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WEST HAM HOSPITAL, STRATFORD, E.
1734 fever, whooping-cough,
or He had always measles. happy, lively little fellow. The fact that the onset of the paralysis had been so sudden indubitably pointed to the lesion being a vascular one. I carefully
been
a
valvular or other trouble. Indeed, the organ appeared to be perfectly sound. The urine was normal. The cause would appear to be due to The pathoa rupture of the left middle cerebral artery. logy of infantile hemiplegia is well known to be shrouded in obscurity and is scarcely alluded to by writers. Strumpell’s view that some of these cases are due to polioencephalitis cannot apply to this case on account of its very sudden onset and previous good health, although (I ought to have mentioned it before) the child was suffering from an intractable form of eczema of both of the lower extremities when taken ill. I might otherwise have given The treatment of the case some colour to Strumpell’s view. was pursued on similar principles to that of adult cases and after a little time from half to one-minim doses of liquor strychninas were given, alternating with two-minim doses of diluted phosphoric acid. The patient at first grew much worse and I almost felt sure he must die. However, after I him on the he at once to improve. He strychnine began put grew stronger and slight movement appeared in the leg and a little later in the arm, but he was still quite speechless and stupid. The patient remained under my care for about six weeks, when he had to be removed to his home some distance off. Just before he left he had recovered very largely the use of his leg and arm but complete aphasia was still present. Quite recently I heard from his friends that he had grown very weak in every respect and the oaly thing he could say was " dada." Kelvedon, Essex.
examined the heart but there
was
no
A Mirror OF
HOSPITAL
PRACTICE,
BRITISH AND FOREIGN. Nulla autem est alia pro certo noscendi via, nisi quamplurimas e morborum et dissectionum bistorias, tum aliorum tum propriaø collectas habere, et inter se comparare.-MORGAGNi De Sed. et OaU8. Morb., lib. iv. Prooemium. -
WEST HAM
HOSPITAL, STRATFORD, E.
A CASE OF ISCHIATIC HERNIA.
(Under the care of Mr. W. A. GROGONO.) IN the few cases of hernia through the sciatic notch which have hitherto been described it has been situated at so great a depth that it has not been noticed during life. The hernia is described by Sir Astley Cooper as passing between the lower border of the pyriformis muscle and the spine of the ischium. In its clinical manifestations, this closely resembles an " ischio-rectal hernia," of which a very good instance was described by Mr. J. Lynn Thomas in THE LANCET in 1897,1 and we are somewhat inclined to think that the following case was really an ischio-rectal hernia. For the notes of the case we are indebted to Dr. R. Niven, house surgeon. A young woman, aged 22 years, was admitted into the West Ham Hospital on Nov. 23rd, 1899, under the care of LACTATION IN A MALE INFANT. Mr. Grogono. When she was admitted she complained of BY GEORGE M. BLAIR, M.B., CH.B. GLASG. pain on sitting and of a swelling in the left buttock. In August, 1898, she fell from a window ledge on to the floor, of about three feet, alighting in the sitting a distance I WAS consulted a few days ago by a woman whom I had She experienced pain on sitting down for two or posture. lately delivered of a male child at term. She complained three days after this fall. She had slight pain occasionally that her infant was losing flesh and was suffering from on sitting until January, 1899, about which time the pain excessive vomiting and sleeplessness. On examination the became more constant, the act of sitting always causing conchild exhibited two highly developed mammse in size about siderable pain in the left buttock. About this time also she noticed that the left buttock felt considerably harder to that of two walnuts and on slight pressure of the right than the right. In June, 1899, she again fell in the The woman informed touch mamma a quantity of milk oozed out. same position, and since then the pain had been nore severe. me that she had noticed the swelling of the breasts and after the second fall she observed that the left the flowing of milk for some time and had lately got Shortly buttock was somewhat larger than the