H. H. Rightor
1912 Journal of the American Medical Association  
For some time I have been using the 1 per cent. solution of quinin and urea hydrochlorid, marketed in ampoules, as a local anesthetic, with very satisfactory results. In the following instance the results might have been very disastrous. R. C., a white man, aged 20, had just recovered from gonorrhea and was a splendid subject. The ordinary technic for the use of local anesthesia in circumcision was pursued. A rubber catheter was tied around the penis and the quinin solution injected in the line
more » ... njected in the line of the proposed skin and mucous membrane incision. The prepuce was removed in the usual way, and the skin sutured to the mucus membrane without the removal of any of the membrane. There was absolutely no sensation, faintness or nausea following the operation. The next morning the penis was very much swollen and of a violet hue; there was. still no sensation. The patient left for his home in the country to return on the fifth day, at which time the discoloration was still present and there was still no pain. The silkworm sutures were removed at this time. I >:ivv the patient forty-eight hours later. There was a very foul odor, and a. well-marked localized gangrene »»extending exactly to the end of the line of infiltration on both the mucous anil the cutaneous sides of the incision. There was no suppuration at any time. With tissue forceps this gangrenous area was lifted out cu masse, leaving a raw surface about an inch wide in the region of the frcniim and one-half inch wide for the remainder of the circumference of I he penis. Fortunately no considerable amount of the prepuce had been removed, so that in a few days I was able again to approximate the skin ami mucous membrane, except under the frenillo. This line of sutures hehl und in a. week was practically well, except for a short distance where the edges could not be approximated. The infrequency with which the ethmoid and frontal sinuses take part in producing displacement of the eyeball prompts me to report the following case which illustrates the extent to which this can occur without serious injury to the eye st r uct ur es: History.\p=m-\Thepatient, Mr. J. P., aged 34, consulted me March 1, 1912, for an enlargement and displacement of the left eye, giving the history of having been taken ill with severe pain in this eye after a cold of two or three days' duration. This pain lasted three days. Since then the eye had been comfortable except for the gradual development of t he swelling with its accompanying symptoms of congestion and conjunctival irritation, which has been going on for seven weeks altogether. Examination.\p=m-\The eye protruded three-quarters of an inch forward, I inch to the side and about three-quarters of an inch downward. The conjunctiva was greatly injected, almost venous in character; the cornea was clear and the iris functionating, but the pupil was more dilated than on the other side. Qphthalmoscopic examination showed ihe papilla to bo mottled and its outlines Indistinct; the arteries were contracted while the veins were distended and tortuous; one could Well .ke out Ihe swollen papilla by Ihe course of these veins. Vision was very blurred, only 20/70. The Meld^> l" vision for red and white was concentrically contracted. From (hese findings I diagnosed some process pushing ont the eyeball. Examination of ihc mise seemed quite negative at first, except for a large middle turbinate on the left side; there was apparently no discharge from the middle meatus, Not being satisfied, I punctured the middle turbinate, and found a. ¡lisi-lnirge of pus, The tentative diagnosis was an ethmoid abscess. Operation.-Resection of the middle turbinate and entire removal of the ethmoid, which had undergone necrosis to a large extent, and perforation of the orbital plate wore done under local anesthesia. An unsuccessful attempt was made to go into the frontal sinus. The cavity was loosely packed with Xeroform gauze, which was removed the next day. The result of this operation was a gradual return of the eye into its socket; it returned very promptly toward the median line, but a slight forward and slightly downward dislocation still persisted; as the discharge from the nose had about cleared up I sent, the patient home with instructions to report should more displacement recur or a swelling appear above the eye. About a month after the lirst operation, a tumor about the size of a small hazel-nut was seen just below the orbital ridge and just outside of the supra-orbital notch. The next step was a radical frontal sinus operation-the usual curved incision and removal of the floor of the sinus far enough back so that all parts of the sinus could be reached; no opening was made above the orbital ridge, as the upper gart of the sinus could readily be reached from below. A perforation was found in the floor corresponding to the tumor below the ridge. The sinus was thoroughly curetted and the frontonnsal duct enlarged, which, by the way, was only a little slit. The entire cavity was packed with iodoforin gauze, with the strip protruding into the nose and the incision was closed with the exception of a, small drain at the lower angle. The gauze was slowly removed through the nose in the course of a week, and a rubber tube, provided with a collar to keep it in place, was substituted therefor. The external wound healed by first intention and the eyeball has returned to its normal place. Drainage through the nose was carried on very effectively, and the rubber tube was left in lor two months, at which time there was no discharge, outside of some niueus. Diplopia did not occur following the last operation. The vision, as far as I can tell, has returned to about normal; the patient sees 20/30, which is a little less than in the right eye. The color fields are also a little smaller than on the other side. Bacteriologically the ease showed nothing distinctive. Interesting points in tho case might be summarized aa follows: 1. Absence of pain outside of the first three days. 2. No lasting rise of temperature. For two days it was 00.5 F. .'i. Absence of permanent injury to the eye. 4. Absence of facial deformity following the operation. POSTOPERATIVE HI CCUP The following briefly described experience with a case of persistent singultus attending an appendectomy has some features of practical interest. F. F., man, aged 38, American, machinist, developed an ordinary attack of appendicitis for which I operated at the end of thirty-six hours, when the symptoms were becoming more marked in spite of medical remedies. After removing the enlarged congested appendix containing considerable pus distal to a stenosed lumen, the abdominal incision was closed in the usual manner. The effects of the ether passed off uneventfully except for some slight irritation of a former mild bronchial catarrh which had come on in the line of his work. On the second day, however, the patient developed a marked attack of hiccup which became more frequent and, under the circumstances, soon began to take his strength to a very noticeable degree. He had never previously been specially troubled with this disturbance. This diaphragmatic spasm ceased when the patient fell asleep, only to reappear as obstinately as ever on his awakening. Various remedial agents were used in turn: oil of amber, Hoffmann's anodyne* ether sprayed on the epigastrium, inhalation of nitrite of iimyl, countcrirritation over the diaphragm, holding of the breath, psychic effect oi" fright, etc. There were no noticeable results. Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/26/2015
doi:10.1001/jama.1912.04270090122019 fatcat:gdwlfnlexff6pmxikcnneweqoa