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to be followed by vomiting, which ceases only with death. Especially is this so on operations on the abdominal or pelvic organs. Herniotomy and lithotomy are now and then followed by fatal vomiting, and subsequent search brings nothing to light; no injury to the peritoneum, no hæmorrhage, to the inflammation, no other lesion ; nothing but hugely distended bowel.
The case which led me to believe that, in certain instances death begins in the gut from entire cessation of action in the intestinal muscular fibre, and that the cessation was due to fatty degeneration, I now briefly cite.
Several years ago, a lady so stout that she had long been confined to her room—the staircase of her house was also narrow and awkward-without any previous complaint, began to vomit. The vomiting, at first occasional, became incessant and fæcal in character, and she sank in two or three days. I examined the the body. The intestinal canal was from end to end enormously distended with gas, but there was nowhere any localized obstruction of any kind. The bowel was strikingly yellow in appearance ; and the amount of fat, not only on the body, but within the abdomen, could only be described in words that would savour of carricature. After the most careful examination, no other appearances could be found to account for death.
Another case which made a vivid impression in my mind, was that of an exceedingly stout man. He got out of doors a little in a specially made phaeton with a bottom so low that it just cleared the road, and was reached with one short step. Without injury or premonitory incident of any kind, symptoms of intes. tinal obstructiсn (sometimes urgent and sometimes with intervals of ease) set in, and in a few days he died. A very yellow distended bowel was seen; indeed, I remarked in this case, as I have in others, “ The bowel seems a tube of fat.” The distension was not uniform, but more in some coils than in others. There was, however, no band, or twist, or stricture, or cause of obstruction of any kind. I had not yet concluded that death might be caused by fatty failure of the gut. I was more supicious, and afraid that it might be so, or I should have called in the aid of the microscope.
In a case of strangulated hernia, in a very stout man, the bowel was reduced easily and with marked gurgling, and for a few hours he seemed better, but vomiting returned, and he died. On examination no inflammation, or gangrene, or aparently adequate cause for death was found. The abdominal organs were greatly loaded with fat. The heart was somewhat softer than natural. The extreme yellowness of the bowel so struck me, and my reflections and fears had now taken so clear a shape, that I determined to have a microscopical examination of the muscular fibre of the bowel. This was carefully made for me by an experienced microscopist, Dr. Wood (one of our staff), and left no doubt of the marked fatty change in the suspected structure. Dr. Wood did not content himself with the appearance of the fatty intestine ; he examined portions of health intestines, and found a striking contrast.
Not long ago I had two cases of lithotomy, both of which ended fatally within twenty-four hours, after several hours of incessant vomiting. The cases were singularly alike, a description of one will serve both. A big fat“ drinking” man of sixty had enlarged prostate and large vesical calculus. There was no tangible evidence of renal or other visceral disease. There was no peculiarity in the operative steps to account for the result. I could not to-day alter any single step in the operation for the better. He was free from hæmorrhage or marked shock. Ilis condition for a few hours was quite comfortable ; then occasional vomiting set in, and tympany of the abdomen appeared. The vomiting became frequent and was associated with great exhaustion, and ended fatally. In a subsequent examination, a description of the appearances would answer for both bodies. The internal organs were loaded with fat; the heart was somewhat pale and soft; and the kidneys were not healthy. The intestinal canal was singularly and uniformly yellow, and everywhere enormously distended. There was no signs anywhere of inflammation, or peritoneal injury, or extravasation of blood, or infiltration of urine.
I believe the operation here destroyed the vitality, so far as contractility was concerned, of the bowel. Flatulent distension
followed, and irratrievably spoiled the gut. This condition, affecting all or a large portion of the canal, and affecting it even to the vicinity of the stomach, was practically a condition of acute, high up, and complete obstruction.
Here the question naturally arises, what are the customary explanations now and heretofore, of the causes of death after continuous vomiting which follows the reduction of strangulated hernia, which follows also operations for uncomplicated herniæ, which follows lithotomy and other operations on the pelvis and abdomen. The very variety of the explanations testifies to their improbability. One says shock; another says shock with feeble heart; another says ether or chloroform vomiting; another says rapid septic poisoning; another says incipient peritonitis. I am far from saying that these, or some of them, are inadequate causes of death under certain circumstances; but they do not satisfactory account for death in the cases I bring forward. In pure shock, with or without cardiac degeneration, vomiting is rare; in cases of say, crushed knee-joint, or amputation at the hip, or even in severe abdominal injury (in healthy persons), nervous muscular action dwindles down to death without vomiting. That ether or chloroform vomiting should recur after some hours of comfort is at least hypothetical; hypothetical is also rapid septic poisoning without rigor or rise of temperature, and any other likeness to the known septic state. Peritonitis without the slightest sign of peritonitis is too metaphysical a pathology to grasp. In fatty change and a consequent failure of the gut, we have an explanation which is based on clinical and microscopic observation, which clears up all difficulties, and which is consistent with known pathological laws.—British Medical Journal.