right, and the swelling anxious as to the cause. With the exception of the scrotum, increased in size till about three months before which at present only contains on palpation one testicle, gradually when it apparently ceased to enlarge. She had admission, the external genitals and other parts are normal. This is not noticed any increase in the size of the swelling during the woman’s second confinement, but in the former one the child only lived a few hours and nothing remarkable was the past three months. The patient stated that on sitting sensation of " something noticed. I am indebted to Mr. Evan Jones, whose practice down she sometimes experienced a in her had always been abdomen. Her bowels moving" I am at present attending, for kind permission to publish the regular. There was no pain on defecation. above. On Nov. 24th the patient was seen to be a well-nourished, Goswellroad E.C. i Lroswell-roaa, E C healthy looking girl. The left buttock was occupied by a tense, well-defined, and almost spherical tumour situated WATER-SUPPLY OF MALMESBURY principally to the inner side of the tuberosity of the ischium. At a meeting of the Malmesbury Town Council held on The swelling measured about two and a half inches in Dec. 12th the water-supply of the town came under dis- diameter both vertically and horizontally. The superficial There was no cussion. The medical officer of health (Mr. C. W. Pitt), who veins over the swelling were enlarged. reported two fatal cases of typhoid fever, stated that the reddening of the skin which was freely moveable over the water was deleterious to health, and the county medical swelling. A slight impulse could be made out on coughing. officer of health also said that unless the water was pre- There was considerable tenderness on firm pressure, the viously boiled it was unsafe for drinking purposes. After a tenderness being most marked when the swelling was pressed No pain was experienced considerable discussion it was decided to approach the com- against the ischial tuberosity. except when the patient sat or lay on the affected side. pany with a view to the Council purchasing the waterworks. The was described as being of a sickening character. TENURE OF OFFICE OF MEDICAL OFFICERS OF The pain and the sacro-iliac articulation appeared to be hip-joint HEALTH.-At a meeting of the Okehampton Rural District normal. The bowels were regular. The temperature was Council held on Dec. 9th a letter was read from the Local normal and the was full, slow, and registered 72 beats pulse Government Board stating that they had under consideration per minute. Rectal examination revealed a slight bulging generally the question of the tenure of office of medical on the left side. There was no tenderness in the rectum. officers of health, and where, as in the case of Dr. E. The diagnosis rested between hernia, lipoma, chronic H. Young, the medical officer of the rural district of abscess, and chronic bursitis, and it was decided to make an Okehampton, a medical officer held a diploma in public incision. Accordingly, on Nov. 26th an inhealth they would be prepared to consider favourably an exploratory cision was made over the swelling dividing the skin, subapplication for sanction to his re-appointment without limit cutaneous tissue, and fascia. A large loop of small intestine of time. The communication added that if the rural district was found in a thin-walled sac of peritoneum, protruding at council were willing to so appoint Dr. Young they would be the inner border of the maximus and resting on gluteus willing to sanction the re-appointment accordingly. The that muscle. The hernia was felt to be protruding through council eventually decided to re-appoint Dr. Young without limit of time. 1 THE LANCET, July 24th, 1897, p 191. _______________
(WILTSHIRE).-
1735 sacro-sciatic foramen. The index finger could be of the sac through the foramen. The bowel appeared to be perfectly normal. As a radical operation was considered to be impracticable no attempt was made to reduce the hernia and the wound was closed. Remarks by Mr. GROGONo.-This case shows, in my opinion, that the sensations of the patient should not be too lightly passed over. Had I paid more attention to the statement of the patient that she feltsomething moving" in her abdomen on sitting down I might have been able to arrive at a positive diagnosis of the case.
