OPERATION ON THE EXSANGUINATED PATIENT

899 may occur, and this was previously suggested by WorsterDrought and MeMenemey (1933). These workers also refer to Bruce’s (1907) case of herpes zoster affecting the right seventh and eighth dorsal segments, followed three weeks later by pyramidal changes and ipsilateral dissociated ansesthesia below this level, In 1924 Lhermitte and Nicholas commented on perivascular cuffing in the pyramidal tract as a result of supposed involvement by the zoster virus. In their later paper Lhermitte and Vermes - (1930) described scattered vascular and cellular changes. These changes were confirmed by Denny-Brown et al. (1944). In all the cases described the latent period was almost the same. Thus there is ample evidence to support our contention that the hemiplegia complicating herpes zoster is due to direct local spread into the corticospinal tract from the trigeminal ganglion. The lesion is due to direct attack and not to vascular thrombosis. Conclusions

In hemiplegia due to ophthalmic zoster the virus settles in the trigeminal ganglion producing ophthalmic herpes. After a latent period of about three weeks the virus invades the nearby brain area, attacking the pyramidal tract and causing a hemiplegia by direct

damage.

of the duodenal channel that an anterior added. from Progress.-Apart thrombophlebitis of the right internal saphenous vein following intravenous infusions into this vein, convalescence was uneventful until the seventh postoperative day. From then until the twelfth postoperative day there was evidence of gastric retention, which was controlled by gastric suction and by intravenous fluid and electrolyte replacement. At this stage the patient had severe hsematemesis and melsena. This recurred frequently within the next twenty-four hours. Despite repeated transfusion with whole blood (8 pints) bleeding continued, and the patient’s condition steadily deteriorated. By the afternoon of the fourteenth postoperative day the patient was semiconscious, with a feeble pulse. The bloodpressure had fallen to unrecordable levels and death seemed imminent. The attempt to get the patient into a fit state for operation by means of transfusion had failed. Following the suggestion (Smith and Fairer 1953) that the phenthiazine derivatives reduce basal metabolism, produce effective autonomic block, and induce a shock-resistant state, a mixture of chlorpromazine (’Largactil ’) 50 mg., promethazine (’Phenergan ’) 50 mg., and pethidine 50 mg., made up to 20 ml. in normal saline, was cautiously injected intravenously. Definite improvement resulted. The blood-pressure could be recorded at 40 mm. Hg systolic, and there was an improvement in

in such narrowing gastrojejunostomy

was

,

pulse-volume. Laparotonay was done in the theatre, without removing the patient from his bed. Anaesthesia was induced with thiopentone 0-15 g. and ,

REFERENCES

Baudouin, E., Lantuejoul, P. (1919) Gaz. Hôp., Paris, 92, 1293. Biggart, J. H., Fisher, J. A. (1938) Lancet, ii, 944. Brissaud, A. (1896) J. Med. Chir. 67, 209. Bruce, A. (1907) Rev. Neurol. Psychiat. 5, 885. Carter, A. B., Dunlop, J. B. W. (1941) Brit. med. J. i, 234. Cornil, L. (1930) Rev. neurol. i, 280. Denny-Brown, D., Adams, R. D., Fitzgerald, P. J. (1944) Arch. Neurol. Psychiat., Chicago, 51, 216. Faure Beaulieu, M., Lhermitte, J. (1929) Rev. Neurol. 1, 1250. Gordon, I. R. S., Tucker, J. F. (1945) J. Neurol. Psychiat. 8, 40. Hassin, G. W., Rabins, I. (1946) J .Neuropath. 3, 355. Hughes, W. N. (1951) Neurology, 1, 167. Krumholtz, S., Luhan, J. A. (1945) Arch. Neurol. Psychiat. 53, 59. Lhermitte, J., Nicholas, M. (1924) Rev. neurol. i, 361. — Vermes, Y. (1930) Ibid, i, 1231. Schiff, C. I., Brain, W. R. (1930) Lancet, ii, 70. Taterka, J. H., O’Sullivan, M. E. (1943) J. Amer. med. Ass. 122, 737. Whitty, C. W. M., Cooke, A. M. (1949) J. Neurol. Psychiat. 12, 152. Worster-Drought, C. W., McMenemey, W. H. (1933) J. Neurol. Psychopath. 14, 52.

