Francis Hare
1906 The Lancet  
On admission his temperature was 1010 F. and his pulse was 116. His face was pinched and anxious-looking. The abdomen was rigid, the pain on pressure being very severe. I was called up at once and operated, finding on the anterior surface of the stomach towards the pyloric end a clean, punched. out perforation. The aperture was circular, it being as cleanly defined as the lace-hole in a boot before the ring is inserted and of the same size. The ulcer was excised by an elliptical incision an
more » ... cal incision an inch in length and the edges of the wound were closed by three rows of continuous suture as in gastro-enterostomy. There was a track of inflamed area from the vicinity of the ulcer leading backwards towards the junction of the liver and the right kidney. The area was visible by the white exudation due to the escape of part of the contents of the stomach. This was carefully wiped away with gauze sponges and then copiously washed out with salt solution. There appeared then so little contamination that it was deemed right to close the abdominal wound completely and to do without draining either there or in the flanks. A quantity of the saline solution was purposely left in the peritoneal cavity. After recovering consciousness the patient's pain had disappeared and at the first observation the temperature and pulse had both declined ; his facial appearance was quite different, being free from the pinched and anxious look. The patient's subsequent history was uneventful. His face for a time had a passively congested look, due doubtless to the manipulation of the parts in the near neighbourhood of the sympathetic plexus. He was dismissed well on Oct. llth. THE interest of the following case lies in the complete success of the use of a local anesthetic in an operation for strangulated hernia occurring in advanced life. On the morning of Nov. 2nd last I was called to see a man who was said to be in great pain. On arrival at the house I found that the patient, who was a well-nourished man, aged 77 years, had a strangulated inguinal hernia of the right side. Some two hours previously he had been feeding pigs, when on lifting something heavy he suddenly felt a violent pain in the inguinal region. He had been ruptured for years and so at first thought that the old rupture was a little pinched and would go back, but as he had worked at it for two hours without success he thought it necessary to seek medical aid. Morphine was given hypodermically and gentle taxis was tried, but as it became clear that no good was likely to accrue operation was suggested. The patient was unable to make up his mind to undergo the ordeal until later in the day, when Mr. G. G. Parsons having very kindly come over from Westbury the operation was commenced at 8 P.M. On the ground of the patient's great age and the fact that he had a very weak heart it was decided not to give a general aesthetic, but to use a local anaesthetic and the choice fell upon "ansesthunder," a mixture of betaeucaine, suprarenal extract, and phenol. A line was taken from the pubic spine parallel to Poupart's ligament for three inches, and along this line the local anesthetic was subcutaneously injected. 20 minims were used, and after an interval of three minutes the skin along the line was incised without pain Until the gut was reached during the operation (which was not specially interesting except for the action of the local anaesthetic) only 60 minims of the anaesthetic were used. The tissues were carefully injected layer after layer ; no pain was felt, and there was hardly any bleeding. When it became necessary to incise the internal ring, where in the circumstances of the operation it would have been dangerous to inject the anesthetic, pain was severe but fortunately of short duration. The bowel was replaced without much difficulty, one deep stitch was inserted, and the incision in the skin was closed by four superficial sutures. Hpaling was by first intention, and the stitches were removed upon the eighth day after the operation. Throughout the ccurse of the recovery no pain was felt. The patient is now quite out of danger and in addition has a good prospect of a radical cure. Bratton, near Westbury, Wilts. THE patient was married and aged 26 years ; she had one child, four years old. Three years after the birth of the child she missed two periods. At the end of the second month irregular haemorrhage set in, with severe pain in the right iliac region, the pain being especially noticed during walking. On examination the uterus was found to be retroverted and enlarged and a cystic swelling was felt behind and to the right of the uterus. A diagnosis of ruptured tubal pregnancy was made. Operation was performed. The right tube was ruptured and the ovum with about a pint of blood clot was found between the two layers of the right broad ligament. This was evacuated by the extraperitoneal method; the ovary and tube were not removed. The patient did not become pregnant again until nine years after the operation. The history of the next gestation was as follows. On August lst, 1906, I was called in to see the patient, who complained of pain in the left iliac region and over the lower part of the abdomen, with sickness after food ; there was amenorrhcea of two months' duration. On physical examination the breasts were tender and slightly enlarged ; no secretion could be obtained. The vulvse were bluish in colour and the uterus was somewhat enlarged and retroverted. Owing to the extreme tenderness it was impossible to replace the uterus. Ichthyol plugs were applied per vaginam for seven days, the patient remaining in bed. On the 8th, while straining to pass a motion, severe pain was felt in the lower part of the abdomen, with shooting cramp-like pains in the legs. When seen the patient was in a state of collapse, the skin was cold and blanched, and the face was drawn and anxious. She lay on the left side with the knees bent and the thighs drawn up to the abdomen. Examination under an anaesthetic showed that the uterus was no longer retroverted, but drawn up high into the pelvis and pushed over to the right side. A cystic swelling was found behind and to the left of the uterus. Operation was performed. The abdomen was opened. Behind and to the left of the uterus was found a large adventitious sac containing the ovum and about a quart of blood clot. The sac was formed by the posterior wall of the broad ligament in front, the ruptured tube above, and the intestines posteriorly. The clot and ovum were removed along with the tube and ovary on that side. The right tube and ovary were found to be bound down by adhesions and were not removed. The patient made a good recovery.
doi:10.1016/s0140-6736(01)33421-9 fatcat:dtc7dkmdjjeaja3zdfcb5rcyfm