the
great
passed along the neck
month previously when she was just out of bed from an attack of influenza which had confined her there for a fortnight. The history of this illness was that six weeks previously while at work in a razor factory she was suddenly taken ill with pains in her head, back, and neck, and a feeling of general malaise. She was unable to continue at work and took to bed where she remained for a fortnight ; the chief symptoms of her attack were vomiting and the above-mentioned pains. She noticed nothing wrong with her sight until she left her bed, when she discovered that she could not read. Subsequently her sight had remained about the same. There was nothing else of interest in her past history. She had never worked in lead or suffered from
there was no history of chorea, rheumatic fever, scarlet fever. The urine was of specific gravity 1013, THREE OPHTHALMIC CASES. acid, and contained no albumin or sugar. On examination a convergent strabismus of the right eye was seen. There (Under the care of Mr. SIMEON SNELL.) The pupils reacted well to light and to was no nystagmus. THE case of papillitis recorded below is a good example of accommodation. The vision in each eye was 6 . The There is no tissue of the patient could not read small print in Jaeger’s types. an important sequela of influenza. is liable in this disease, so Examination of the fundus disclosed well-marked papillitis which not to be involved body remarkable for the number and variety of its sequoias. Dr. in each eye. CASE 3. C7iancre of the 11pper eyelid.-A girl, aged seven Weeks, in the Nem York Medical Jonrnal, 1891, has collected years, was admitted into the infirmary on Nov. 12th, 1897. several similar cases. With regard to the third case the eyelids A pimple had been noticed on the right upper eyelid a few are not very rarely the seat of ectopic primary syphilitic sores, weeks before admission ; this had later developed into an but it is difficult to assign any reason for their occurrence in ulcer which at the time of her coming under observation this situation. It has been stated that attacks of syphilis involved a considerable portion of the lid. The whole eyelid arising from ectopic sores are more severe than those due to was much swollen and indurated ; the ulcer occupied the sores in the usual situations, but this idea is probably due to central two-thirds and was emitting a scanty discharge. the fact that extra-genital chancres are frequently not The glands behind the angle of the inferior maxilla were diagnosed early. For the notes of the cases we are indebted much enlarged, but, unlike what is usual in cases of chancres to Mr. J. Wilfred Stokes, late assistant house surgeon. of the eyelid or conjunctiva, the pre-auricular gland was not CASE 1. Embolism of the arteria centralis retinae.-A man, implicated. Two days after admission a rash appeared all aged 60 years, attended at the Sheffield Royal Infirmary on over the front of the chest and abdomen and extended down Nov. 8ch, 1897, and stated that at 6.15 A.M. that morning on to the thighs ; this after a few days began to fade and while stooping to tie his bootlace his right eye became disappeared in about ten days. On Dec. 21st the eyelid was suddenly blind ; after this for about half an hour there was much reduced in size and the red area was limited to a small some slight pain over the right eye and right side of the head. portion at the centre of the lid. The enlargement of the When the patient was first seen at 11 A.M. the condition glands had disappeared. At the time of admission the child was as follows. With the right eye there was the faintest was put on a course of mercury internally. No history whatperception of light, the pupil was somewhat dilated and ever as to the source of infection was obtainable. fixed, the fundus was pale, and the arteries were empty and barely distinguishable ; the veins were, generally speaking, also empty but in one or two a column of blood was noticed. The appearance this latter presented was very distinct, as ROYAL HOSPITAL FOR SICK CHILDREN on either side of the column the lumen was observed as AND WOMEN, BRISTOL. empty. There was no distinct "red spot" at the macula A CASE OF VERY ACUTE DIABETES IN A BOY, AGED and there was an absence of the effusion so generally FIVE YEARS. At the seen in cases of embolism of the central artery. emergence of the artery from the disc there was a small spot the of Dr. E. LEONARD LEES.) care (Under suggestive of the embolism and the effect on the vessels was IT has been frequently pointed out that diabetes mellitus more marked in the descending arteries, as if the plug interfered more with the flow of blood through these vessels is a more serious disease in childhood than later and that, as than it did through the ascending branches. Mr. Snell a rule, as the age increases the acuteness of the symptoms immediately commenced to massage the globe and after this diminishes. Nocturnal incontinence of urine suddenly arising had been continued for a few minutes