HUDDERSFIELD INFIRMARY.
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294 on his toes; but he had no pain. The abdomen was then not so tense, but he still had the contractions at times. These, however, gradually passed off, and he left the in- firmary quite well on June llth. HUDDERSFIELD INFIRMARY. CASE OF STERCORACEOUS VOMITING AFTER OPERATION FOR STRANGULATED INGUINAL HERNIA. (Under the care of Mr. KNAGGS.) WE are indebted to Mr. William Robert Smith, assistant house-surgeon, for notes of the following case :- G. K-, aged forty-five years, was admitted on the evening of May 5th, with an irreducible inguinal hernia, which had been down for about six hours. There was no vomiting nor pain, and the bowels had acted since the gut had descended. The taxis having been employed unsuc- cessfully, hot fomentations were applied, and opium given. May 6th.-Has slept well, but has vomited twice matter of a stercoraceous character; skin rather dry; pulse of fair volume, 84; tongue slightly furred. During the night, as was afterwards learnt, he made frequent but ineffectual at- tempts to return the rupture. He was then placed fully under chloroform, careful taxis again tried, and this fail- ing, the operation was performed in the usual manner. A small quantity of serum escaped on opening the sac, and the intestine was found much congested. Some difficulty was experienced in returning the bowel, in consequence partly of its size, but also from there being a double con- striction. 7th.-Fæcal vomiting twice since operation. Slept well; pulse 96; no abdominal tenderness. 8tb.-Complains of pain in chest, and cough; breathing difficult, with rusty expectoration. In other respects much the same. No vomiting during last twenty-four hours. 10th. - The patient progressed favourably until this morning, when the fascal vomiting recurred. The wound was in a healthy state, and no appearance of any descent of intestine. An enema of water-gruel brought away but little feculent matter. The abdomen not distended nor tympanitic ; pulse 96 ; tongue covered with dirty-white fur. Up to this time opium has been administered daily since the operation. llth.-Passed a very good night. Pulse 96; tongue covered with dry brown fur; abdomen distended, but not decidedly tympanitic. At 2 P.M. rigors; anxious counte- nance ; stercoraceous vomiting; pulse 100. 12th.-Vomiting continues; abdomen distended, tym- panitic, and tender to touch. Pulse small, 110; tongue dry and brown. No evacuation from the bowels up to this time, though several doses of calomel and enemas have been given since the 10th. A consultation of the medical officers was called, when it was decided to propose to the patient and his friends (after fairly stating the uncertainty as to any good resulting from the operation) that the returned intestine should be cut down upon and examined, so that if any internal strangulation existed, as seemed probable, it might be relieved. The man himself consented, but his wife objected; and therefore, having regard to the many elements of uncertainty presented by the case, the idea of operation was abandoned. 13th.-The patient continued gradually sinking, and died about 12 A.M. Autopsy, two hours after death.-On opening the abdomen there was general peritonitis, and a quantity of serum escaped from the peritoneal cavity. In the left iliac region extensive adhesions were found, binding the intestines firmly down; and these adhesions existed around the pre- viously strangulated intestine. On slitting up this, a quan- tity of thin faecal fluid escaped. The mucous membrane was congested and softened. On its peritoneal surface several spots of deep congestion were observed, but no gangrene, nor was there any direct mechanical obstruction to the pas- sage of the contents of the bowel. There are few cases more anxious to the practical sur- geon than those where feculent vomiting recurs repeatedly after the operation for strangulated hernia. In this case it would probably have been more frequcnt from the first, had not care been taken to avoid putting much food upon the stomach, and also to keep the patient to some extent under the influence of opium. What was the condition upon which the vomiting depended? Clearly not upon in- flammation alone, beca.use it occurred too soon after the operation. The symptoms did not point to gangrene, unless it might be during the last twenty-four hours of life. The most obvious inference was that it must depend either upon a paralysed bowel, unable to propel its contents, or upon some mechanical obstacle within the abdomen. The supervention of inflammation was merely an addition to the symptom, not the originating cause of it. From the exami- nation after death it is clear that paralysis of the protruded bowel, no doubt the result of too much taxis, was the first cause of the