Patient's statements.?She stated that she was months' pregnant, and that having felt slight pain in the abdomen a day and-a-half previously, she had then called in a native midwife who had employed gentle massage locally. Since when more or less continuous bleeding had been taking place from the vagina, for which and for the consequent exhaustion she had come to hospital. This is the only statement she adheres to. Others she has made from time to time : one being that she felt the movements of the child up to a month ago when they suddenly ceased ; another that three weeks ago she lifted a heavy child and felt something give way inside her, but these she has denied since. On examination the fundus of the uterus was found to reach to two fingers' breadth above the umbilicus, and immediately to the right of the uterus was a marked swelling which had a doughy feel and was dull on percussion. This swelling appeared to be continuous with the uterus, and the entire tumour was immoveable. Vaginal examination revealed a soft mass filling the right half of the pelvis which gave the sensation of fluctuation to the examining finger. The cervix just admitted the tip of the finger. There was only slight oozing of blood from the canal. Diagnosis.?Rupture of the uterus having been diagnosed, immediate operation was decided on, without waiting for the arrival of the Obstetric Surgeon, Lieut.-Col. Joubert. Treatment prior to operation.?Prior to operation, on account of her very weak general condition, the patient was given a hypodermic injection of strychnia and ether, and three pints of normal saline solution were injected under the breasts. Ether was the anaesthetic employed during the operation. Operation.?The abdomen was opened by a four-inch incision in the median line below the umbilicus, the incision being afterwards extended upwards for another three inches. The parietal peritoneum was found to be thickened, and lying immediately beneath this and adherent to it was the placenta. This was gently separated from the parietal peritoneum which enabled the hand passed beyond it to palpate the breech of a fo3tus which was lying upwards and to the right, and appeared to have protruded through a dense line of adhesions outside the uterus. The separation of the placenta from the parietal peritoneum caused only slight bleeding. The foetus, which was lying partially inside and partially outside the uterus, was now removed through the abdominal incision, and this was followed by a rapid and ssvere gush of dark blood. The foetus was dead and partially decomposed, measured twelve inches in length, weighed about 2 lbs. 6 ozs., and appeared to be about six months old. seven
OF RUPTURE OF THE GRAVID : ABDOMINAL SECTION AND REMOVAL OF FCETUS AND UNIVERSALLY ADHERENT PLACENTA: ENTERECTOMY? RECOVERY.
A CASE
UTERUS
By Hubert M.
Earle,
captain,
I.M.S., Resident Surgeon, Eden Hospital.
Muni A, a Mussalmani, aged twenty-five, by occupation a nurse, was admitted into the Eden Hospital on March 30th, 1899, in a very collapsed
condition.
Sept. 1899. j
329
j^UPTURE OF THE GRAVID TJTERTTS.
Subsequent course.?Nothing
was
given by
the mouth during the first week except detached
a teaThe placenta was now gradually to of hot water occasional^. Nutrient from surrounding omentum and intestine spoonful enemata consisting of peptonised beef tea and which it was firmly adherent and removed. This was a very lengthy proceeding as the branoy alternating with nutrient enules (B. W. & were which Co.) were administered, and retained well up numerous, very large, adhesions, to at all recent, the eighth day when the rectum showed signs thick and tough, and evidently not of irritability, and the patient being in a low state all required clamping and ligaturing. small quantities of nourishment were adminisThe membranes, which had ruptured previtered by the mouth, and the enemata given less ously in part, came away with the placenta. On the fourteenth day all feeding with become had frequently. incorporated They partially the rectum were discontinued. were to some extent and by structures, surrounding firmly attached to the inner lining of the uterine Local condition.?On the day following the operation the superficial dressings which were cavity. They were in a state of partial decomsoaked were changed, but the Izal gauze plugposition. The rupture was found to extend from the middle of the front of the fundus, ging the wound was left for forty-eight hours so as to allow of the formation of adhesions, and the which was situated about one and-a-half inches above the umbilicus, obliquely downwards and cutting off of the wound from the general abdolhe minal cavity. Subsequently the gauze was to the as the cervix, as far right nearly edges of the rupture were shaggy, and the wallsremoved daily. of the uterus were much thinned andvery friable, The membranes lining the interior of the and incorporated internally with membranes anduterus, which were in a partially decomposed state, gradually sloughed away, as did also the externally with omentum and intestines. Beyond the edges of the uterine tear a falseuterine wall for the most part, finally leaving sac had evidently formed, and this also had rup-only an irregular saucer-shaped mass above the tured allowing of partial protrusion of the foetus.cervix. Two bared knuckles of intestine which An almost complete rupture of the smallbulged into the wound one on each side of its intestine was now discovered situated above thelower part looked as if they would give way. fundus of the uterus ; this appeared to be soThat on the