a marked change in a child should always suggest the possibility of diabetes. the general pallor was lessened and the was evident ; A case in many ways similar to the one recorded below was column of blood in the vein already especially alluded to was lengthened. Later the veins and arteries published in THE LANCET in 1896,1 though the course be to charged with blood. At 4 P.M. the was a littleonlessanacute. In these rapid cases any asudden appeared absolute anti-diabetic diet or great patient was again seen when it was found that there insistence limitation of the amount of water taken seems to prewas blood in the arteries and that to a considerable extent circulation had been restored. The next morning dispose to the onset of coma. For the notes of the case we he was again seen by Mr. Snell. The patient could then are indebted to Dr. W. A. Milligan, resident medical officer. A boy, aged five years, was admitted into the Royal count fingers and the appearance in the fundus presented a marked contrast to what it had done on the Hospital for Sick Children and Women, Bristol, at 2 P.JYI. on previous day. Both arteries and veins contained blood June 30th, 1899, under the care of Dr. Lees. On admission patient was seen to be in a very weak state ; he was very though the fundus was still pale when compared with the the left. Two days later a change had again taken place. He much wasted, had a sallow complexion, and complained could no longer count fingers and the arteries had become much of thirst, constantly asking for water to drink. The markedly altered, appearing like threads. On Dec. 20th the most marked symptoms at a first glance were the rapid sighoptic papilla had passed into the white atrophic condition ing breathing (40 per minute) and the restlessness. The usually seen after embolism of the artery. The patient’s pulse was 140 and the temperature was 97’4° F. The tonguea past history and general present condition were good ; there was coated with a thick fur, the breath, however, having was no history of any illness. The heart sounds were distinctly sweet smell. The heart and lungs were normal. normal, the first sound perhaps being weak; no murmur The knee-jerks were exaggerated. The history of the case as obtained from the parents was was heard. The urine was of specific gravity 1010, clear, pale, and neutral, and contained no albumin. The patient that 10 days before admission the patient was very constiwas a heavy drinker. pated, so much so that his father, who is an asylum CASE 2. Post-influenzal papillitis.-A well-developed girl, attendant, administered enemata on three successive days aged 18 years, attended at the out-patient department of the with good result and much relief. Besides this, and infirmary on Nov. 5th, 1897, complaining of defective 1 THE vision. She stated that her sight had been good until a LANCET, Nov. 14th, 1896, p 1376.
SHEFFIELD ROYAL INFIRMARY.
plumbism ; or
or He had always measles. happy, lively little fellow. The fact that the onset of the paralysis had been so sudden indubitably pointed to the lesion being a vascular one. I carefully
been
a
valvular or other trouble. Indeed, the organ appeared to be perfectly sound. The urine was normal. The cause would appear to be due to The pathoa rupture of the left middle cerebral artery. logy of infantile hemiplegia is well known to be shrouded in obscurity and is scarcely alluded to by writers. Strumpell’s view that some of these cases are due to polioencephalitis cannot apply to this case on account of its very sudden onset and previous good health, although (I ought to have mentioned it before) the child was suffering from an intractable form of eczema of both of the lower extremities when taken ill. I might otherwise have given The treatment of the case some colour to Strumpell’s view. was pursued on similar principles to that of adult cases and after a little time from half to one-minim doses of liquor strychninas were given, alternating with two-minim doses of diluted phosphoric acid. The patient at first grew much worse and I almost felt sure he must die. However, after I him on the he at once to improve. He strychnine began put grew stronger and slight movement appeared in the leg and a little later in the arm, but he was still quite speechless and stupid. The patient remained under my care for about six weeks, when he had to be removed to his home some distance off. Just before he left he had recovered very largely the use of his leg and arm but complete aphasia was still present. Quite recently I heard from his friends that he had grown very weak in every respect and the oaly thing he could say was " dada." Kelvedon, Essex.
examined the heart but there
was
no
A Mirror OF
HOSPITAL
PRACTICE,
BRITISH AND FOREIGN. Nulla autem est alia pro certo noscendi via, nisi quamplurimas e morborum et dissectionum bistorias, tum aliorum tum propriaø collectas habere, et inter se comparare.-MORGAGNi De Sed. et OaU8. Morb., lib. iv. Prooemium. -
WEST HAM
HOSPITAL, STRATFORD, E.
A CASE OF ISCHIATIC HERNIA.
