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HYDROPS VESICÆ FELLEÆ.PYLORIC OBSTRUCTION; ASPIRATION OF GALL-BLADDER;

RELIEF OF SYMPTOMS.

BY J. M. CLARKE, M.B., M.R.C.S., L.R.C.P. LOND.

MRS. B-, an old lady of healthy habit of body, agedsixty-seven, a moderate drinker of alcoholic stimulants,with a history of cancer in the family, developed symptomsof jaundice, accompanied by an enlargement of the liver,the latter being of a somewhat nodulated character, situatedin the region of the lower hepatic border. This fact, togetherwith the history of the case, the resistance of the icterus totreatment by saline purgatives, podophyllum, calomel, andblue pill, led to the surmise that (considering the age of thepatient) we had to deal with a tumour or tumours of acancerous nature; and in the absence of symptoms, afterthe jaundice had persisted for three to four months, treat-ment consisted simply in keeping the bowels open bymeans of saline purgatives. About this time a pyriformnew growth of a fluctuant character was noticed in theregion of the gall-bladder, and projecting below the lowerborder of the liver. This increased slowly but percep-tibly until it attained the size of a goose’s egg, whensymptoms of pyloric obstruction with vomiting wereadded to the patient’s troubles. The diagnosis of thesecondary tumour was hydrops vesicæ felleæ, caused byocclusion of the common bile-duct by pressure of the primarynew growth, and on this diagnosis a preliminary investiga-tion was made by a puncture with a hypodermic syringe,and the tumour was found to be of a fluid character, and thisHaid to answer to the chemical reactions for bile-acids andpigments. On aspiration about fourteen ounces of a yellow,tenacious,translucent fluid were withdrawn,and the symptomsof pyloric obstruction disappeared, as did also the vomiting.The lady some little time after this died from biliarytoxaemia; but as the friends objected to an autopsy, no verifi-cation of the diagnosis of carcinoma hepatis could be made.Manchester.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

ST. THOMAS’S HOSPITAL.RESECTION OF THE INTESTINE FOR GANGRENE IN A CASE

OF STRANGULATED UMBILICAL HERNIA ; DEATHFOLLOWING A MISCARRIAGE FIFTEEN

DAYS AFTERWARDS; NECROPSY.

(Under the care of Mr. SYDNEY JONES.)

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et mor-borum et dissectionum historias, tum aliorum tum proprias collectashabere, et inter se comparare.—MORGAGNI De Sed. et Caus. Morb.,lib. iv. Proœmium.

THE attention of surgeons in this country has been recentlydirected to the treatment to be pursued in cases whereduring the performance of operations for strangulated herniathe gut has been found gangrenous. The case here recorded

must, we think, be placed amongst those of successfulresection of the gangrenous portion of intestine. The patientprogressed satisfactorily for thirteen days after the operation,having been allowed solid food, when the miscarriage tookplace, after which it would appear septic peritonitis de-veloped, causing death two days later. There is considerable

ambiguity about the account given of the condition of theresected portion of intestine as found post mortem; butthe fluid found in the abdominal cavity does not appear tohave had any fæcal odour. For the notes of the case we areindebted to Mr. E. S. Sugden.

L. R-, aged forty-two, married, was admitted onMarch 24th, and died on April 8th, 1885. The patient, a verystout but otherwise healthy-looking woman, was admittedsoon after midday, complaining of pain and swelling in thefront of the abdomen, headache, nausea, and almost incessant

vomiting. She gave the following history. She had beenmarried twice, and had had twelve children. After the birthof the eleventh child, six years ago, she first noticed a smalllump near the umbilicus, which had since become graduallylarger, and for four years she had worn a truss. Four daysbefore admission, after carrying a rather heavy weight, itbecame larger, and the next day vomiting commenced. Onthe 22nd the pain became very severe, and has continued so.The bowels acted on the same day, but not since; the vomitingbecame offensive in smell on that day. There was no vomit-ing on the 23rd, but it recommenced on the morning ofadmission.Examination of the abdomen showed a large, very tense,

lobulated hernial protrusion, irreducible, and situated belowand to the left of the umbilicus, which ivas apparentlydisplaced to the right. The swelling measured eight inchesin the long vertical diameter by six inches in the transverse.It was painful and tender. The vomiting continued,with othersymptoms of strangulation. Accordingly the patient wasplaced under ether, and Mr. Sydney Jones operated. Alongvertical incision was made through the skin and sub-cutaneous tissue in the middle line, commencing just abovethe protrusion. The sac, which was very thin, was thencarefully opened. It contained a large amount of omentum,and within this a knuckle of intestine, measuring about sixinches in length. On opening the sac a fetid odour wasgiven off, and the strangulated bowel was found to begangrenous. The very tightly constricting fibres at theneck of the sac were divided to enlarge the outlet, and it wasthen found that at the points of constriction the bowel wasulcerated through as far as the internal coats. The operatorconsidered that the return of the bowel in this condition washopeless, and decided to remove the knuckle of bowel andsuture the divided ends together. Accordingly clamps wereapplied beyond each constriction, and the gangrenous portionbetween removed with the scissors. All bleeding points weresecured by ligatures, and then the mucous coat of the intestinewas brought together by fine silk sutures placed closely thenother fine silk Lambert sutures were passed through theexternal coats. The ends of the intestine were thus broughtinto very accurate apposition and the sutures tied, the bowelbeing returned to the abdominal cavity. The intestine waskept moist and warm by means of fine flannel cloths wrungout of hot water ; these also prevented the entrance of bloodand other material into the abdominal cavity. The omentumwith the sac was then ligatured in two portions on eachside and removed, the edges of the orifice brought togetherwith sutures, a drainage-tube placed over, and the woundclosed with silk and catgut sutures. Altogether about thirty tothirty-five or forty sutures were applied. lodoform was freelysprinkled on the wound, and pine wood-wool bags applied,with gauze bandages. The operation lasted about two hoursand a half ; the patient did not appear to suffer from shock.On the following day she complained much of thirst,

