383

LONDON HOSPITAL.IRREDUCIBLE HERNIA RENDERED REDUCIBLE BY REST

AND DIET.

(Under the care of Mr. MAUNDER.)WE are indebted to Mr. E. J. Havens for the notes of the

following case :-J. H-, aged thirty-five, a tram-car conductor, was

admitted on May 18th, 1877, with a scrotal hernia on theright side. There was impulse on coughing. Five yearsago he ruptured himself in applying the brake of a car.The hernia was reduced, and a truss was worn. The bowelcame down once between that occasion and this, but wasproperly reduced.Immediately atter admission the patient was placed under

the influence of an anaesthetic, and taxis was employed invain. When Mr. Maunder saw the case he advised rest inbed, with the thighs flexed and comfortably supported on apillow; a crutch pad to support the scrotum with its con-tents in order to favour the return of blood by the omentalveins; and the application of an ice-bag. The rationale ofthe treatment was explained to the patient. He was en-joined to eat and drink as little as he could possibly do with,so as to reduce himself, and promote absorption of the fat ofthe body generally, but especially that contained in the pro-truded omentum. A saline aperient was also given often.In about ten days the tumour began to diminish in size,

and was pushed up higher into the canal by a repetition oftaxis, the intestine being now reduced. On June 12th thepatient was again submitted to taxis, with partial success.He was getting tired of bed and of the treatment, but wasencouraged to submit a little longer. On July 10th reduc-tion was again tried, with success, and a truss was ordered.In some remarks on this case, Mr. Maunder laid stress on

the importance of trying all reasonable means to reduce ahernia, and said that he had learned this particular planfrom a former surgeon to Guy’s Hospital. He had latelyhad an equally successful case in private practice, but at theexpenditure of much less time. Unfortunately the processwas often a slow one, and patients frequently tired of therestriction placed on their diet.

LEEDS GENERAL INFIRMARY.CASE OF PNEUMONIA ; ENLARGEMENT OF GALL-BLADDER ;

PARACENTESIS ; RECOVERY.(Under the care of Dr. HEATON.)

FOR the following notes we are indebted to Dr. E. H.Jacob, resident physician.

P. S-, an Irishman, aged twenty-two, was admitted onAugust 2nd, 1877. He had enjoyed good health till six daysbefore, when he fell into a quarry, some seven feet, injuringhis right side. From that time he suffered from great painand shortness of breath, and was unable to lie on the leftside. He had very little sleep, and reported that for threedays after the accident he was delirious at night. He hadhad no rigors.On admission he was rather thin, pale, and ansemic ;

respiration 40; pulse 110; temperature 1006° (in the evening101°). He complained of pain in the abdomen and rightside, worse on inspiration and at night. On the right sideof the chest motion was impaired. There was dulness overthe whole of the right lung, from the level of the third ribdownwards in front, and from half way down the scapulabehind. At the upper part of this area breathing was tubularwith slight ægophony; below, breath-sounds, vocal resonance,and fremitus were very faint. The left lung and heart werehealthy. The abdomen was hard and tender, especially overthe liver, but there was no enlargement of the latter.Aug. 6th.—Temperature has averaged 101° in the evening,

995° in the morning ; pulse 120 ; respiration 40. He com-plained of great pain and swelling in his left side. There isa hard elastic swelling over the region of the liver, extend-ing to the umbilicus, six inches below the edge of the ribs,but not extending beyond the middle line. He says hisbreathing is rather easier. Breathing is clear and tubularat base of the right lung. He cannot sit up, and can onlylie on his right side. There is a slight tinge of icterus inhis conjunctivæ. He vomited his food to-day. Bowels con-fined. He was ordered a saline mixture, with some opium,and a jalap purge. Extract of belladonna and glycerine tobe applied to the abdomen.