(Under the care of Mr. W. A. GROGONO.) IN the few cases of hernia through the sciatic notch which have hitherto been described it has been situated at so great a depth that it has not been noticed during life. The hernia is described by Sir Astley Cooper as passing between the lower border of the pyriformis muscle and the spine of the ischium. In its clinical manifestations, this closely resembles an " ischio-rectal hernia," of which a very good instance was described by Mr. J. Lynn Thomas in THE LANCET in 1897,1 and we are somewhat inclined to think that the following case was really an ischio-rectal hernia. For the notes of the case we are indebted to Dr. R. Niven, house surgeon. A young woman, aged 22 years, was admitted into the West Ham Hospital on Nov. 23rd, 1899, under the care of LACTATION IN A MALE INFANT. Mr. Grogono. When she was admitted she complained of BY GEORGE M. BLAIR, M.B., CH.B. GLASG. pain on sitting and of a swelling in the left buttock. In August, 1898, she fell from a window ledge on to the floor, of about three feet, alighting in the sitting a distance I WAS consulted a few days ago by a woman whom I had She experienced pain on sitting down for two or posture. lately delivered of a male child at term. She complained three days after this fall. She had slight pain occasionally that her infant was losing flesh and was suffering from on sitting until January, 1899, about which time the pain excessive vomiting and sleeplessness. On examination the became more constant, the act of sitting always causing conchild exhibited two highly developed mammse in size about siderable pain in the left buttock. About this time also she noticed that the left buttock felt considerably harder to that of two walnuts and on slight pressure of the right than the right. In June, 1899, she again fell in the The woman informed touch mamma a quantity of milk oozed out. same position, and since then the pain had been nore severe. me that she had noticed the swelling of the breasts and after the second fall she observed that the left the flowing of milk for some time and had lately got Shortly buttock was somewhat larger than the right, and the swelling anxious as to the cause. With the exception of the scrotum, increased in size till about three months before which at present only contains on palpation one testicle, gradually when it apparently ceased to enlarge. She had admission, the external genitals and other parts are normal. This is not noticed any increase in the size of the swelling during the woman’s second confinement, but in the former one the child only lived a few hours and nothing remarkable was the past three months. The patient stated that on sitting sensation of " something noticed. I am indebted to Mr. Evan Jones, whose practice down she sometimes experienced a in her had always been abdomen. Her bowels moving" I am at present attending, for kind permission to publish the regular. There was no pain on defecation. above. On Nov. 24th the patient was seen to be a well-nourished, Goswellroad E.C. i Lroswell-roaa, E C healthy looking girl. The left buttock was occupied by a tense, well-defined, and almost spherical tumour situated WATER-SUPPLY OF MALMESBURY principally to the inner side of the tuberosity of the ischium. At a meeting of the Malmesbury Town Council held on The swelling measured about two and a half inches in Dec. 12th the water-supply of the town came under dis- diameter both vertically and horizontally. The superficial There was no cussion. The medical officer of health (Mr. C. W. Pitt), who veins over the swelling were enlarged. reported two fatal cases of typhoid fever, stated that the reddening of the skin which was freely moveable over the water was deleterious to health, and the county medical swelling. A slight impulse could be made out on coughing. officer of health also said that unless the water was pre- There was considerable tenderness on firm pressure, the viously boiled it was unsafe for drinking purposes. After a tenderness being most marked when the swelling was pressed No pain was experienced considerable discussion it was decided to approach the com- against the ischial tuberosity. except when the patient sat or lay on the affected side. pany with a view to the Council purchasing the waterworks. The was described as being of a sickening character. TENURE OF OFFICE OF MEDICAL OFFICERS OF The pain and the sacro-iliac articulation appeared to be hip-joint HEALTH.