OPERATION ON THE EXSANGUINATED PATIENT REDUCTION OF RISK

JOHN C. GRANT M.B. Glasg., F.R.C.S.E.,

IAN GORDON M.B. Glasg., F.R.C.S.E., F.R.F.P.S.

F.R.F.P.S.

CONSULTANT SURGEON

SURGICAL REGISTRAR

KENNETH C. GRIGOR M.D.

Glasg.,

F.F.A. R.C.S.

CONSULTANT ANÆSTHETIST

THE VICTORIA

INFIRMARY,

GLASGOW

THE case reported here illustrates an anaesthetic technique which may enable major surgical operations to be undertaken on gravely ill, exsanguinated patients. For fifteen consecutive days intravenous infusions were given into the cephalic vein without adjustment of the

apparatus. A man,

aged 73,

was

admitted

Victoria

on

Feb.

21, 1954,

to the

Infirmary, under the care of Mr. Robert Mailer. He ’was seen by one of us (J. C. G.), and perforated peptic ulcer was diagnosed. In the first instance the patient was treated expectantly, but twenty-four hours later evidence of increasing peritoneal involvement made operation imperative. Operation (J. C. G.) revealed an indurated anterior duodenal ulcer, with a large central perforation. This was closed and covered with an omental patch." This procedure resulted "

maintained with nitrous oxide and oxygen, following oral intubation. Subsequently thiopentone 0-11 g. and gallamine 80 mg. were administered. A blood-transfusion which was set up in the leg because of extensive thrombosis of the superficial arm veins, was not adequate. The left cephalic vein, at shoulder level, was subsequently exposed after the method of Antia (1954) ; after extraction of a considerable length of blood clot this route proved entirely satisfactory, coping with two pints of whole blood in thirty minutes. On re-opening the wound (I. G.), the whole upper abdomen was found to be a mass of adhesions, with a purulent bilestained collection lying below the liver. With some difficulty the various organs-stomach, duodenum, gall-bladder-were exposed and identified. While this was being done the anastomosis was damaged, and, being open, was examined for bleeding, but none was found. The duodenum was opened through the site of the perforation, when the bleeding was seen to be coming from a vessel in the superior margin of the ulcer. The bleeding point was underrun with a catgut stitch, the duodenum repaired, and the anastomosis reconstituted. During the operation, which took just under an hour, the blood-pressure did not rise above 40 mm. Hg systolic until the bleeding-point was ligated ; thereupon the pressure began to rise steadily, and at the end of operation it was 70 mm. Hg

systolic. Progress.-During the next

six days the patient’s condition, under the circumstances, was considered to be satisfactory. The blood-pressure rose to 105/70 mm. Hg, the pulse had become steady at 90-100 per min. and the fluid balance was adequately maintained. Throughout this period there had been some discharge from the wound of thin, brownish, bilethere had stained fluid, indicating duodenal leakage; been no bleeding externally nor into the alimentary track. It was hoped that the fistula would close spontaneously. But from the seventh day after the second operation the discharge became more profuse, and the patient ultimately died on the fifteenth day after the second operation.

It falls to all general surgeons to be faced with the of a patient exsanguinated as a result of bleeding from a peptic ulcer. Often transfusion with whole blood will so improve the patient’s condition that surgical treatment can be undertaken with a reasonable chance of success. Occasionally-perhaps most frequently in the elderly patient-transfusion fails to produce improvement ; and operation under such circumstances, using the standard methods of anaesthesia, is bound to fail. The deaths in operations for bleeding ulcer are mostly in cases where the surgeon feels compelled to operate though the chances of recovery are negligible. rescue

900 The introduction of an anaesthetic technique which produces an effective blockage of the autonomic nervous system and lowering of the basal metabolic rate may help to solve the problem. Fortified in this manner against shock, the patient may be able to withstand the additional trauma of operation. In the present case the patient would probably have stood up to the more extensive procedure of gastrectomy, and death from fistula might

have been avoided.