8th. -Bowels open freely ; motions of light colour.9th. -The swelling now reaches the level of the anterior

iliac spine. No more vomiting. No cough. There is freefluctuation over the abdominal swelling, and a wave obtain-able by palpation from side to side.13th.-A trocar was inserted in the most prominent part

of the hepatic swelling, and five pints and a half of fluidevacuated. The liquid is of dark-green colour; sp. gr.1002; solidifies into jelly on standing; contains muchalbumen, and gives bile reactions with nitric acid and sul-phuric acid with sugar. He was ordered five grains of iodideof potassium with half a drachm of aromatic spirits ofammonia thrice daily.

14th.-Feels better. No swelling can be detected belowthe ribs. No change in the lung.15th.-He had a slight rigor this morning. The swelling

has reappeared, and extends to the umbilicus, with obscurefluctuation.

21st. - The swelling has further increased, and forms aprominent globular tumour, extending to the level of theiliac crest and two inches to the left of the middle line.Paracentesis was again performed, seven pints being drawnoff. The fluid was of similar colour to that previously ex-tracted, but contained glairy masses, the last pint especially,necessitating frequent clearing of the tube. Iodide of potas-sium omitted, and an effervescing saline ordered.27th. -The swelling has again appeared, extending as far

as the iliac crest, but not across the middle line to the left.General conditions of patient about the same; the tempera-ture irregular, varying at night from 99° to 100°, and notapparently influenced by the tapping.31st.-The swelling is now about the same dimensions as

before the last tapping. Eight pints and a half were nowdrawn off, the fluid being of similar consistence, but of muchlighter culour than the last. The temperature is now normalboth night and morning.

Sept. 5th.-There is now dulness on percussion below theribs on the right to about half an inch below the umbilicus,but little feeling of fulness or fluctuation. Still signs of con-solidation of the lung from the fourth rib in front and thespine of the scapula behind. There is considerable tender-ness over the liver, but he takes food fairly. His tempera-ture is rising, averaging 101 5° at night.llth.-The abdominal swelling is smaller. Bowels rather

loose; motions light-coloured.12th.-Motions of very dark colour to-day, but loose.24th.-Temperature irregular, averaging 100. A.1L, 101’5"

P.M. Abdominal swelling about the same.Oct. 6th.-Evening temperature averaging 102°; swelling

rather larger.16th.-The swelling is rather smaller, reaching from the

level of the umbilicus on the right side in a curved directionup to the ensiform cartilage. There are the same signs ofconsolidation of the lung, but vocal fremitus is less per-ceptible. Patient is much emaciated and very short ofbreath. The temperature remains the same.Nov. 3rd.—Ordered five grains of iodide of potassium,.

with half an ounce of concentrated syrup of sarsaparilla.12th.-Dulness now extends only two inches below the

ribs, and as far as two inches to the right of the median line.16th.—Dulness hardly perceptible below the ribs. Even-

ing temperature averages 101° F.24th.-No dulness below the ribs. There is now fair

resonance over the right lung as far as the angle of thescapula. Breathing is to a certain extent vesicular, butvocal resonance is much increased. Temperature now below100° morning and evening.Dec. 4th.-Feels pretty well. Can walk well. Still some

signs of consolidation at the base of the right lung. In theabdomen, two inches to the right of middle line, a hard sub-stance (? edge of liver) can be felt.20th.-He has gained 6¼ lb. in the last week, and feels

very well.24t1.—Had a rigor to-day. Temperature 103°.26th.-Has been unwell for the last two days. Feels sick.

Spits some muco-purulent matter, and there is some oozingof blood from the gums. There is general dulness over the lower half of the right lung behind, with obscurity of breath-sounds, vocal resonance, and fremitus. No abdominal dul-ness in front. Saline eflervescent ordered.

Jan. lst, 1878. -Temperature has averaged 102° since lastnote, but is now normal.

Feb. 1st.—Has steadily improved, and now feels pretty! well. He has a little pain in both hypochondria on forced