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dosed, whilst the external wound was sutured and dressed in ashortly returned. Physical examination showed a fairly well After the nnourished man with great abdominal distension, generally she usual way, a drainage-tube being inserted. patient had been put to bed a gum elastic catheter was tied rresonant, and tenderness, chiefly over the umbilical and

1 n the bladder and the urine allowed to run off. The first left hypochondriac regions, but no tumour could be felt. - rew ounces of urine that passed were blood-stained, but sub- Rectal I examination was negative, and the urine conno albumen. The temperature was 97° F. As the t sequently it came away quite clear, twenty-one ounces being tained ,oided in the first fifteen hours. There was no vomiting, ssymptoms on admission did not appear imperatively to and the case progressed to convalescence without a hitch. call for operation, tincture of belladonna (ten minims) was ( The patient has been seen since she left the hospital, and ordered ( every four hours, and several simple enemata were r although she has had one or two slight attacks of retentionadministered, bringing away a considerable amount of faeces. there has been no return of the pain or discomfort previouslyThe r vomiting, though it continued, was very slight in amount at long intervals, and the abdominal distension, pain, I complained of. The cicatrix in the groin is firm, and thereand is no evidence of any return of the hernia. : and tenderness remained much as before. As, however, after Remarks by Mr. RosE.-This is certainly an unusual case iforty-eight hours the symptoms still persisted, Mr. Thompson and presents many points of interest. From the previouswas asked to see the case, and after consultation laparotomy history it would appear that the patient had for some time was decided upon. been in the habit of going about with an over-distended Oct. 26th, 8.30 P.M.—The patient being under chlorobladder, which no doubt led to the formation of the saccule form, a median incision two inches long was made below the Jound in connexion with the hernial protrusion. No cause umbilicus, and this was gradually increased, as necessity for this over-distension of the bladder could be disarose, to six inches. The great omentum was found to be covered; there was no urethral obstruction or growth at adherent to the anterior abdominal wall in almost its entire the orifice. It was, therefore, probably one of those extent, and the dissection had to be carried through that cases of spasmodic contraction of the neck of the bladder before the intestines were reached. The small intestines occasionally met with in nervous females. The saccule con- were found to be intensely distended, but on passing the sisted mainly of the mucous membrane and of the sub- hand into the cascal region the caecum was felt to be mucosa, it was considerably thickened, and no muscular collapsed. Owing to the great distension of the small fibres could be seen. The connexion between the hernial sac intestines almost the whole of them were gradually allowed containing omentum and the vesical protrusion was quite to escape from the abdomen (and covered with hot antisufficient to account for the pain and discomfort experienced septic towels) before the seat of the obstruction could be by the patient. I contented myself with simply suturing the discovered. This was found to be situated in the ileum about opening made in the bladder, and did not attempt to remove four inches from the ileo-cascal valve, and was caused by a the protruding portion, hoping that the eradication of the band of tissue, apparently springing from the mesentery, hernial sac would remove the symptoms from which she was encircling the gut, and then attached by its distal end close ,31-lffering, an opinion borne out by the subsequent progress of to the opposite side of the mesentery. This band was divided the case. It would have been very difficult for me to have and the constriction at once disappeared, so as to allow the efficiently closed the bladder at the bottom of the wound, visible passage of flatus along the bowel. The lumen of the had I excised the whole of the saccule. The opening was bowel after the division of the band was seen to be manifestly sutured in the same way as should always be employed in smaller than that immediately above and below the constricted dealing with the extra-peritoneal portion of the portion. The intestines were then returned with considerable by passing the sutures through the whole of the thickened difficulty and the abdominal incision sutured. walls, except the mucous membrane, a second row of stitches 27th.-The passage of a rectal tube last evening was still further ensuring the accurate closure of the wound with followed by free escape of flatus, and to-day the distension is the mucous membrane well inverted. The man’s condition is

bladder-viz.,

disappearing. he is suffering from much shock.