-At a meeting of the Okehampton Rural District normal. The bowels were regular. The temperature was Council held on Dec. 9th a letter was read from the Local normal and the was full, slow, and registered 72 beats pulse Government Board stating that they had under consideration per minute. Rectal examination revealed a slight bulging generally the question of the tenure of office of medical on the left side. There was no tenderness in the rectum. officers of health, and where, as in the case of Dr. E. The diagnosis rested between hernia, lipoma, chronic H. Young, the medical officer of the rural district of abscess, and chronic bursitis, and it was decided to make an Okehampton, a medical officer held a diploma in public incision. Accordingly, on Nov. 26th an inhealth they would be prepared to consider favourably an exploratory cision was made over the swelling dividing the skin, subapplication for sanction to his re-appointment without limit cutaneous tissue, and fascia. A large loop of small intestine of time. The communication added that if the rural district was found in a thin-walled sac of peritoneum, protruding at council were willing to so appoint Dr. Young they would be the inner border of the maximus and resting on gluteus willing to sanction the re-appointment accordingly. The that muscle. The hernia was felt to be protruding through council eventually decided to re-appoint Dr. Young without limit of time. 1 THE LANCET, July 24th, 1897, p 191. _______________
(WILTSHIRE).-
1735 sacro-sciatic foramen. The index finger could be of the sac through the foramen. The bowel appeared to be perfectly normal. As a radical operation was considered to be impracticable no attempt was made to reduce the hernia and the wound was closed. Remarks by Mr. GROGONo.-This case shows, in my opinion, that the sensations of the patient should not be too lightly passed over. Had I paid more attention to the statement of the patient that she feltsomething moving" in her abdomen on sitting down I might have been able to arrive at a positive diagnosis of the case.
the
great
passed along the neck
month previously when she was just out of bed from an attack of influenza which had confined her there for a fortnight. The history of this illness was that six weeks previously while at work in a razor factory she was suddenly taken ill with pains in her head, back, and neck, and a feeling of general malaise. She was unable to continue at work and took to bed where she remained for a fortnight ; the chief symptoms of her attack were vomiting and the above-mentioned pains. She noticed nothing wrong with her sight until she left her bed, when she discovered that she could not read. Subsequently her sight had remained about the same. There was nothing else of interest in her past history. She had never worked in lead or suffered from
there was no history of chorea, rheumatic fever, scarlet fever. The urine was of specific gravity 1013, THREE OPHTHALMIC CASES. acid, and contained no albumin or sugar. On examination a convergent strabismus of the right eye was seen. There (Under the care of Mr. SIMEON SNELL.) The pupils reacted well to light and to was no nystagmus. THE case of papillitis recorded below is a good example of accommodation. The vision in each eye was 6 . The There is no tissue of the patient could not read small print in Jaeger’s types. an important sequela of influenza. is liable in this disease, so Examination of the fundus disclosed well-marked papillitis which not to be involved body remarkable for the number and variety of its sequoias. Dr. in each eye. CASE 3. C7iancre of the 11pper eyelid.-A girl, aged seven Weeks, in the Nem York Medical Jonrnal, 1891, has collected years, was admitted into the infirmary on Nov. 12th, 1897. several similar cases. With regard to the third case the eyelids A pimple had been noticed on the right upper eyelid a few are not very rarely the seat of ectopic primary syphilitic sores, weeks before admission ; this had later developed into an but it is difficult to assign any reason for their occurrence in ulcer which at the time of her coming under observation this situation. It has been stated that attacks of syphilis involved a considerable portion of the lid. The whole eyelid arising from ectopic sores are more severe than those due to was much swollen and indurated ; the ulcer occupied the sores in the usual situations, but this idea is probably due to central two-thirds and was emitting a scanty discharge. the fact that extra-genital chancres are frequently not The glands behind the angle of the inferior maxilla were diagnosed early. For the notes of the cases we are indebted much enlarged, but, unlike what is usual in cases of chancres to Mr. J. Wilfred Stokes, late assistant house surgeon. of the eyelid or conjunctiva, the pre-auricular gland was not CASE 1. Embolism of the arteria centralis retinae.