Rupture of Ovary with Massive Hemorrhage As a Complication of An

portun i ty to act upon the blood, that after a RUPTURE OF OVARY WITH MASSIVE period of a quarter to half an hour nearly all HEMORRHAGE AS A COMPLICATION of the carbon monoxide had been eliminated OF AN ACUTE APPENDICITIS from the blood.8 REPORT OF A CASE, WITH REVIEW OF THE LITERA- Recently the American Gas Association, TURE representing practically all of the illuminating By Henry S. Penn, M.D., Lawrence. Mass. gas interests of the country, has requested Dr. C. K. Drinker, of the Harvard Medical School, Rupture of an ovary with hemorrhage of to organize a commission for the further investi- various degrees may occur entirely independent gation of the subject of resuscitation from il- of cctopic pregnancy. Such accidents are not but are of much more common luminating gas poisoning. The members serv- only possible occurrence than we The ing on this commission are, Dr. as naturally imagine. Drinker,, voluminous literature on the testifies Drs. D. L. W. B. subject chairman, Edsall, Cannon, L. to that effect. The of serious hemor- J. Henderson, W. K. Lewis, F. W. possibility Peabody, rhage was pointed out as early as 1851 by Nela- Mr. C. B. Scott of the Bureau of Safety, ton,1 Rokitansky1 in 1855, and Peuch4 in 1858, Dr. K. R. Sayers of the U. S. Bureau of the latter calling it "ovarian apoplexy." Drs. Howard W. and Yan- Mines, Haggard In addition, a number of cases were reported dell Henderson. two The last named have been by Wilson,2 who states that "there is a case appointed a sub-committee to investigate the on record of a woman who died from a shock efficacy of the above-mentioned treatment. on the eve of her marriage, as a result of a Through the courtesy and cooperation of the profuse intraperitoneal hemorrhage from a Consolidated Gas Co., of New York City, which ruptured corpus luteum"; and similar papers has placed at our sendee its emergency wagons, by Hollins, Hind, Penny,1 Richard R. Smith/ and with the support of Health Commissioner and a host of others. Schumann,8 in his recent Copeland, and the hospital authorities of New review, brings the subject up to date. The extent of the may York City, we have been able to give the hemorrhage naturally vary from a small amount up to a fatal exsan- method an extensive test. The results indicate guination, as in the case reported b}' Peuch, that a deeply asphyxiated who can be patient, where three pints of blood were lost. reached within a half-hour—and the utmost The etiology of a purely ovarian hemorrhage at this speed time is essential for success—and is so far entirely hypothetical. who is then given inhalations of oxygen con- Jaile5 claims that rupture of small cysts of taining 5 per cent, carbon dioxide, can be the ovary is a frequent cause of blood in the practically freed from carbon monoxide within pelvis. 30 to 40 minutes. Frequently also conscious- Sohambacker8 found that hemorrhage was ness returns. often due to rupture of utero-ovarian plexus of veins. The demand for cheaper gas on the part of the and the rise in the cost of crude According to Primrose,1 a sudden strain, a public, sudden rise in intra-abdominal petroleum, the introduction of the mantle burn- pressure, espe- if this a few before or dur- er, the increased use of gas for cooking and cially happens days have resulted in ing the menstrual period, may act as the cause heating purposes, inevitably of the accident. an increased number of fatalities from illumi- Novack8 maintains that the site of For those cases which original nating gas asphyxiation. Graafian follicle is the can be reached in time the treatment above hemorrhage perifollicu- lar stroma, and that it later breaks into the indicated will, it is our belief, not only increase only the chances of follicle, and "in certain cases . . . the hem- survival, but also the probability is of and freedom from the dis- orrhage of the perforative type, the blood complete recovery the tressing sequelae sometimes associated with poi- breaking through surface of the ovary, an abdominal hemorrhage" (Abstract soning by illuminating gas, or the exhaust gas causing of automobiles. of discussion, Journal A. M. A., Vol. 77, page 695). REFERENCES. Richard R. Smith7 thinks that the cases of 1 Fielder, A. C, Straub, A. A., and Jones, O. W. : Jour, of Indus. Engineering' Chem., 13 (1), 1821. acute hemorrhage from a ruptured Graafian ' 61, Jan., Henderson, Y., Hogg»"', H, W., league, M. C, Prince, A. L., follicle or corpus luteum should be grouped by and Wunderlich, R. W. : Jour, of Indus. Hygiene, S (34), 70, 137, Aug., 1921. because are not 8 themselves, they apparently Henderson, Y., and Haggard, II. W. : Jour, of Indus, ami Engin. condition the Chem., 14 (3), 22», Mar., 1022. caused by any pathological of Haggard, II. W. : Amer. Jour, of Physiol., 00, 1022. or 8 244, April, ovary pelvic organs. Haggard, II, W„ and Henderson, Y. : Jour. A. if. A., 77, 1005, Oct., 1021. Schumann,8 on the other hand, points out «Haggard, H. W. : Jour, of Phnrni. and Exper. Thera., 10 (5), that a massive occurs from 401, Dec., 1020. when hemorrhage 'Hamilton, Alice: Jonr. A. M. 78, 027, Mor. i, 1922. an is to be some 8 A., ovary there usually found Henderson, Y., and Haggard, II. W. : Jour, of Pharm. and Exper. Them., 10 (1), Aug., 1920. pathological process of the ovarian blood-ves-