Throughout the second postoperative period, lasting fifteen days, the patient was given 56 litres of intravenous fluids. This was all transmitted through a cannula inserted into the left cephalic vein as it lies in the sulcus between the deltoid and the pectoralis-major muscles. This allowed the patient the free use of his arms, and although he was restless the flow was never interrupted. The only complication observed was slight oedema of the hand and forearm.

satisfactorily

REFERENCES

BREAST CARCINOMA THE INFLUENCE OF A FEBRILE ILLNESS ON AN ARRESTED CASE

B.Sc., M.B. Lond., F.F.R. UNIVERSITY COLLEGE

CASE-REPORT

The

patient, when first examined, was a healthy-looking aged 46. She gave an eighteen months’ history of a lump in the right breast ; there had been an occasional stabbing pain in the breast, more severe during menstruation. In the upper inner quadrant of the right breast she had a woman

hard nodular tumour attached to the skin but not to the deep fascia ; this lump caused a visible swelling of the upper and inner part of the breast. No enlarged glands were palpable in the right axilla or in the right supraclavicular region. The left breast and glandular drainage areas appeared normal, and radiography of the chest showed no pulmonary metastases.

mastectomy

carcinoma

was

showed

diffusely invading

an

performed. Section of the actively growing medullary

the stroma of the breast and

Fig.I rig. <—
metastasis witn tnin

this period showed no extension of the metastases in the bones but only an increase in the surrounding sclerosis

during

A year later (ten years after the operation) the patient had acute febrile illness during an influenza epidemic and never fully recovered from it. Her general condition deteriorated, she steaiily lost weight, pain returned in the lower part of the back, and multiple skin metastases appeared in the mastectomy area. Radiography of the pelvis showed a break in the sclerotic ring and an extension of the rarefied area (fig. 3). Radiotherapy was given to the skin deposits; there was a temporary response only, and two weeks after the treatment the skin nodules began to enlarge again, and fresh ones appeared even in and above the irradiated area. Bone metastases appeared in the left scapula, lumbar spine, and pelvis, and the general condition rapidly became worse. The patient could not attend as an outpatient, and when she was admitted she was considered too ill for further radiotherapy. She died shortly after admission. ;.,r ecropsy showed metastatic growths throughout the body, involving the skin in the mastectomy area, the parietal and visceral pleura, the lymphatics of the lungs, the hilar and para-aortic abdominal glands, both adrenal glands, and the leptomeninges, besides widespread skeletal deposits. an

THE following note illustrates how a carcinoma of the breast with bone metastases, which had appeared to be stationary while under observation for nine years, suddenly became generalised after an acute febrile illness.

A radical

an

(fig. 2).

GWEN HILTON

operation specimen

radiotherapy. enlarged gland became palpable in the left supraclavicular triangle ; it was irradiated and regressed. For the seven years after the bone metastases in the pelvis had been diagnosed the patient’s general condition had remained good, and such secondary deposits as had appeared were consistently radiosensitive. She had led a normal life and had no pain. Radiography of her pelvis and femora to

A year later

Antia, N. H. (1954) Unpublished data. Smith, A., Fairer, J. G. (1953) Brit. med. J. ii, 1247.

DIRECTOR, RADIOTHERAPY DEPARTMENT, HOSPITAL, LONDON

the peripheral areolar tissue ; several lymph sinuses were full of cancer cells, but the stroma showed a fair degree of reactive fibrosis. Section of the gland showed considerable hyperplasia of the reticulum but no malignant invasion. Convalescence was uneventful, and the patient remained well or two years. Two years after operation she experienced pain at the bottom of her back and down both legs. Radiography of the pelvis and femora showed several metastases, which were ostoolytic, with a little surrounding sclerosis. Fig. 1 shows No radiotherapy one of these metastases in the left ilium. was given to the metastases, for the pain had subsided when the patient attended the radiotherapy department two weeks after radiography. ’Ihereafter she was clinically well. Three years later an enlarged gland was found on the medial wall of the right axilla. This gland was irradiated and regressed, leaving an area of induration with indefinite edges. After another three years several glands became palpable at the apex of the right axilla and in the right supraclavicular triangle. These enlarged glands were irradiated and responded

COMMENTS

This case demonstrates clearly the importance of the defence mechanism of the body. Glandular metastases appeared during the ten years after the operation but

Fig. 3

Fig.2 margin

01 sclerosis in len mum.

Fig. 2-Same metastasis six years later, showing increase in thickening of sclerotic ring.

rig.

j-zoame metastases atter iedriie

Illness, snowmg cisappearance

of lower and outer part of sclerotic in ilium.

area

ring

and increase of

rarefied]