vomiting, and of the reversed peristaltic action of the intestines. But during life it was not equally clear, and the case is brought forward to show how difficult it is to distinguish between reversed peristaltic action as the re- sult of paralysis of intestine, and that dependent upon more direct mechanical occlusion of the bowel. Reviews and Notices of Books. The Agricultural Labourer: A short Summary of his position, partly based on the Report of Her Majesty’s Conimis- sioners appointed to inquire into the Employment of Women and Children in Agriculture ; and republished in part from the Pall ill-all Gazette and the Cornhill Magazine. By T. E. KEBBEL, Barrister at Law, of the Inner Temple, Esq. London : Chapman and Hall. MR. KEBBEL’S high reputation as a thoughtful and candid expositor of Conservative principles in Church and State will be enhanced by this well-informed, well-considered, and well-written little work on the condition of the agricul- tural labourer. The subject, as everyone knows, has been examined by a Royal Commission, whose bulky reports,. while they attest its gravity, are apt to repel all but the specially interested reader. Between the Commissioners and the educated public Mr. Kebbel plays the part of in- terpreter, explaining the importance of the problem, the difficulties besetting it, and the mode in which it may be- most satisfactorily solved. His volume, indeed, is a very favourable specimen of a too scantily represented class of literature-a class holding a middle place between Com- missions of Inquiry and the non-official community. Few men who have for the first time to master an exhaustive blue-book can fail to appreciate the value of a careful digest of its contents by a writer who is himself an autho- rity ; and medical readers will understand the nature of Mr. Kebbel’s work when we say that it performs for the reports of the Commissioners on the agricultural labourer the part so well played by Mr. John Simon for the medical reports of the Privy Council. We have entered so fully from time to time into the blue-books of the Agricultural Commission as to absolve us from a detailed criticism of Mr. Kebbel’s digest. He has overlooked no significant fact in the evidence before him ; while the judgment with which he has weighed and applied it is always sound, and often acute. The chapter on Hiring is a good specimen of the tenor of the work. After a very full and impartial statement of the arguments for and against the system of yearly hiring, Mr. Kebbel inclines to regard it’as, on the whole, the least objection- able of the numerous systems which have either been tried, or proposed, as substitutes for it. One consideration which he advances strikes us as at once novel and just. "V’e must remember," he says, (( that this system of yearly hiring tends to circulate the population, and to infuse new blood into rural communities. The carter or ploughman who takes a place at some distance from his native village chooses a wife among the strangers, and settles down there perhaps for the rest of his life. At all events he has done ’ better, physiologically, than if he had remained at home
Transcript of HUDDERSFIELD INFIRMARY.
294
on his toes; but he had no pain. The abdomen was thennot so tense, but he still had the contractions at times.These, however, gradually passed off, and he left the in-firmary quite well on June llth.
HUDDERSFIELD INFIRMARY.CASE OF STERCORACEOUS VOMITING AFTER OPERATION
FOR STRANGULATED INGUINAL HERNIA.
(Under the care of Mr. KNAGGS.)
WE are indebted to Mr. William Robert Smith, assistanthouse-surgeon, for notes of the following case :-
G. K-, aged forty-five years, was admitted on theevening of May 5th, with an irreducible inguinal hernia,which had been down for about six hours. There was novomiting nor pain, and the bowels had acted since the guthad descended. The taxis having been employed unsuc-cessfully, hot fomentations were applied, and opium given.May 6th.-Has slept well, but has vomited twice matter
of a stercoraceous character; skin rather dry; pulse of fairvolume, 84; tongue slightly furred. During the night, aswas afterwards learnt, he made frequent but ineffectual at-tempts to return the rupture. He was then placed fullyunder chloroform, careful taxis again tried, and this fail-ing, the operation was performed in the usual manner. Asmall quantity of serum escaped on opening the sac, andthe intestine was found much congested. Some difficultywas experienced in returning the bowel, in consequencepartly of its size, but also from there being a double con-striction.
7th.-Fæcal vomiting twice since operation. Slept well;pulse 96; no abdominal tenderness.
8tb.-Complains of pain in chest, and cough; breathingdifficult, with rusty expectoration. In other respects muchthe same. No vomiting during last twenty-four hours.