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UNIVERSITY OF MINNESOTA LIBRARIES on September 11, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. like in sels present. This deduction is based on a case Conclusion.—Apparently in this case, where the microscopic examination of the ovary the one reported by Primrose, the hemorrhage did show degenerative fibrous changes of the was due to the increased intra-abdominal pres- blood-vessels. sure brought about by the persistent vomiting. It is also worth that the men- In the author's case the hypotheses of Prim- noting patient's strual took a after the rose and Novack seem to be well sustained, and period place day opera- as far as the literature could be traced this is tion. ovary, tube the second case on record where an acute ap- Pathological Report.—Received Tube is dark was a and appendix. slightly thickened, pendicitis complicated by ruptured ovary adhe- with massive, hemorrhage. The first and almost red in color, and shows fibrous serosal sions. The is normal in size, and identical case was reported by Primrose.1 ovary pale, shows an area of on surface communi- A of this condition, rupture preoperative diagnosis with small cavities, which can be while is in a very cating theoretically possible, reality stretched to a distance of 1 cm. The ap- difficult in the of open problem, especially presence measures 7 cm., with fibrous thick- acute abdominal as this case pendix pale, condition, hap- ened wall and dilatation of the terminal one- be. two vital are of pens to However, points half of the lumen. practical importance in. the diagnosis: First, examination of shows lu- early of the hemorrhage and imme- Microscopic ovary recognition teal tissue and area of hemorrhage; diate and to Bovee,4 probable operation; second, quote source of hemorrhage. Fallo- "that from the as well as from the intraporitoncal personal tube shows extreme of vessels, medical a of pian congestion legal standpoint, diagnosis ectopic with, slight infiltration of wall with should not be made in cases in which polymor- pregnancy The mucosa shows no not exist" phonucloar leucocytes. pregnancy should (Bovee quoted by pathological change. Schumann3). Diagnosis.—Corpus luteum and hemorrhági- cum. Acute congestion of tube. Chronic CASE HISTORY. fibrous appendicitis. (Pathological Depart- ment, Tuffs Medical School.) Present Illness.—Woman, age 20, married i one month. Has always been well except for IMíFKHENCES. an occasional pain in the right side. The pres- 1 Primrose: ITemorrhatre into Peritoneal Cavity Caused by Acci- ent attack about five hours with dental Rupture of Ovary, Ann. of Surgery, 1012, p, 125. began ago, a Schumann : Extrauterino Pregnancy, p, 118. severe abdominal pain and persistent vomiting. :l-Schumann: .lour. A.M.A., vol. lxxvÜ, p. 692, Mlovee: Diagnosis of TulmT1 and Ovarian Pregnancy, Am. Jour. of Obstetrics, 1018, 70:370. 1.20. " Physical Examination.—Pulse, Temper- i latarini : Olintoal Diagnosis <>f Eotopio Pregnancy, Am. Jour. ature, 100°. There was marked tenderness and of Obstetrics, 19: 79: 716. ''Smith, Richard; ITemon-hmcrcs into the Pelvic Cavity other than spasm over the right lower quadrant, other- tho*? of Eotopio Pregmancy, Tr. Am. Oynee. Soc, 45:321, 1920. wise White negative. count, 14,000. Vaginal lililí St. examination disclosed nothing abnormal. A Hnvorliill diagnosis of acute appendicitis was made and operation advised, Avhich was refused. About in next a hurried 3 o'clock the morning, day, LiteratureDepartment call was sent and patient was found in bed, Current pale, weak, with a feeble and thready pulse and in almost complete shock. She complained ABSTRACTORS. of a great deal of pain, headache and dizziness. Gerardo M. Rai.doni Chester M. Jones Ohari.es H. Abdomen was somewhat distended, all Laurence D. Chapín Lawrence pain Austin W. Cheever Herman A. Osqood over, but more so over the right lower quad- IsADOR CORIAT Francis W. Palfrey rant. Temperature, 100°. Pulse, 136-140. Ernest M. Dai.and Edward H. Risley and Horace Gray William M. Shedden Operation.—Right rectus incision. Free Rorert M. Green George G. Smith clotted blood escaped upon opening the peri- John B. ITawes, 2d John B. Swift, Jr. toneum. Bleeding seemed to come from pelvis. John S. Hodgson Wilder Tileston Appendix found markedly injected and kinked. Fred S. Hopkins Bryant P. Wetherell Incision enlarged downward and uterus brought POSTERIOR I ¡»SECTION OF THE RECTUM AND ReCTOSIG- into to source view. Right ovary found be the moid (KitASKE on Modified Under Regional of hemorrhage. Tf; was normal in size, some- Anesthesia. what twisted on its pedicle, and presented a Graafian from which active I/Ahat, G. L. (Johns Hopkins Hospital llullctttn,, ruptured follicle, April, 1022), discusses bis method of performing the bleeding look place. Ovary and tube were re- opération Cor resection of the rectum under local moved, also the appendix. Abdomen cleansed anesthesia, recapitulating as follows: of blood, amounted to about 11 to 12 1. The choice of the method of anesthesia is one whjch of the most eonnected with the ounces. Small rubber drain inserted and interesting problems surgery of the reel um und rectosigmoid. wound closed in the usual manner. Patient 2. Most, of the postoperative complications may he made an uneventful recovery. attributed to Inhalation narcosis, especially ether, and