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Preceding the Onset of Acute Symptoms. Although The 779 grain of atropine was administered subcutaneously, andi at the operation. The opening into the parietal peri- soon as she was placed in bed she was surrounded by lie toneum was situated above the crest of the ilium, and water bottles and enveloped in warm blankets. had quite firm margins. So far as I can see, it For the first few days nutrient injections were adminiis- was a purely abnormal internal hernia. The whole of tered. Convalescence was somewhat delayed by a sha),rp the circumference of the bowel was not involved ; it attack of bronchitis, which came on towards the end of tltie would therefore come under the class described as Richter’s first week. She was discharged cured at the end of a rnontl.h. hernia in an abnormal position, the cause of the obstruction The temperature was perfectly normal for four days aft;erI being apparently an acute kink in the gut owing to the the operation, but on the fifth day, owing to the attackofI bowel being fixed at its circumference, and to paralysis of the bronchitis, it rose to 102&deg;, subsiding, however, to tlhe muscular coat at the obstructed spot. It is interesting to normal again in two days. The bowels acted twice on tl] note that, although the bowel was ruptured on being with- fourth day, and again on the sixth. Vomiting entirel drawn from its abnormal position, careful stitching by ceased after the operation. She is now quite well. H(er Lembert’s sutures completely and effectually occluded the recovery was owing in a great measure to the careful afte:r- opening, and that the bowels were moved naturally within treatment and to the skilful nursing which she received b four days. The absence of tympanites seemed to be explained the staff of the hospital. by the copious vomiting, which apparently occurred quite The special points worthy of notice in the case jusst easily, and without giving the patient great distress, except related are-the diagnosis, the cure by laparotomy afteer from the fact of the vomit being stercoraceous; in fact, the such a long period of obstruction as ten days, the absencce patient effected for herself what Kussmaul has proposed to do of tympanites, the character of the obstruction, thie in cases of intestinal obstruction -that is, to clear the rupture of the weakened bowel, and its successful suturee. stomach and upper bowel by regular washings out. It Although the recognition of intestinal obstruction1is seemed surprising that such severe symptoms could have usually easy, a correct diagnosis of the cause is unn- persisted ten days, and that at the end of that time the doubtedly one frequently attended by considerable peir- bowel should have been found in no worse condition than it plexity; and if space permitted there would be no difficult;y was at the time of operation. It cannot be doubted that in relating errors made by most able clinicians. A very death must have occurred had the patient not been operated instructive paper on the subject of diagnosis in intestina11 on, and I believe that the mistake usually made in such obstruction appeared in THE LANCET for Sept. 22m,d cases is to wait too long before surgical help is sought. It and 29th, 1888, by Dr. MacDougal, the gist cf the essa;,y seems to me that, whilst abdominal obstruction is entirely being that a period spent at the bedside in taking a carefuzl a so-called medical ailment, medical treatment alone should history is usually the best help in making a correct dia9,- be relied on for a very brief period, for there is small credit gnosis; and this, I feel sure, is often the only way to arrive’e either to the physician who may have made the diagnosis at a distinction between a primary obstruction, as in tliiLe or to the surgeon who carries out the treatment in case related above, and one secondary to peritonitis, as &Igrave;ln operating when it is too late; and one cannot help the case of perforating ulcer of the stomach with genera feeling that hitherto surgical help has, as a rule, been peritonitis on which I operated in November, 1888, when’e sought only when it is seen that the patient is going to die. all the symptoms pointed to sudden obstruction of thee Not long ago I had a good illustration of this. Having urged bowels, and where the patient herself said she had beer immediate operation in a case of intestinal obstruction, I well up to the time of the attack, which came orn heard nothing further of it until after the lapse of a fort- duringperfectly active exertion ; but the history in this case, gleanecd night, when it was evident the patient was going to die. I not from the patient but from her