Metcalfe Johnson
1882 The Lancet  
479 the damaged though now patent intestine; secondly, the diarrhoea, associated with a sloughy and ulcerated state of the mucous membrane of the strangulated portion of intestine ; and it is to the association of this symptom with ulceration of the mucous membrane that I wish to draw attention. This connexion is supported by the fact that, in those cases in which, in the absence of peritonitis, death has occurred from the non-recovery of the injured gut (as shown by the state of the
more » ... part and the dilatation of the part above), and in which this ulceration of the mucous membrane has occurred, diarrhoea has been a prominent symptom after the operation, with or without the return of the vomiting. It is also supported by the records of two cases of death from intestinal obstruction. In both constipation had been complete-in one case for a week, in the other for two weeks; in both vomiting of a semi-feculent and finally of a feculent fluid was present; and in both two days before death a very loose motion occurred, followed by diar-rhœa of a thin watery fluid mixed with faeces of a pultaceous character. At the post-mortem one was found to be a case of internal strangulation of a portion of ileum by an old fibrous band ; the constricted gut was port-wine colour, but smooth and shining on the surface, certainly not gangrenous ; the mucous membrane was sloughy and ulcerated at the situation of the constricting band. Here also the floor of one of the sloughs had given way, and the patient died collapsed from the sudden shock of the escape into the peritoneal cavity of the intestinal contents. In the other a narrowing of the calibre of the ascending colon was found just beyond the csecum by a fibrous stricture involving the whole circumference of the gut; here, too, the mucous membrane had sloughed away at the site of the stricture, though no perforation of the intestine occurred, and the patient died apparently from exhaustion. In both these cases general peritonitis was absent. Diarrhoea just before death was present, associated with an ulcerated and sloughing condition of the mucous membrane of the constricted portion of intestine. The question of causation of course still remains. The death and removal of the turgid mucous membrane may have removed so much of the obstruction as to allow the passage of fluids through the narrow aperture which before was completely blocked, or the laying bare to the irritating influence of faecal fluid of the sympathetic nervous plexus in the gut wall beneath the mucous membrane may have acted reflexly on the rest of the intestinal tube, causing increased peristaltic action and watery secretion, or both these conditions may have acted in combination; at any rate, the destruction or injury of this nervous plexus would seem to be a sufficient cause for the paralysis of the portion of intestine so injured and the return of feculent vomiting in some cases in whlch, though the obstruction be removed, the gut fails to recover, and yet no actual gangrene of its coats can be detected. Turning, on the other hand, to cases in which recovery takes place, I find from the notes, as indeed is pointed out in Sir James Paget's Clinical Lectures, that frequently no action of the bowels occurs for some days after the operation, the patient meanwhile continuing to improve in every respect. In all the cases of death from non-recovery of the strangulated intestine which I have observed, and in which general peritonitis has been absent, the temperature has been uniformly low throughout-in some normal, in several averaging 99°, in a few only reaching 100°; the gradual increase in the frequency of the pulse, and in diminution of strength, pointing at the same time to cardiac depression and failure. This association of lowness of temperature with irriration and injury of sympathetic nerve plexuses in the intestinal wall points, as has been suggested, to some considerable interference with the thermogenic function of the nervous system, whether by causing vaso-motor paralysis of the intestines, iu which case the rectal temperature would be raised while that of the surface was lowered, or by some frigorific action of the irritated sympathetic nerves, as maintained by Bernard, there is no evidence to show. With regard to the operation for the relief of strangulated hernia, it would seem, from the above remarks, that it is quite possible to return a portion of intestine which, though externally smooth and shining, slippery in texture, not hopelessly congested, certainly not gangrenous, is all the while internallv in a far more advanced stage of decay, the mucous membrane having passed into a sloughing and ulcerated condition. Moreover, it is natural to suppose that, since the damage is done by the blood stream failing to leave, not failing to reach, the constricted portion, the injury would be greatest in the highly vascular slightly resisting mucous coat. Whether this condition of the interior of the gut can be ascertained by the feel of the part at the time ot the operation is very doubtful ; if it cannot, it would seem that the gut might be more frequently opened than returned in these advanced inflammatory and yet not outwardly gangrenous conditions of the intestine, and, above all, one more reason is added to the many which have been so often urged for very early operation in all cases of irreducible strangulated hernia. (Concluded from page 436.) M. N-, female, aged thirty-five (two children), when seen, had symptoms of flooding, in which an ovum or hydatid was passed. She complained of pain and tenderness over the left ovary, also soreness on pressure over the fourth and fifth dorsal vertebrae, with tingling of the hands and feet. These symptoms were relieved by rest in the prone position and soothing remedies. It seemed at first likely to end in hysteric spinal irritation, but is now, after the lapse of three years, quite well. Here the spinal irritation arose distinctly from functional disorder of the ovary. A consideration of some of the symptoms developed under the hypodermic use of morphia may assist to throw light upon the physiology of a narcotic acting through the nervous system. After the insertion of the remedy, there is, first, a disposition to sigh, with a sense of constriction at the praecordia, followed by a slight confusion in the head and a tremor in the limbs, which, producing a warm glow, is followed by ease of the pain and generally sleep. Bfter a longer or shorter interval, on waking a sense of comfort pervades the body, until, on assuming the erect position, nausea and vomiting are often produced. Again, on inserting the needle it often happens that the prick is felt on the spot exactly corresponding with it on the opposite side of the body. At times, when little or no pain follows the insertion of the needle, but a rather more copious discharge of blood ensues, a peculiar form of urticaria instantaneously covers the whole body, attended with intense itching at the soles of the feet and at the verge of the anus. It would seem fair to infer from these phenomena that, after touching the peripheral loop of the sentient nerve, the influence at once passes to the semilunar ganglion (præcordial constriction), thence to the middle cervical ganglion (globus), and then through the middle cerebral artery-whose capillaties are filled by the paralysis of the ganglionic nerve-to the grey matter of the convolutions (tremor and sense of fulness in the head), whose congestion promotes either sleep or mental activity, as the case may be. After the nettle-rash has appeared, the effect of the drug is generally mote active, as might be supposed, from its presence in the circulation. The following circumstance illu-trates the action of the sympathetic nerve upon the sensoiium. While strapping the testis of a man be suddenly fell faint, knocking his head against the wall. The blow at once restored his consciousness, so that he did not fall to the ground. A short résumé of the modus operandi of a sentient act will assist in rendering more clear the influence of a disordered as well as of a heatthy ganglionic nerve.
doi:10.1016/s0140-6736(02)21625-6 fatcat:to4tgdf3wjfyxdnqdmkty4krmm