- Email: [email protected]
SPONTANEOUS RUPTURE OF THE SPLEEN IN A PREGNANT WOMAN
694 acetabulum had disappeared. He has no idea of the date at which the dislocation had taken place. It is not proposed to do anything to him, for no useful end would be gained by gouging a trough in the outer side of his femur, he has no sequestrum to remove, and his sinus will probably heal as readily as the other two have done. It is problematical that any good could be done by reducing his hip-joint ; the posterior wall of his acetabulum has been absorbed, and as the joint has probably been -out of place for 18 months his muscles have all accustomed themselves to their altered length. He is able to get about fairly well.
continued normally except for severe albuminuria in the last few weeks. At the end of April, 1932, there was a normal confinement for a healthy female child and the albuminuria disappeared. The patient has remained in excellent health.
The blood condition was investigated fully soon after the operation and at later dates, by A. F. S. and the spleen was also examined. On Nov. 15th the Wassermann and van den Bergh reactions were both negative; the latter was again negative on Jan. 25th, 1932. Blood counts gave the following results :-
Nov. 15th,
Jan. 25th,
1931.
1932.
Red cells.... Hb.
3,760,000 67%
Colour-index ..
SPONTANEOUS RUPTURE OF THE SPLEEN IN A PREGNANT WOMAN BY A. H. D. HON.
White cells
SURGEON, LLANELLY GENERAL
HOSPITAL
DIRECTOR OF THE BECK LABORATORY, SWANSEA
Mrs.
A., aged 31, was first morning of Oct. 28th, 1931 ;
seen
she
by W. J. M. on the complained of slight
discomfort in the left upper abdominal area and of slight pain in the chest which had begun on the previous morning. (On that day, Oct. 27th, she had done the washing for her family.) On the morning of the 28th, on waking, she felt weak, and she vomited on rising. She had pain below the left costal margin-that same afternoon but did not feel so ill as to be compelled to remain in bed. There was not the slightest suggestion of any injury, but it was found that she was three months pregnant and had for a few days suffered from palpitations ; there had also been considerable vomiting associated with the pregnancy. Previous health had been good and her past obstetric history satisfactory. Careful physical examination revealed no abnormality. The pulse was rapid and irregular; there was no f ever. The patient looked pale but said this was her usual state; sihe sat up in bed easily. Her condition was ascribed to
59%
....
0.61 9800
....
6213
....
14,600
..
..
per c.mm. 9576 per c.mm. 3942
1932. ....
....
....
....
5,660,000 92% 0.81 8600
....
5418
2795 215 86 86 30.... The earlier films showed slight polychromasia and anisocytosis of red cells, the last count showed quite normal cells. At each date the red cells were tested for fragility and on each occasion slightly increased " toughness " of cells was found.
Lymphocytes.. Monocytes Eosinophils Basophils
..
W. J. MORRISON, M.B. BELF. ; AND A. F. SLADDEN, D.M. OXF.
....
0-89
4,800,000
’
Polymorphs
SMITH, M.C., M.B. EDIN.
....
Nov. 1st,
..
....
1022 30 .... ....
..
3116 294 1477 30 ....
Haemolysis started.
November, 1931....
January, 1932
....
November. 1932....
0-43% 0-42 % 0.43%
....
....
....
Complete. , , 0-34% 0-28 % 0-26%
......
......
......
