulous but not lacerated. The endometrium was shaggy and dark red, and the fundus was covered by grayish stringy material.
Mic:roscopic
f)iac/nosis.--Acute
focal hemorrhage in the lungs postpartum uterus.
pas~lit’
an11
vorlgest.iori
rTOlll:a~~h
: toxic.
01
liii.
Itepnlt,si+
luring,
li\,‘r.
:IIIII
neplirswii:
;iu,l
splwn wimlt!i~
Microscopic lkscription : Sections of the spleen showc~l xiuu~oids iuarketlly ~iilat~wl In snnt6’ :,l“‘:ii and engorged with erythrocytrs and l)(ll~rttorphonu~~l~?:ir I~~u~~o~~ytes. the walls of the sinusoids were disintrgraletl with the i’orrnation ol’ lsf~ds in i lit’ rplenic tissue. Some of these (.ontaine~l llinkish. granula I’ 17~11ctrixl. probably lokerl blood. while others c~~mtainrtl chiefly 11ryi 11rl.I(dytos. The nm@n3 of 111~ ltw:rk iI! tli
The liver showed nrarked dilatation ~rf the central vttins a1111 sinusoids. ln some of the latter thrrfn were no recognizabh ret1 ~~11s hut only N granular fluid like that l’ht~ wits of th,b liver i~ortls w6~w niarkedl> tkscrihetl in pools in The splem. granular with vacuolization of their @oplasru. The kidneys showed swelling of tl~ ~?llS of tllr coTlrllllrtwl tuhulw :,h well ah pronounced granularity of their cytoplasm. The uterus presented ulceration of the endometrium with a moderate polymorphonuclear infilt,ration of the surface. ‘I’he blood sinuses w t’r~ large anal c~ollap~ed. The muscle fibers were hypertrophied. Sections of the bone marrow revrale~l no abnormality. ‘l’lle heart, aorta, arterie suprarennls. pamrear, breast, ovary, amI gall hladdrr :tppraro
Tn all, I_ o’) cases including the present relmrt, have bee11 recorded in the literuture. In addition, 6 cases of rupture of an aneurysm of the splenic artery complicating pregnancy were found (Smith, Wessenbe,rg, Lundwall, Mayer, Remmelt,’ and Rohleria). All the cases of splenic~ rupture occurred in white women, and these, with the exception of one, were’ multiparas. Due to a lack of sufficient information, the exact time in gestat,inu at which thi. * accident occurred was not definitely known in the entire group. Twenty of these cases give some information as to the time of occurrence in pregnancy. Of these,, 12 occurred after viability, 7 early in pregnancy, and I in the immediate puerperiurn. Of the cases whil*h happened late in pregnancy 5 oc~urrcrl during labor, besides the present ease (Kotschnew, Simpson, McMerrimey, Sonrmer and v. Hoch). In the last three cases mentioned, signs referable to subrapsular rupture of the spleen were present days before the actual onset of labor. Ten rxses out of 22 came to surgery. Of these 8 recovered after splenectomy. One case
.\I:\RS
1. ;\ case of spontaneous rupture of thrl spleen complicating labor is reported. It is believed to be the first case recorded in the American literature. 2. Twenty-one cases of splenic, rupture complicating pregnancy, labor? and the puerperium have been collected from the literature. 3. Due to difficulty in diagnosis and rapidity of death, spontaneous splenic rupture complicating labor may be an unrecognized cause, albeit a minor one, of fatal obstetric shock.
LE
VINE
AND
WOLF:
DIFFICULT
LABOR
DUE
TO AMORPHOUS
MONSTER
327
REFERENCES (2) Kotschnew, M. S., and (1) Walton, A. J. : Brit. M. J. 22: 1496, 1928-1929. f. GynKk. 49: 3106: 1930. (3) De Lee, J. B.: PrinManenkow, P. W. : Zentralbl. Philadelphia, W. B. Saunders Co., Chapt. ciples and Practices of Obstetrics, (5) Barcroft, T’. J., 4, p. 108. (4) Dameshek, W.: Arch. Int. Med. 47: 968, 1931. and Stevens, J. G. : J. Physiol. 66: 32, 1928. (6) Kehrer, E.: Zentralbl. f. Gyniik. 45: 941, 1921. (7) Strettwn, J. L.: Brit. M. J. 1: 901, 1926. (8) Bolder, E.: Bull. Sot. d’Obst. et de Gynec. d’Paris 21: 141, 1932. (9) Smith, A. H. D., Morrison, W. J., and Bladder, A. F.: Lancet 1: 694, 1933. (10) Burnett, E. C., and McMerrimey, W. H. : Brit. M. J. 1: 1122, 1935. (11) Sommer (Berlin): Ztschr. f. Geburtsh. u. GynLk. 116: 107, 1932. (12) 21. Hoch, Iz.: Deutsche med. Wchnschr. (14) 64: 48, 1938. (13) Bolder, E.: Bull. Sot. d ‘obst. et de gym%. 22: 707, 1933. Serbin, W. B.: AM. J. OBST. & GYNEC. 34: 486, 1937.
DIFFICULT I.
LE
VINE,
LABOR 1\!.n.,
DUE .4ND
I.
TO AMORPHOUS J.
WOLF,
M.D.,
MONSTER
PIZTERSON,
N. J.
AMORPHUS is a form of essential monster born with a sepaCARDIACUS rate homologous twin or triplet, which is usually normal and on which it depends for its imperfect development in the uterus. Only 8 cases of amorphous monster have been reported in the American literature since 1882.1 Most of the reports We have been prompted to report this have appeared in the German literature. case because of its rarity and the difficulty it presented in delivery.
A
CASE
REPORT
Mrs. M. P., aged 37 years, gravida ii, had her last menstrual period on Dec. 7, 1938. Quickening was felt April 21, 1939 and her estimated confinement was Sept. 19, 1939. Her family history was negative. Four sisters and one brother were living and well. There was no history of multiple births, or the birth of monsters in her family to the best of her knowledge. Her past history was negative. Her menses began at the age of fifteen, occurring every twenty-eight days, and lasting five days with moderate flow and slight pain. She had been married four years. Her husband’s health was good, and they had one child aged 2.5 years. Her previous delivery was normal and she had had no miscarriages. The patient received routine prenatal care. Her abdomen seemed large during pregnancy but a multiple pregnancy was not diagnosed. Only one fetal heart was heard. No extra fetal mass was palpable in the abdomen. Prior to the delivery the uterus measured about six inches above the umbilicus. The patient was admitted to the Barnert Hospital, Sept. 13, 1939, at 1:30 A.M. Her pains were irregular and by 9:00 A.M. were recurring regularly with moderate severity. At 1:20 P.M. she was delivered of a live female infant weighing 41h pounds which presented by the breech but was delivered without difficulty. Following the birth of the baby, a mass was palpable in the abdomen, delivery of which was awaited about an hour. When this failed to occur, one ampoule of pituitrin was divided into three doses and each part was given at ten-minute intervals without effect. The patient was anesthetized and an intrauterine examination was made. A smooth rounded mass was felt which had an opening suggesting a mouth. This was grasped and delivery was attempted but was unsuccessful. Delivery was finally accomplished by making lateral incisions into the mass and placing the hooked ends of an obstetric forceps into each side. The monster was extracted in this way. A single placenta followed. A normal amount of bleeding followed, and there were no lacerations. The mother was given sulfanilamide for a few days and recovery was uneventful. The baby was weak, nursed poorly, had facial twitching and nystagmus but left the hospital in fairly good condition on Sept. 24, 1939.