fairly good, although

He has only been sick once and has been able to take and retain small quantities of

nourishment. 28th.-Flatus collecting again ; ordered Seidlitz powder STRANGULATION OF INTESTINE BY A BAND; LAPAROTOMY; every six hours ; tongue dry and brownish. RECOVERY. 30th.-Bowels have been freely moved; distension has (Under the care of Dr. FRANK NICHOLSON and disappeared; takes nourishment well; some bronentirely Mr. HENRY THOMPSON.) chitis, probably from position ; ordered mixture of senega, THE symptoms of strangulation of the small intestine byaand change of position every two hours. a band or through a hole in the mesentery are practically the 31st.-Tongue clean and moist for the first time ; bronchitis same as those depending on strangulation in a hernial sac.Jmuch less. Nov. 7th.-Spurious diarrhoea. Rectal examination revealed This case presents some points of interest, one of which is the a firm mass anteriorly and externally to the rectum, almost recovery of the patient after operation performed so many it. This was thought to be a large hsematoma, days after the commencement of symptoms. According to Mr.occluding derived from the vessels of the divided adherent probably Treves the average duration until death in a case of strangu- omentum. A morphia suppository was ordered to be given lation under a band is six days, but this duration depends on night and morning. Gradual but steady improvement went ’the tightness of the strangulation and the amount of bowel on from this date, and he was discharged cured on Dec. 6th. before discharge showed the rectal obstruction Involved ; the most rapidly fatal cases are those in which a Examination to be scarcely perceptible. considerable amount of bowel has been severely strangulated. Remarks Dr. FRANK NtcHOLSOrr.-The clinical interest Opium exercises considerable effect in prolonging the length in this caseby centred in the very slow development of the
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REVIEWS AND NOTICES OF BOOKS.