fellow-servants, elicite&ograve;dwas then asked to open the abdomen, which I perhaps un- the fact that she had had pain after taking food for somee wisely did, for the result realised my expectations. I weeks previously, thus enabling a correct diagnosis to bee believe that laparotomy should be performed early in all made before the operation was performed. I believe it is nott initially acute cases: first, as a means of diagnosis, if that <incommon for many cases of perforation of the vermiformti be otherwise impossible ; secondly, as a means of removing appendix to be mistaken for primary instead of secondaryythe cause of strangulation, if such be discovered ; and intestinal obstruction. Several errors of this kind havee thirdly, as a means of giving relief, if no cause can be found, come under my own observation, and I believe that in somee by performing enterotomy, or, as recommended by Dr. Senn, of these cases an absolute diagnosis cannot be made until1 by short circuiting the obstruction. the abdomen is opened, although usually there is some3 The conclusions which I would draw from this and other history of pain in the region of the ccccum for some times cases coming under my own care, from post-mortem exallli- preceding the onset of acute symptoms. Although the nations, and from recorded cases, are: First, that in chronic usual division of cases of intestinal obstruction into acute cases-that is, where obstruction is the prominent symptom, and chronic is a most useful one, there are instances where there being no sign of strangulation-medical treatment may auch a division is impossible; as in the case of a lady whomi relieve, or, if the obstruction be due to faecal accumulation, I saw in 1887, suffering from symptoms of acute intestinal1 may cure; but that in many such cases colotomy or some obstruction, with the history that she had been perfectlyother operation will be so plainly indicated as to leave no a should done. in well up to certain Sunday, when, whilst lifting something,, doubt concerning what be Secondly, that she felt a sudden pain in the abdomen, and soon afterwards; cases where acute symptoms supervene on chronic, medical to vomit, the vomit quickly becoming stercoraceous. and expectant treatment may at first be wise, but that, if beganOn opening the abdomen, a malignant stricture was found relief do not come rapidly, laparotomy should be performed. in the splenic flexure of the colon, which must have beenThirdly, that in initially acute cases laparotomy should be growing for some months at least, and without premonitory performed without loss of time, delay being as dangerous as symptoms it had suddenly become occluded. But, for all. would the postponement of kelotomy in strangulated hernia. practical purposes, cases of intestinal obstruction may be Leeds. conveniently grouped into two great classes&mdash;(1) cases of obstruction as a rule the obstruction the chronic, being CASE OF prominent symptom, acute troubles only coming on at a ,later period, or earlier if hastened by meddlesome treat- INTESTINAL OBSTRUCTION CAUSED BY AN ment ; (2) cases acute from the onset, which may be broadly IMPACTED GALL-STONE. divided into three classes-(a) those of internal strangula- tion, including intussusception, volvulus, bands, &c. ; BY W. A. DE WOLF SMITH, M.D., L.C.P. & S. QUE., lIb) enteritis, or other cases of purely functional obstruc- MEMBER OF THE BRITISH COLUMBIA MEDICAL COUNCIL, SURGEON tion ; (c) cases of perforation attended by acute peritonitis. TO THE BRITISH COLUMBIA PENITENTIARY, ETC. The history of the case I have just related led us to diagnose obstruction, either by band or by internal hernia, from the M. S-, a patient who had been an inmate of the Insane fact of the had a hernia some time patient having right ,, Asylum here for some time, suffering from a mild form of it had not descended for a from previously, although year; melancholia, was noticed on lst, 1888, to be suffering the fact of the pain commenced in iliac July having the right from constipation. She was very in her habits, and region; from its having come on suddenly without collapse; quiet and from the fact of vermicular action of the bowels requested to be taken to the closet, but was taken always sit down when at that one The hernia in this case seemed neverthere periodically by the attendant; would starting point. to be entirely unconnected with the rupture ; nor can I told to, and when told to get up would do as she was bid. explain anatomically the cause of the condition found When it was discovered that the bowels had not acted 780 for a couple of days, the superintendent, Dr. R. J. Bentley gave her a dose of calomel.
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