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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°, 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 Ìln 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, eliciteòdwas 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
for a couple of days, the superintendent, Dr. R. J. Bentley gave her a dose of calomel. This failing to producea A CASE OF DIABETES MELLITUS WITH motion, she was ordered enemas, which brought away a TYPHOID FEVER. small quantity of fæcal matter. There still being ai evident obstruction, Dr. Bentley ordered her two smal BY J. DEARDEN, M.D., F.R.C.S.E. doses of croton oil, which, however, had no effect excep that she once manifested a desire to go to stool, but withou As the above form of disease with typhoid complications. result. On the of the 4th had morning vomiting alread3 is rather rare, I should like to place on record a case which set in, and the matters vomited had taken on a decidedly has occurred to me. stercoraceous character. My opinion was then asked 01 lately P. called at on Nov. the case, and before I had seen the patient we decided t( F-, aged forty-one, my surgery 6th, try the plan recommended by Kussmaull of washing out 1888, about 9 A.M., as he was going to his office. He com- the stomach frequently with warm water, holding the ques plained of great weakness, shivering, headache, pains in the tion of operation in reserve. This was done, and the patieni back and head, thirst, and restlessness during the night ;, seemed somewhat relieved by the warm water until thE also that he had been flesh lately, or, to put it evening, about 9.45 P. M., when I was telephoned for to comE losing in his own " The flesh is and see the patient, who had had two or three convulsivE words, just peeling off my bones "; attacks. In company with Dr. Bentley, I saw the womar still, he was not so thin as such an expression would imply. at 10.10 P.M. She had then had three attacks of con He informed me that three weeks previously he had had vulsions, and a fourth came on while we were present. two right upper molars removed for toothache, but that Pulse 106, moderately full, regular; no elevation of tem- the gums had remained soft and spongy ever since, and perature ; breathing stercoraceous ; eyeballs insensitive tc the teeth generally loose, so that he had not been able to, the touch, though when we first saw her they reacted masticate his food properly. He looked pale and languid, slightly to light. She had been taking quarter-grain and his usual buoyancy and liveliness were absent. On, doses of morphia during the afternoon, and had taken slight examination, in addition to the foregoing, I found the altogether two grains. She had not apparently been in pulse to be rapid (125), weak, and thready; the tongue dry, pain, but the morphia was given to quiet the convulsions. and coated with a thin brown fur; thirst present, but not, Her teeth were tightly clenched, so that a stick was inserted excessive ; and no great desire for food. I requested him between them to keep her from biting her tongue. She had to return home as soon as possible, informing him that the been unable to retain anything on her stomach for two days. symptoms generally pointed to typhoid. He did so about The woman was evidently sinking, and we decided that noon, and went to bed. I visited him next morning operation was useless. She died at 10.45 A.M. on the 5th. (Nov. 7th), when I found that he had passed a restless. At the necropsy, the abdomen only was opened. The night, complaining of severe headache ; the tongue, thirst,. stomach was distended with gas, as was also the small and pulse much the same as on the previous day; tem- bowel to within a foot or fifteen inches from the ileo-cfecal perature 101° ; the skin moist and inclined to per- valve, where the gut presented the signs of inflammation, spire ; no action of bowels since the previous day; urine- and was obstructed by an oval body, which felt, through the rather abundant, and of a pale straw colour.’ On the 8th intestinal walls, very similar to a walnut. Below the he was much the same. The urine which had been passed obstruction the bowel was pale and empty. On removing during the previous twenty-four hours amounted in quantity the substance, it was found to be an oval body, three inches to four litres ; sp. gr. 1048 ; on testing it with sulphate of and a half in circumference in the long diameter by two copper and liquor potassge I found it loaded with sugar. inches and three-quarters in circumference about the middle. Later in the day he was seen by Sir William Roberts, of It was at first thought that it might be a foreign bodyswal- Manchester, who agreed in toto as to the nature of the case, lowed at some time-a not uncommon fancy of lunatics; but pointing out that the extraction of the teeth might be play- when split through the middle (which was done easily) it ing an important part in the development of the glycosuria;. showed a centre of a yellowish colour and vitreous fracture, and undoubtedly the typhoid owed its origin to defective while the circumference was composed of layers of darker sanitary arrangements of the house. The visits night material, arranged concentrically. It was evidently a gall- and morning (which will serve no wise end to record), stone which had escaped from the gall-bladder, and had showed that under the treatment adopted, or the peculiar passed down the gut until it reached a point where it could form of illnesses, the glycosuria was daily giving way, as proceed no further. Whether it had escaped from the gall- shown by the steady falling of the specific gravity of the bladder through the duct when small, and had grown to its urine to 1030 on the 12th ; but the typhoid fever was making present size by degrees during its passage through or sojourn equally steady progress, a few rose spots being visible on the in the bowels, or whether it had ulcerated from the gall- abdomen; there was no diarrhaea, however, and the bowels bladder into the duodenum, I am not prepared to say, as always freely acted after an enema of soap water, the stools. there were no symptoms of the passage of a gall- being dark and offensive; the temperature varied, but never stone, such asprevious sudden pain, collapse, hiccough, &c., with exceeded 103°. On the morning of the 15th the symptoms . their subsequent sudden subsidence; nor did we at the generally were changed; there was low muttering delirium, necropsy (which was a hurried one) discover any signs that picking at the bedclothes, and subsultus. He answered it had ulcerated through the walls of the gall-bladder and questions when roused, but quickly lapsed into uncon. duodenum. sciousness. General tympanites was present, with hiccough. I have no doubt that the proper treatment of this case, Occasionally he vomited a little dark grumous fluid, of the as of cases of intestinal obstruction in general, would be "coffee-ground" character. The pulse was about 140 and laparotomy ; and if the obstruction was found to be caused scarcely to be felt. He was bathed in perspiration. There by an impacted gall-stone, its removal or breaking up by was no chest disturbance. The temperature was a little means of a fine needle, as recommended by Mr. Lawson Tait,2 over 102°. He had passed no urine during the night ;, would be the proper course to pursue. The diagnosis in about four ounces were removed by the catheter; specific ;his case, beyond constipation, was by no means easy gravity 1020. The exhalation from the lungs, which from intil vomiting had set in, as the patient would give no the first had the diabetic odour, was so offensive as to expression of her feelings, and the abdominal walls were make it almost impossible to stand nearer to the patient so thick that no tumour could be made out. than three yards without feeling the sickly effects. At New Westminster, British Columbia. 2 o’clock P.M. he appeared to be rapidly sinking. I injected ten minims of ether into the arm, which had the 1 THE LANCET, Feb. 14th, 1885. 2 Ibid, Dec. 10th, 1887. effect of rousing him, so that he answered a question or two in monosyllables, such as "Doctor," &c. I repeated the injections four times at short intervals of about fifteen ROYAL UNITED HOSPITAL, BATH.-The sixty-third minutes. He gradually sank, and died at 9.40 P.M., ten annual report of this institution states that during the year days from my first seeing him. 1888 no special circumstances and events occurred which The treatment in this case commenced with citrate of called for notice. There were 1004 admissions, being an soda and potash, with tincture of conium ; afterwards the increase of 29 as compared with the previous year. The effervescing saline, with conium, and eight grains of out-patients numbered 7879, against 8602 in 1887. The salicine every four hours in milk—the latter at the special expenditure was £5381 15s. 8d., leaving a balance in hand suggestion of Sir William Roberts The restlessness was of £359 19s. 2d. endeavoured to be combated by a pill composed of a,.