left side appeared thinner and more recent that presumably it must have been caused congested than the one on the right side. during the extraction of the foetus. It did not On the tenth day a round worm was found occur as far as could be seen during separationwith its body half-way through an opening, just of the placenta, although nothing would havelarge enough to let it pass, in the protruding been easier when placenta, omentum and intesknuckle on the left side, through which it had tine were so incorporated. burrowed, thus causing a fcecal fistula. The Owing to the presence of a very thick adhesion worm was removed through the wound. The a resection of two inches of the gut was made, sutured intestine which was situated at the upper and a Y-shaped piece of mesentery removed. The extremity of the wound, and was adherent edges of the mesentery having been brought there, held firm and did not leak. together by a continuous suture, the divided ends The wound was now dressed four times a day. of the intestine were united by means of Lem- The cavity gradually contracted up and the disbert's sutures. of fseces lessened. By the middle of J une, The wound was now cleansed by means of charge or about two months after the burrowing of the sponges, and the abdominal walls united in the round worm, the fistula had completely closed. upper part of the wound (above the level of the General conditions.?The severe shock of the fundus of the uterus) with silkworm gut sutures. It was impossible to remove the uterus or to operation in the feeble state of the patient rendered her condition an shut off its cavity from the extremely general abdominal naturally cavity owing to the friability of its walls and precarious one. She rallied, however, from the and their incorporation with subsequently?although on several surrounding structures, shock, she gave cause for so that the abdominal walls were occasions left ununited anxiety by getting below the level of the fundus of the uterus, into a collapsed condition, from which she was and the entire cavity plugged with twenty-four revived by means of hypodermic injections of strychnia and ether and sub-mammary injecyards of Izal gauze two inches in width. During the operation the patient was given tions of saline solution?gradually improved,and three injections of strychnia and ether onaccount at the beginning of July was discharged from of flagging of the pulse. During the last half hospital both looking and feeling extremely well. hour of the operation the pulse was imperceptible. Her temperature remained at about 100? E1., After the operation and prior to removing the highest point reached being 102?F., the day her from the table one pint of saline solution after the round worm burrowed through the inwas injected under each breast, brandy and hot testine. The day following it fell to normal, water given by the rectum and auto-transfusion and there was no further rise.
employed.
330
THE INDIAN MEDICAL GAZETTE.
Her pulse which was almost invariably 120 per minute and feeble also fell to the normal rate of frequency at this time and became stronger in volume. Remarks.?There is no question as to this being a true case of rupture of the uterus during pregnancy,ruptured tubal or interstitial gestation being entirely negatived by the condition found. The question that arises is as to the causation of the rupture. The only history that can be obtained from the woman and that she adheres to, is that thirtysix hours before she came to hospital, she felt pain in the womb, and sent for a dhai or native midwife who employed gentle (?) massage, and that following this she had free bleeding from the vagina up to the time of her admission. This is a quite inadequate explanation. She has, however, made other statements, and then contradicted them ; but it is never possible to place any reliance on what these patients tell one. The probable explanation to my mind is that a primary rupture had taken place in a thinwalled uterus caused either by some injury or possibly by the normal contractions that occur during pregnancy, that a partial false sac has formed outside the uterus, and that a secondary rupture through this, allowing of the protrusion of the breech of the foetus, took place at the time of the massage. The result of the enterectomy was entirely satisfactory. The question naturally arises as to whether the leakage, which took place on the tenth day, was not through the line of intestinal sutures. This, however, was not the case. The enteroraphy was done in a very adherent part of the small intestine lying above the fundus of the uterus. The intestine that gave way was situated low down on the left side of the wound, was seen to have been exposed by sloughing of membranes and uterine wall, to be congested and thinned, and to protrude into the wound, two or three days before the perforation took place, when a round worm was found half inside the intestine and half inside the wound having burrowed through an opening just large enough for its passage. I am indebted to Lieut.-Col. Joubert, Professor of Midwifery in the Medical College, for permission to publish this case. o
o
[Sept.
1899.
OF RUPTURE OF THE GRAVID : ABDOMINAL SECTION AND REMOVAL OF FCETUS AND UNIVERSALLY ADHERENT PLACENTA: ENTERECTOMY? RECOVERY.
A CASE
UTERUS
By Hubert M.
Earle,
captain,
I.M.S., Resident Surgeon, Eden Hospital.
Muni A, a Mussalmani, aged twenty-five, by occupation a nurse, was admitted into the Eden Hospital on March 30th, 1899, in a very collapsed
condition.
Sept. 1899. j
329
j^UPTURE OF THE GRAVID TJTERTTS.