for some time past determined that, given the absence of a definite tumour to be made out either by rectal examination or to be felt through the abdominal wall, I would make an abdominal incision for the purpose of diagnosis, even if it had to be followed by a lumbar or inguinal colotomy. Some A Text- boo7o of the Theory and Practice of Medicine. By of my colleagues held that in this particular case colotomy American Teachers. Edited by WILLIAM PEPPER, M.D., was called for, and not laparotomy, but if I had followed LL. D. Vol. II. Philadelphia : W. B. Saunders. London r that advice the large gut would have been found collapsed F. J. Rebman. 1894. and then a further abdominal incision would have had to be THIS volume completes a work of great utility and of a high made. 2. Strangulation by a band which was probably congenital is not, I believe, common in a man of the advanced standard of excellence. We had occasion to speak in terms. age this patient was. The band was probably one of those of commendation of the first volume, and can equally testify omphalo-mesenteric bands so well described by Mr. Treves as to the sound teaching and clear descriptions of disease which follows : "A cord may be found to stretch from the root of the mesentery to be attached to the margin of the ileum are contained within the volume before us. The number of (close to its mesentery), opposite the spot from which the contributors is not large, but it is evident that they have diverticle most commonly arises. Leichtenstern believes that been judiciously chosen, whilst the name of the editor is a, such bands represent that part of the omphalo-mesenteric guarantee of the quality of the material which he has had at vessels that extends between the bowels and the main The volume opens with an extremely interesting The band command. bloodvessels at the root of the mesentery." of the General Biology of Bacteria, Infeclucid account and was about the diameter of a toothpick, and was probably about three or four inches long. It was composed tion and Immunity, by Dr. Welch. It speaks strongly for of firm, stringy material, but I am sorry to say that the position which bacteriology has established for itself to it was mislaid after the operation, so that its anatomical find that its lessons are deemed essential to be inculcated in. character was not made out. It is strange, granted that the medical text-books. It implies further that medical educaobstruction was congenital, that the man had had no previous tion of the present day must include a sound knowledge of of but I lumen of that the obstruction ; symptoms suppose the gut was sufficient to allow of the passage of the the general principles at least of this science, which has fasces, &c., in an ordinary way until some large substance revolutionised the conception of infectious diseases and has. either totally or partially blocked up the narrow channel. at the same time made clear and comprehensible much that 3. Another fact that calls for notice was the great relief was obscure and difficult in the pathology of this. previously afforded to the distended intestines by the frequent wearing of the rectal tube and the free administration of Seidlitz important group of diseases. Dr. Welch does not enter into powders as recommended by Mr. Lawson Tait. 4. The special detail, but has succeeded admirably in fixing attention puzzling presence, as found out on Nov. 7th, of the large upon the important features of bacterial morphology and hrematoma, causing again partial obstruction attended by bacterial life in relation to the causation of disease, and in spurious diarrhoea. 5. The recovery of the patient in spite explanation of the problems of infection and immunity. This, of his age and collapsed condition. article is followed by one on Diathetic Diseases, by Dr. H. M. Lyman, introductory to a series of articles on the different affections included under this head or allied to it-e.g., LEEDS GENERAL INFIRMARY. Rickets, Obesity, Saccharine Diabetes, Rheumatoid Arthritis, CASE OF LITHOTRITY IN A CHILD. Gout, and Rheumatism. The following passage introducing the subject of gout may be quoted as an example of the spirit (Under the care of Mr. MAYO ROBSON.) in which the matter is treated. The writer says :WHATEVER may be the merits or demerits of the operation "A concise and accurate definition of gout is impossible. of lithotrity in children it is important that all cases operated It is the most conspicuous manifestation of the arthritic on by crushing should be reported, so that surgeons may diathesis. It is always a chronic disease, and when it is the make up their minds on the subject as to whether the result of hereditary causes it persists throughout the whole of successful operation of lithotomy in children should be life ; when acquired after birth it embitters the entire replaced by a method said to be still more successful and remainder of existence. Once acquired, the predisposition permanent, and the more conspicuous outbreaks of the conservative; hence the reason for reporting a single case, is disease are to be considered as temporary exaggerations of a, of which the notes have been furnished by the house surgeon, peculiar morbid constitutional condition in which the nutriMr. Oldfield. tion of the entire organism is retarded and perverted. Gout, A boy six years of age was admitted to the Leeds General therefore, belongs to that remarkable group of diseases which Infirmary with the symptoms of vesical calculus, which had may exist either in the same individual or among members of been present for at least six months. On sounding a the same family who have derived their morbid predispositions There was an elongated prepuce, from a common ancestral source.......It is impossible in the large stone was felt. and the urethral orifice appeared to be small. On present state of our knowledge to explain with perfect satisFeb. 15th, 1894, with the patient under an anaesthetic, faction the nature of those errors of nutrition which determine Weiss’s small lithotrite was used, and the stone, which the appearance of diabetes in one patient, obesity in another, measured an inch in length, was crushed until no tangible and gout in a third.......The gouty patient often becomes the fragment could be found. The fragments were washed out victim of obesity, while the diabetic subject may give birth to through a silver tube equal to a No. 6 catheter attached to a gouty progeny, which in its turn manifests now one and now Bigelow’s wash bottle. A second introduction of the instru- another of the different diathetic diseases." ment was necessary, and a final washing left the bladder Dr. William whose name and fame as a teacher and apparently free from fragments. The operation lasted half scientific writerOsler, are so well known and appreciated in this an hour, and the fluid returned from the bladder was barely tinged, proving that the vesical walls were uninjured. The country, contributes the articles upon Diseases of the Blood. detritus weighed a drachm and a half. The patient had He has himself done not a little to elucidate this difficult neither discomfort nor abnormal temperature after the operasubject, concerning which there is still a large field open for tion and returned home within the week. The following He prefaces his discussion of the various week he was taken as an out-patient, and his mother said investigation. forms of a-n2amia by an account of the knowledge now had the that he had been perfectly well and had never slightest discomfort since going home. He was to be taken possessed of the constitution of the blood and the methods back in case of any return of the symptoms, but so far there of examination, a coloured plate being usefully appended to has been no need for further advice. exhibit the various kinds of corpuscular elements brought Remarks by lB1r. l4ZAyo RoBSOT.--The operation was quite to light by the methods of staining introduced by Ehrlich, as easy as in the case of an adult, and the recovery being so The subject of Progressive Pernicious Anaemia is ably absolutely uneventful would lead me to speak favourably of the method and to repeat it when called on to operate for dealt with. and it is instructive to learn that Dr. Osler’s experience of the good effects attributed to arsenical treatment is stone in a child.

Reviews

and

Notices of Books.