Therapeutic value of Croton-Chloral. - In a very interesting paper read before the Ulster Medical Society, Dr. Riddell, (Dublin Medical Journal, April, 1879), reports his experience of the great therapeutical value of croton (butyl) chloral. He mentions first a case of severe paroxysmal headache ineffectually treated for many years by all the great guns of the Pharmacopæia, but cured by five grains of butylchloral twice daily and ten grains taken at night dissolved in spirits of wine and glycerine, with a little acid and syrup of orange to cover the flavor. The patient continues the five-grain doses at night, and now enjoys better health than she has done for years. Since that case, Dr. Riddell says they have used it largely—sometimes failing, sometimes relieving—till, by keeping an account of all his cases, it began to be clear, which were most benefited by the drug. Since then, the number of cases relieved (some permanently) has increased. These cases are : headache in females arising from mental distress; those cases of headache frequent at the menopause—in fact all those called neuralgic, except a few arising from internal mischief, are benefited and in many instances cured. In that distressing species of neuralgia called tic douloureux, he has found it in many cases acting like a charm. Of course, he does not include any arising from cranial or intercranial causes. He has tried it in neuralgia of the ovaries, but no good resulted. In insomnia, it is not so reliable, as the hydrate ; but in some cases where, the loss of, or inability to, sleep is accompanied by a weak or fatty heart, it is to be preferred, as it has no weakening effect on the central organ of the circulation. In one case of delirium tremens, where the circulation was very feeble, the combination of croton chloral with digitalis had a wonderful effect, and it seemed as if the drugs could be given together in much smaller doses to produce the same results than singly. In this, he pushed it from ten to thirty grains every three hours, with drachm and twodrachm doses of the infusion of digitalis. In pain arising from caries of teeth, he has found it useless in most cases, and in all inferior to Richardson's “ tinctura gelsemini" ; but in one case of a nervous young lady, by giving her two ten-grain does, he was able to extract a tooth next to painlessly, to her great satisfaction. In these cases, it is in affections of those parts supplied by the fifth pair of nerves that it is of most use ; but to be of service, the drug must be given in far larger doses than prescri bed in the Pharmacopoeia for adults, five grains three or four times daily, gradually increasing if required ; if stimulants be wanted, dissolve it in rectified spirit; if not, dissolve it in glycerine. In all cases complicated with hæmorrhoids, give glycerine. If anæmia exist, combine it with iron, or what he believes better, arsenic; then gradually lessen the chloral, in all cases he has found it better to give it in solution than in powder or pill. Dr. Riddell mentions also severe pain with photophobia, and blepharospasm after injury, in which atropia failed, but ten grains of butyl-chloral repeated in an hour gave complete relief; and a case of acute painful facial carbuncle, in which the effect of ten grain doses every three hours was “ simply marvellous,” the disease going through its subsequent stages almost without the patient knowing anything of the matter from the sense of feeling. This remedy is probably less used in practice than its remarkable anodyne powers deserve.—British Medical Journal.
Congenital Inguinal Hernia.-(Operation for the radical cure of congenital inguinal hernia in the child. By George Buchanan, M.A., M.D., Professor of Clinical Surgery in the University of Glasgow.)—Professor John Wood's operation for the radical cure of inguinal hernia in the adult is, on the whole, so successful and so free from danger, that I am surprised so few of the many hundreds affected with hernia in every community seek the relief it affords. I presume it is because there must always be some hesitation in accepting the present risk, however small, which accompanies an operation; and a hope that the much greater danger of strangulation may
But in the case of young boys the risk arising from an operation is much less. I think it has been shown that the peritoneal cavity, especially under antiseptic precautions, may be opened with impunity. But even this risk is, in Mr. Wood's plan, not encountered ; but it seems to me strange that boys who have a congenital hernia which cannot be kept permanently reduced by any aparatus—a state of matters which every hospital surgeon sees repeatedly—should be allowed to grow up with a deformity which prevents them from being useful and happy members of society, and debars them from a great many employments.