-A man, implicated. Two days after admission a rash appeared all aged 60 years, attended at the Sheffield Royal Infirmary on over the front of the chest and abdomen and extended down Nov. 8ch, 1897, and stated that at 6.15 A.M. that morning on to the thighs ; this after a few days began to fade and while stooping to tie his bootlace his right eye became disappeared in about ten days. On Dec. 21st the eyelid was suddenly blind ; after this for about half an hour there was much reduced in size and the red area was limited to a small some slight pain over the right eye and right side of the head. portion at the centre of the lid. The enlargement of the When the patient was first seen at 11 A.M. the condition glands had disappeared. At the time of admission the child was as follows. With the right eye there was the faintest was put on a course of mercury internally. No history whatperception of light, the pupil was somewhat dilated and ever as to the source of infection was obtainable. fixed, the fundus was pale, and the arteries were empty and barely distinguishable ; the veins were, generally speaking, also empty but in one or two a column of blood was noticed. The appearance this latter presented was very distinct, as ROYAL HOSPITAL FOR SICK CHILDREN on either side of the column the lumen was observed as AND WOMEN, BRISTOL. empty. There was no distinct "red spot" at the macula A CASE OF VERY ACUTE DIABETES IN A BOY, AGED and there was an absence of the effusion so generally FIVE YEARS. At the seen in cases of embolism of the central artery. emergence of the artery from the disc there was a small spot the of Dr. E. LEONARD LEES.) care (Under suggestive of the embolism and the effect on the vessels was IT has been frequently pointed out that diabetes mellitus more marked in the descending arteries, as if the plug interfered more with the flow of blood through these vessels is a more serious disease in childhood than later and that, as than it did through the ascending branches. Mr. Snell a rule, as the age increases the acuteness of the symptoms immediately commenced to massage the globe and after this diminishes. Nocturnal incontinence of urine suddenly arising had been continued for a few minutes a marked change in a child should always suggest the possibility of diabetes. the general pallor was lessened and the was evident ; A case in many ways similar to the one recorded below was column of blood in the vein already especially alluded to was lengthened. Later the veins and arteries published in THE LANCET in 1896,1 though the course be to charged with blood. At 4 P.M. the was a littleonlessanacute. In these rapid cases any asudden appeared absolute anti-diabetic diet or great patient was again seen when it was found that there insistence limitation of the amount of water taken seems to prewas blood in the arteries and that to a considerable extent circulation had been restored. The next morning dispose to the onset of coma. For the notes of the case we he was again seen by Mr. Snell. The patient could then are indebted to Dr. W. A. Milligan, resident medical officer. A boy, aged five years, was admitted into the Royal count fingers and the appearance in the fundus presented a marked contrast to what it had done on the Hospital for Sick Children and Women, Bristol, at 2 P.JYI. on previous day. Both arteries and veins contained blood June 30th, 1899, under the care of Dr. Lees. On admission patient was seen to be in a very weak state ; he was very though the fundus was still pale when compared with the the left. Two days later a change had again taken place. He much wasted, had a sallow complexion, and complained could no longer count fingers and the arteries had become much of thirst, constantly asking for water to drink. The markedly altered, appearing like threads. On Dec. 20th the most marked symptoms at a first glance were the rapid sighoptic papilla had passed into the white atrophic condition ing breathing (40 per minute) and the restlessness. The usually seen after embolism of the artery. The patient’s pulse was 140 and the temperature was 97’4° F. The tonguea past history and general present condition were good ; there was coated with a thick fur, the breath, however, having was no history of any illness. The heart sounds were distinctly sweet smell. The heart and lungs were normal. normal, the first sound perhaps being weak; no murmur The knee-jerks were exaggerated. The history of the case as obtained from the parents was was heard. The urine was of specific gravity 1010, clear, pale, and neutral, and contained no albumin. The patient that 10 days before admission the patient was very constiwas a heavy drinker. pated, so much so that his father, who is an asylum CASE 2. Post-influenzal papillitis.-A well-developed girl, attendant, administered enemata on three successive days aged 18 years, attended at the out-patient department of the with good result and much relief. Besides this, and infirmary on Nov. 5th, 1897, complaining of defective 1 THE vision. She stated that her sight had been good until a LANCET, Nov. 14th, 1896, p 1376.
SHEFFIELD ROYAL INFIRMARY.
plumbism ; or