The spleen weighed 740 g. and was firm and rounded in contour. The site of the laceration has already been described ; the spleen when manipulated showed intense congestion. Histological examination showed the splenic sinuses filled with red blood-cells and clots, the latter containing some pigment. The larger blood-vessels were distended with clot but showed little thickening of the walls. Malpighian corpuscles were few and poorly developed ; the splenic pulp tissues contained many clear spaces simulating the appearance of fatty connective tissue as seen in paraffin sections. Fibrosis was not a feature of the condition, which conformed closely to the accepted descriptions of the spleen in " Banti’s disease." with her and disturbances associated Commentary.-The unsatisfactory status of " Banti’s pregnancy digestive an alkaline mixture prescribed, but next morning when seen disease " as a clinical and pathological entity is widely again by W. J. M. her condition gave rise to anxiety. The recognised and it is not possible to assign this case pulse-rate had risen to 130 and was irregular ; there was no fever but she looked ill, pale, and sallow, and complained of with any certainty to the Banti group of splenoabdominal pain at intervals. The abdomen appeared fuller megalies. There was thrombosis of the spleen but and there was discomfort and slight resistance over the left no adhesions, and no enlargement or cirrhosis of the lower area ; pelvic examination showed no abnormalities, liver was detected. Lord Moynihan stresses the but there was some suspicion of dullness in the flanks and splenic area. Vomiting had ceased and the patient was importance of splenic adhesions in late cases of taking food ; urine was found normal. Banti’s disease and splenic anaemia, so that these On the evening of the 29th A. H. D. S. saw her in observations indicate a recent, rather than a remote consultation and found a pulse-rate of 120 and slight development of the splenomegaly. The blood picture, fever, 1002° F. The patient looked somewhat dis- even 12 months after the splenectomy, shows no leucotressed but was not clammy, nor did her condition penia, but this may be due to persistence of the usual an internal there polymorphonuclear increase following this operation. was, however, haemorrhage ; suggest It is of interest that eosinophilia has not occurred. some abdominal distension, and rigidity and tenderness The maintenance by the red cells of increased resistwere found in the left iliac region. It was recognised ance to hypotonic saline is noteworthy and is perhaps that some acute abdominal condition was present a point in favour of a diagnosis of splenic ansemia. and ruptured ectopic gestation or left-sided appendicitis were both considered as possible. Apart from the aetiology of this splenomegaly the was decided removed practical points emerging are: (1) absence of any Laparotomy upon and the case forthwith to Llanelly Hospital for this purpose. The history of trauma as the cause of the splenic rupture; surgeon (A. H. D. S.) opened in the midline and found much (2) associated pregnancy, with its successful course; free blood in the abdomen ; the pregnant uterus was normal (3) improvement in health subsequent to splenectomy. as were also the other pelvic viscera, but the source of bleeding was traced to the left upper abdomen where further investigaThe pre-existence of splenomegaly in every recorded tion revealed a spleen moderately enlarged, of firm consistcase of spontaneous rupture of thespleen is emphasised ence, and having between the hilum and the splenic notch a lacerationin. long from which blood freely poured. The by Mr. A. J. Walton,2to whom we extend our thanks incision was prolonged upwards and after freeing some for the interest he has taken in this report. adhesions the spleen was removed with comparative ease. was left a uneventful and the Recovery patient hospital 1 Moynihan, Lord: Brit. Med. Jour., 1932, ii., 701. month later and resumed her household work ; the pregnancy 2 Walton, A. J.: Proc. Roy. Soc. Med., 1928-29, xxii., 1496.
continued normally except for severe albuminuria in the last few weeks. At the end of April, 1932, there was a normal confinement for a healthy female child and the albuminuria disappeared. The patient has remained in excellent health.
The blood condition was investigated fully soon after the operation and at later dates, by A. F. S. and the spleen was also examined. On Nov. 15th the Wassermann and van den Bergh reactions were both negative; the latter was again negative on Jan. 25th, 1932. Blood counts gave the following results :-
Nov. 15th,
Jan. 25th,
1931.
1932.
Red cells.... Hb.
3,760,000 67%
Colour-index ..
SPONTANEOUS RUPTURE OF THE SPLEEN IN A PREGNANT WOMAN BY A. H. D. HON.
White cells
SURGEON, LLANELLY GENERAL
HOSPITAL
DIRECTOR OF THE BECK LABORATORY, SWANSEA
Mrs.
A., aged 31, was first morning of Oct. 28th, 1931 ;
seen
she
by W. J. M. on the complained of slight
discomfort in the left upper abdominal area and of slight pain in the chest which had begun on the previous morning. (On that day, Oct. 27th, she had done the washing for her family.) On the morning of the 28th, on waking, she felt weak, and she vomited on rising. She had pain below the left costal margin-that same afternoon but did not feel so ill as to be compelled to remain in bed. There was not the slightest suggestion of any injury, but it was found that she was three months pregnant and had for a few days suffered from palpitations ; there had also been considerable vomiting associated with the pregnancy. Previous health had been good and her past obstetric history satisfactory. Careful physical examination revealed no abnormality. The pulse was rapid and irregular; there was no f ever. The patient looked pale but said this was her usual state; sihe sat up in bed easily. Her condition was ascribed to
59%
....
0.61 9800
....
6213
....
14,600
..
..
per c.mm. 9576 per c.mm. 3942
1932. ....
....
....
....
5,660,000 92% 0.81 8600
....