10th. - The patient progressed favourably until this
morning, when the fascal vomiting recurred. The woundwas in a healthy state, and no appearance of any descent ofintestine. An enema of water-gruel brought away but little feculent matter. The abdomen not distended nortympanitic ; pulse 96 ; tongue covered with dirty-white fur.Up to this time opium has been administered daily sincethe operation.llth.-Passed a very good night. Pulse 96; tongue
covered with dry brown fur; abdomen distended, but notdecidedly tympanitic. At 2 P.M. rigors; anxious counte-nance ; stercoraceous vomiting; pulse 100.12th.-Vomiting continues; abdomen distended, tym-
panitic, and tender to touch. Pulse small, 110; tongue dryand brown. No evacuation from the bowels up to this time,though several doses of calomel and enemas have beengiven since the 10th. A consultation of the medical officerswas called, when it was decided to propose to the patientand his friends (after fairly stating the uncertainty as toany good resulting from the operation) that the returnedintestine should be cut down upon and examined, so thatif any internal strangulation existed, as seemed probable, itmight be relieved. The man himself consented, but hiswife objected; and therefore, having regard to the manyelements of uncertainty presented by the case, the idea ofoperation was abandoned.13th.-The patient continued gradually sinking, and died
about 12 A.M.Autopsy, two hours after death.-On opening the abdomen
there was general peritonitis, and a quantity of serumescaped from the peritoneal cavity. In the left iliac regionextensive adhesions were found, binding the intestinesfirmly down; and these adhesions existed around the pre-viously strangulated intestine. On slitting up this, a quan-tity of thin faecal fluid escaped. The mucous membrane wascongested and softened. On its peritoneal surface severalspots of deep congestion were observed, but no gangrene,nor was there any direct mechanical obstruction to the pas-sage of the contents of the bowel.There are few cases more anxious to the practical sur-
geon than those where feculent vomiting recurs repeatedlyafter the operation for strangulated hernia. In this case itwould probably have been more frequcnt from the first,had not care been taken to avoid putting much food uponthe stomach, and also to keep the patient to some extent
under the influence of opium. What was the conditionupon which the vomiting depended? Clearly not upon in-flammation alone, beca.use it occurred too soon after theoperation. The symptoms did not point to gangrene, unlessit might be during the last twenty-four hours of life. Themost obvious inference was that it must depend eitherupon a paralysed bowel, unable to propel its contents, orupon some mechanical obstacle within the abdomen. Thesupervention of inflammation was merely an addition to thesymptom, not the originating cause of it. From the exami-nation after death it is clear that paralysis of the protrudedbowel, no doubt the result of too much taxis, was the firstcause of the vomiting, and of the reversed peristaltic actionof the intestines. But during life it was not equally clear,and the case is brought forward to show how difficult it isto distinguish between reversed peristaltic action as the re-sult of paralysis of intestine, and that dependent upon moredirect mechanical occlusion of the bowel.
Reviews and Notices of Books.The Agricultural Labourer: A short Summary of his position,
partly based on the Report of Her Majesty’s Conimis-sioners appointed to inquire into the Employment ofWomen and Children in Agriculture ; and republishedin part from the Pall ill-all Gazette and the CornhillMagazine. By T. E. KEBBEL, Barrister at Law, of theInner Temple, Esq. London : Chapman and Hall.MR. KEBBEL’S high reputation as a thoughtful and candid
expositor of Conservative principles in Church and Statewill be enhanced by this well-informed, well-considered,and well-written little work on the condition of the agricul-tural labourer. The subject, as everyone knows, has beenexamined by a Royal Commission, whose bulky reports,.while they attest its gravity, are apt to repel all but the
specially interested reader. Between the Commissionersand the educated public Mr. Kebbel plays the part of in-terpreter, explaining the importance of the problem, thedifficulties besetting it, and the mode in which it may be-
most satisfactorily solved. His volume, indeed, is a veryfavourable specimen of a too scantily represented class ofliterature-a class holding a middle place between Com-missions of Inquiry and the non-official community. Fewmen who have for the first time to master an exhaustiveblue-book can fail to appreciate the value of a carefuldigest of its contents by a writer who is himself an autho-rity ; and medical readers will understand the nature ofMr. Kebbel’s work when we say that it performs for thereports of the Commissioners on the agricultural labourerthe part so well played by Mr. John Simon for the medicalreports of the Privy Council.
We have entered so fully from time to time into theblue-books of the Agricultural Commission as to absolveus from a detailed criticism of Mr. Kebbel’s digest. Hehas overlooked no significant fact in the evidence beforehim ; while the judgment with which he has weighed andapplied it is always sound, and often acute. The chapteron Hiring is a good specimen of the tenor of the work.After a very full and impartial statement of the argumentsfor and against the system of yearly hiring, Mr. Kebbelinclines to regard it’as, on the whole, the least objection-able of the numerous systems which have either been tried,or proposed, as substitutes for it. One consideration whichhe advances strikes us as at once novel and just. "V’emust remember," he says, (( that this system of yearlyhiring tends to circulate the population, and to infuse newblood into rural communities. The carter or ploughmanwho takes a place at some distance from his native villagechooses a wife among the strangers, and settles down thereperhaps for the rest of his life. At all events he has done
’ better, physiologically, than if he had remained at home