Subsequent course.?Nothing
was
given by
the mouth during the first week except detached
a teaThe placenta was now gradually to of hot water occasional^. Nutrient from surrounding omentum and intestine spoonful enemata consisting of peptonised beef tea and which it was firmly adherent and removed. This was a very lengthy proceeding as the branoy alternating with nutrient enules (B. W. & were which Co.) were administered, and retained well up numerous, very large, adhesions, to at all recent, the eighth day when the rectum showed signs thick and tough, and evidently not of irritability, and the patient being in a low state all required clamping and ligaturing. small quantities of nourishment were adminisThe membranes, which had ruptured previtered by the mouth, and the enemata given less ously in part, came away with the placenta. On the fourteenth day all feeding with become had frequently. incorporated They partially the rectum were discontinued. were to some extent and by structures, surrounding firmly attached to the inner lining of the uterine Local condition.?On the day following the operation the superficial dressings which were cavity. They were in a state of partial decomsoaked were changed, but the Izal gauze plugposition. The rupture was found to extend from the middle of the front of the fundus, ging the wound was left for forty-eight hours so as to allow of the formation of adhesions, and the which was situated about one and-a-half inches above the umbilicus, obliquely downwards and cutting off of the wound from the general abdolhe minal cavity. Subsequently the gauze was to the as the cervix, as far right nearly edges of the rupture were shaggy, and the wallsremoved daily. of the uterus were much thinned andvery friable, The membranes lining the interior of the and incorporated internally with membranes anduterus, which were in a partially decomposed state, gradually sloughed away, as did also the externally with omentum and intestines. Beyond the edges of the uterine tear a falseuterine wall for the most part, finally leaving sac had evidently formed, and this also had rup-only an irregular saucer-shaped mass above the tured allowing of partial protrusion of the foetus.cervix. Two bared knuckles of intestine which An almost complete rupture of the smallbulged into the wound one on each side of its intestine was now discovered situated above thelower part looked as if they would give way. fundus of the uterus ; this appeared to be soThat on the left side appeared thinner and more recent that presumably it must have been caused congested than the one on the right side. during the extraction of the foetus. It did not On the tenth day a round worm was found occur as far as could be seen during separationwith its body half-way through an opening, just of the placenta, although nothing would havelarge enough to let it pass, in the protruding been easier when placenta, omentum and intesknuckle on the left side, through which it had tine were so incorporated. burrowed, thus causing a fcecal fistula. The Owing to the presence of a very thick adhesion worm was removed through the wound. The a resection of two inches of the gut was made, sutured intestine which was situated at the upper and a Y-shaped piece of mesentery removed. The extremity of the wound, and was adherent edges of the mesentery having been brought there, held firm and did not leak. together by a continuous suture, the divided ends The wound was now dressed four times a day. of the intestine were united by means of Lem- The cavity gradually contracted up and the disbert's sutures. of fseces lessened. By the middle of J une, The wound was now cleansed by means of charge or about two months after the burrowing of the sponges, and the abdominal walls united in the round worm, the fistula had completely closed. upper part of the wound (above the level of the General conditions.?The severe shock of the fundus of the uterus) with silkworm gut sutures. It was impossible to remove the uterus or to operation in the feeble state of the patient rendered her condition an shut off its cavity from the extremely general abdominal naturally cavity owing to the friability of its walls and precarious one. She rallied, however, from the and their incorporation with subsequently?although on several surrounding structures, shock, she gave cause for so that the abdominal walls were occasions left ununited anxiety by getting below the level of the fundus of the uterus, into a collapsed condition, from which she was and the entire cavity plugged with twenty-four revived by means of hypodermic injections of strychnia and ether and sub-mammary injecyards of Izal gauze two inches in width. During the operation the patient was given tions of saline solution?gradually improved,and three injections of strychnia and ether onaccount at the beginning of July was discharged from of flagging of the pulse. During the last half hospital both looking and feeling extremely well. hour of the operation the pulse was imperceptible. Her temperature remained at about 100? E1., After the operation and prior to removing the highest point reached being 102?F., the day her from the table one pint of saline solution after the round worm burrowed through the inwas injected under each breast, brandy and hot testine. The day following it fell to normal, water given by the rectum and auto-transfusion and there was no further rise.
employed.
330
THE INDIAN MEDICAL GAZETTE.
Her pulse which was almost invariably 120 per minute and feeble also fell to the normal rate of frequency at this time and became stronger in volume. Remarks.?There is no question as to this being a true case of rupture of the uterus during pregnancy,ruptured tubal or interstitial gestation being entirely negatived by the condition found. The question that arises is as to the causation of the rupture. The only history that can be obtained from the woman and that she adheres to, is that thirtysix hours before she came to hospital, she felt pain in the womb, and sent for a dhai or native midwife who employed gentle (?) massage, and that following this she had free bleeding from the vagina up to the time of her admission. This is a quite inadequate explanation. She has, however, made other statements, and then contradicted them ; but it is never possible to place any reliance on what these patients tell one. The probable explanation to my mind is that a primary rupture had taken place in a thinwalled uterus caused either by some injury or possibly by the normal contractions that occur during pregnancy, that a partial false sac has formed outside the uterus, and that a secondary rupture through this, allowing of the protrusion of the breech of the foetus, took place at the time of the massage. The result of the enterectomy was entirely satisfactory. The question naturally arises as to whether the leakage, which took place on the tenth day, was not through the line of intestinal sutures. This, however, was not the case. The enteroraphy was done in a very adherent part of the small intestine lying above the fundus of the uterus. The intestine that gave way was situated low down on the left side of the wound, was seen to have been exposed by sloughing of membranes and uterine wall, to be congested and thinned, and to protrude into the wound, two or three days before the perforation took place, when a round worm was found half inside the intestine and half inside the wound having burrowed through an opening just large enough for its passage. I am indebted to Lieut.-Col. Joubert, Professor of Midwifery in the Medical College, for permission to publish this case. o
o
[Sept.
1899.