5418
2795 215 86 86 30.... The earlier films showed slight polychromasia and anisocytosis of red cells, the last count showed quite normal cells. At each date the red cells were tested for fragility and on each occasion slightly increased " toughness " of cells was found.
Lymphocytes.. Monocytes Eosinophils Basophils
..
W. J. MORRISON, M.B. BELF. ; AND A. F. SLADDEN, D.M. OXF.
....
0-89
4,800,000
’
Polymorphs
SMITH, M.C., M.B. EDIN.
....
Nov. 1st,
..
....
1022 30 .... ....
..
3116 294 1477 30 ....
Haemolysis started.
November, 1931....
January, 1932
....
November. 1932....
0-43% 0-42 % 0.43%
....
....
....
Complete. , , 0-34% 0-28 % 0-26%
......
......
......
The spleen weighed 740 g. and was firm and rounded in contour. The site of the laceration has already been described ; the spleen when manipulated showed intense congestion. Histological examination showed the splenic sinuses filled with red blood-cells and clots, the latter containing some pigment. The larger blood-vessels were distended with clot but showed little thickening of the walls. Malpighian corpuscles were few and poorly developed ; the splenic pulp tissues contained many clear spaces simulating the appearance of fatty connective tissue as seen in paraffin sections. Fibrosis was not a feature of the condition, which conformed closely to the accepted descriptions of the spleen in " Banti’s disease." with her and disturbances associated Commentary.-The unsatisfactory status of " Banti’s pregnancy digestive an alkaline mixture prescribed, but next morning when seen disease " as a clinical and pathological entity is widely again by W. J. M. her condition gave rise to anxiety. The recognised and it is not possible to assign this case pulse-rate had risen to 130 and was irregular ; there was no fever but she looked ill, pale, and sallow, and complained of with any certainty to the Banti group of splenoabdominal pain at intervals. The abdomen appeared fuller megalies. There was thrombosis of the spleen but and there was discomfort and slight resistance over the left no adhesions, and no enlargement or cirrhosis of the lower area ; pelvic examination showed no abnormalities, liver was detected. Lord Moynihan stresses the but there was some suspicion of dullness in the flanks and splenic area. Vomiting had ceased and the patient was importance of splenic adhesions in late cases of taking food ; urine was found normal. Banti’s disease and splenic anaemia, so that these On the evening of the 29th A. H. D. S. saw her in observations indicate a recent, rather than a remote consultation and found a pulse-rate of 120 and slight development of the splenomegaly. The blood picture, fever, 1002° F. The patient looked somewhat dis- even 12 months after the splenectomy, shows no leucotressed but was not clammy, nor did her condition penia, but this may be due to persistence of the usual an internal there polymorphonuclear increase following this operation. was, however, haemorrhage ; suggest It is of interest that eosinophilia has not occurred. some abdominal distension, and rigidity and tenderness The maintenance by the red cells of increased resistwere found in the left iliac region. It was recognised ance to hypotonic saline is noteworthy and is perhaps that some acute abdominal condition was present a point in favour of a diagnosis of splenic ansemia. and ruptured ectopic gestation or left-sided appendicitis were both considered as possible. Apart from the aetiology of this splenomegaly the was decided removed practical points emerging are: (1) absence of any Laparotomy upon and the case forthwith to Llanelly Hospital for this purpose. The history of trauma as the cause of the splenic rupture; surgeon (A. H. D. S.) opened in the midline and found much (2) associated pregnancy, with its successful course; free blood in the abdomen ; the pregnant uterus was normal (3) improvement in health subsequent to splenectomy. as were also the other pelvic viscera, but the source of bleeding was traced to the left upper abdomen where further investigaThe pre-existence of splenomegaly in every recorded tion revealed a spleen moderately enlarged, of firm consistcase of spontaneous rupture of thespleen is emphasised ence, and having between the hilum and the splenic notch a lacerationin. long from which blood freely poured. The by Mr. A. J. Walton,2to whom we extend our thanks incision was prolonged upwards and after freeing some for the interest he has taken in this report. adhesions the spleen was removed with comparative ease. was left a uneventful and the Recovery patient hospital 1 Moynihan, Lord: Brit. Med. Jour., 1932, ii., 701. month later and resumed her household work ; the pregnancy 2 Walton, A. J.: Proc. Roy. Soc. Med., 1928-29, xxii., 1496.