Veno-occlusive Disease of Liver in African Children

analgesia a 3-cm. incision was made in the lower part of the scar and 3-4 oz. (85-114 ml.) of clot was removed; but this made little difference to the contour of the abdomen, and it was felt that most of the bleeding was interstitial and generalized, as it so often is in haemophilia. A fuller vaginal examination was done, a large offensivesmelling clot was removed, and a swab was taken for bacterial culture. The impression of a large haematoma in the pelvis was confirmed. On July 14, following the examination of the previous day, there was little vaginal bleeding, but her haemoglobin level had fallen from 13.3 g. per 100 ml. on July 10 to 7.1 g. per 100 ml. It should be mentioned here that it was never possible to measure the rate of bleeding either from the vaginal loss, which was mainly of days-old clot, or by palpation of the lower abdomen, in which the size of the haematoma fluctuated from day to day. The pulse and the patient's own well-being proved the most useful guides to therapy. She was given 1 litre of fresh plasma and 1 litre of fresh blood, and from this time on frequent similar transfusions were given. Large clots were passed with almost unchanging frequency (about four clots a day) per vaginam, and the haemoglobin level was maintained at an average of 10 g. per 100 ml., falling as low as 5.9 g. on July 20, and rising to 13.5 g. on August 6. The presence of vaginal clots caused her great discomfort and removal always gave relief. A culture of E. coli was obtained from clot and urine. The organism was insensitive to penicillin V, which she had been taking, but sensitive to chlortetracycline, which was started on July 15. She became afebrile, but her temperature rose again on July 26, when the chlortetracycline was stopped. From then on sulphadimidine and penicillin V were given and she remained afebrile up to the time of discharge. Her general condition improved with the control of infection, and from July 15 there was a steady reduction in the apparent size of the pelvic mass, as judged by abdominal palpation, and micturition returned to normal in spite of continued bleeding. During her treatment in Oxford she was given 131 litres of fresh plasma, 9 litres of fresh blood, and 5 litTes of stored blood. On average the A.H.G. level was raised to 45% by the transfusion of 1 litre of fresh plasma. On July 29 she had a minor rigor after plasma transfusion, and this recurred on July 30 after plasma. There were fortunately no further similar reactions. On July 31 she woke up to find the eyelashes of all four lids had fallen out on to the sheet in the night. There were no signs of local inflammatory change, and we have not been able to explain this. Fortunately, new growth soon started again. On August 6 the amount of clot passed seemed to be less and it again had a foul smell. We were inclined to take the pessimistic view at this stage, and assumed that she must be forming an infected pelvic haemorrhagic " cyst." To our surprise and satisfaction she improved from then on. Transfusions and clots became less frequent and smaller, and her haemoglobin slowly rose. The abdominal wound was completely healed. On August 11, six weeks and three days after operation, the bleeding finally stopped, and from then she improved rapidly and finally left hospital in good health one month later, her only complaint being of some urgency of micturition. Her abdomen was quite normal on palpation.