ON A CASE OF PLACENTA PRÆVIA

JohnT. Waller
1852 The Lancet  
237 this, however, is not of much importance as regards the operation, but as an after consideration, for this reason, that after the operation, the cavity of the tunica vaginalis being laid open, there is a chance of the aperture leading to the abdomen being filled up with granulat:ons, and the hernia radically cured. For this important fact I am indebted to Mr. Haynes Walton, who has kindly furnished me with the leading facts of the following case in support of it. In 1847, he was called to
more » ... erate on a publican, aged seventy, for strangulated congenital inguinal hernia. At the age of fifteen, the hernia first obliged the wearing of a truss; several times during his life there had been strangulation, and the taxis had been successful. The operation was performed twelve hours after the commencement of the symptoms of strangulation; small intestine alone had come down; there was stricture at both rings; extensive suppuration ensued, and the spermatic cord, which was exposed for several inches, granulated, and coalesced with the healing surfaces of the surrounding parts, and completely closed up the abdominal aperture. A truss was never worn afterwards. The last time Mr. Walton saw the patient, three years after, with Mr. Hutchinson, of Farringdon-street, he was well, and had not the least uneasiness from his former complaint. When the communication between the abdomen and the tunica vaginalis is not obliterated, a hernia may occur without the abdominal ring being abnormally large, or the muscles lax; consequently, by judicious treatment, there is, I think, a greater chance of a congenital hernia being radically cured by the constant pressure of a truss, than any other form of hernia. In the case before us, a large quantity of fluid escaped when the sac was opened; this again is a circumstance demanding our attention: it may give rise to difficulty of diagnosis and embarrassment during the performance of the operation. In this case, however, the symptoms were so well marked, that no doubt could be entertained; but it accounted for the impulse on coughing, and the comparative softness and elasticity. The sac, when distended with fluid, at first sight gives the idea that one is looking on the gut itself. Closer examination will soon correct this. I am inclined to think, that in cases of congenital strangulated hernia, a larger quantity of fluid is generally found in the sac than in hernia not congenital. VIy experience, however, has not been sufficiently extensive for me to state it as a fact. In congenital hernia, too, the intestine is often adherent to the testicle, requring delicate manipulation. 2ndly.-The artificial anus, together with the state of the gut at the time of the operation. In spite of the various rules laid down in books, to enable us to determine the state of the intestine when the sac has been laid open, it is very difficult, in many cases, to do so; and it is much better, in cases where any doubt exists, to return the gut into the abdomen, rather than subject it to various manipulations in order to ascertain its precise condition. In the case before us the intestine was of a uniform black colour, not having the mottled appearance usually said to be characteristic of gangrene; neither did it give way under the fingers: so that it was returned into the abdomen with the hope, though not without considerable doubt, that it might recover itself. This it did not do, having reached a state which rendered it unable to recover, if gangrene had not actually commenced; though the time that elapsed before an artificial anus formed, proved that the return of the gut had been correct, and that there was a chance of its recovering. 3rdly.-The flabby state of the heart is, I think, a point of great interest, being a clue to the state the gut was in at the time of the operation; it is nothing more than we should expect, that in a person with enfeebled circulation from diseased heart or other cause, gangrene should more speedily take place than in a person with a vigorous and healthy circulation; and even if the intestine had not quite reached that point previous to its return, it is an additional reason for its becoming so, and not recovering afterwards; thus being an undoubted argument in favour of early operation. And lastly, the question of giving calomel. If given alone it would undoubtedly be injurious, being irritant in its action on the intestines; but I think, combined with opium, and not given for too long a period, its irritant action does not take place, and we have the constitutional effects alone. In this case there were no symptoms of irritation, and it apparently allayed the peritonitis. If it is injurious in these cases, it is from its lowering a system already enfeebled by the constitutional effect of the strangulation. Still, had it not been given in this case, it is most likely that the patient would have succumbed to the peritonseal inflammation. ON the evening of the 18th December, 1851, about five o'clock, I was sent for to a Mrs. G-, of the parish of R-, aged forty-nine, about three miles from my house. When I went up stairs, I found her lying on the bed, with little or no pain, flooding having been going on some time. I immediately made an examination; found the os uteri well dilated, with placental presentation; and when contraction did occur, which was very slight, the hsemorrhage was fearful. In these trying circumstances, the remarks of your correspondents came to my mind. I gave the patient directly half an ounce of the tincture of ergot of rye, passed my hand into the os uteri, intending, if possible, to go through the placenta, but found that a very difficult affair. I continued my efforts for about a quarter of an hour, and it is just possible I might have got my hand through, but when I was making an extra effort, I felt one edge of the placenta becoming detached from the uterus. I then passed my hand up along the wall of the uterus, turned the fcetus, and in bringing down the legs through the os uteri, the placenta came also, and the labour finished in about an hour from the time I saw her. The child of course was dead. Mrs. R-did as well as usual. Her eldest child is about twenty. She then went eight years to her next child, had three in quick succession, and when I attended the present case, had not been pregnant for seven years. A. W., an iron-moulder by trade, living in Lambeth, had long been troubled with tape-worm; for the last three or four months, indeed, the symptoms had become so annoying, that he was frequently compelled to leave off work for a time, to remove the joints from the anus, as well as those which had accumulated in his trousers. On the 5th ult., I directed him to take, on retiring to bed, a powder composed of four grains of calomel and two of ipecacuanha, together with a strong draught of concentrated compound aloes decoction; at six o'clock on the following morning, he had a drachm of fern-oil, obtained from Morson's. By the action of the draught and powder, a copious evacuation took place at four A.M., bringing away a large quantity of joints and other debris of the worm, and at twelve at noon, just six hours after taking the oil, the whole of the worm was expelled. It measured more than two yards in length, was very perfect, and had twisted itself into two knots; the first eight inches below the head was remarkably complicated, and cost me some. time and patience to unravel; the second eighteen inches lower down presented nothing peculiar. The interest of this case is materially increased by the fact that this patient's wife was greatly afflicted with tape-worm, about seven years ago, and one of the children has now anomalous symptoms which are probably referable to this cause. I have long had a suspicion that tape-worm is more common on the other side of the river than it is here, and certainly much may be due to the impure state of the drinking water, which is greatly complained of. If some of your numerous correspondents who are thoroughly conversant with that district and its diseases, would communicate the result of their experience on this subject, through THE LANCET, they would confer a great obligation upon myself, and, I believe, on the profession generally. A mw ell-street, Feb. 1852.
doi:10.1016/s0140-6736(02)41354-2 fatcat:ftd2gpbplnc63e2qzz3qayu3xi