and was rather restless, more so than during the night.She had had two injections of five minims of solution of

morphia, at intervals of six hours ; she had slept for twohours and a half, and had also dozed a good deal. The pulsewas 86 and of good strength ; the tongue moist. The urine,which had been drawn off with the catheter, was sp. gr. 1026,acid, and no albumen. Her temperature, which was 98.4°the previous evening, was now 994°, and the vomiting hadceased. She was much relieved and without pain. Thebowels had acted slightly.March 26th.—Her condition was satisfactory. She onlv

complained of a slight headache, was less thirsty. Pulse 80,fairly strong. Twenty-nine ounces of urine had been drawnoff, and she had slept nearly the whole night, but had re-quired injections of morphia. Temperature 100c at noonyesterday, not higher than 99° since.

27th.—The bowels acted slightly in the morning, withoutpain. She had slept for nearly eight hours. The pulse was100. Tongue rather dry. She still complained of thirst,and a rather troublesome cough. The headache was better.28th.-Until yesterday afternoon she was only allowed

ice to suck ; since then she has been allowed equal pans ofmilk-and-water every hour. Pulse 92. The wound wasdressed in the afternoon, and was looking well; there wasvery little discharge and no distension of the abdomen: themargin of skin near the umbilicus was looking dark-coloured, and appeared to be losing its vitality.30th.-Since yesterday the patient has been allowed

tablespoonful of barley-water and half a teaspoonful ofBrand’s essence every hour alternately. On the evening oi

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the 29th she had an injection of morphia, and last nighttwo injections were given, the patient being more restless.The urine is still drawn off with the catheter, sp. gr. 1026,alkaline, thick greyish deposit on standing, consistingchiefly of triple phosphate crystals, no blood, no pus.Pulse 96 ; temperature last night 100.2°, this morning 992°.31st.-The wound was re-dressed yesterday afternoon,

and looked well, there being no extension of the skin slough.The tongue, mouth, and skin generally were very dry,the skin also harsh. Pulse 100; micturition normal; no

action of the bowels. Allowed six ounces of beef-tea andthree ounces of wine in addition to the milk, barley-water,and Brand’s essence. Morning temperature 994°; eveningtemperature 988°.

April 1st.—Two injections of morphia were required lastnight. Tongue still very dry. Ten ounces of chicken brothallowed in addition to the other nourishment. The stitcheswere removed in the afternoon and the wound dressed,iodoform and a wood-wool bag being applied.2nd.-She still complains of thirst, and the tongue con-

tinues very dry. She complains also of indigestion, pain,and slight cough. There is still a large deposit of phosphatesin the urine. Temperature 98.8°.

3rd.—Morning temperature 9’l’8° ; evening 97’6°. Thewound was re-dressed in the evening, and looked very well.4th.-The patient was rather more restless, and the cough

was more troublesome. Pulse 88, and rather weaker; tongueand mouth very dry; much thirst. The bowels were clearedby simple enema two days ago. She is now allowed a littlebread-and-butter.6th.-On the night of the 4th the temperature, which had

been normal in the morning, rose to 1030 at 11 P.M. Thelowest temperature yesterday was 100.4°, and this graduallyrose till 3 P.M., when it was 104°, falling to 101-4° in thenight. The wound was dressed and looking well. She isnow allowed nothing by the mouth but milk and Brand’sessence, nutrient enemata having been given every four hourssince the 4th. She has had very little sleep. Pulse 114;respiration 30, chiefly thoracic.7th.-Duringyesterday afternoon she complained of pains

in the lower abdomen; these took on a "forcing" character;and between 1 and 1.30 she was delivered of a foetus, thedevelopment of which corresponded to the fifth month.During yesterday she had slight attacks of shivering, andthe temperature remained above 101°, falling to 99° at 6 A.M.to-day, rising again to 103’20 at 8 o’clock, and to 105° at8’30. The wound was re-dressed and found to be looking well.8th.-She has an anxious and worn look, seems very

weak, and complains of difficulty in breathing (respiration32, laboured) and of a burning pain in the abdomen, withslight hiccough. Tongue very dry and brown down thecentre; has vomited four times; the bowels are acting well.She had a restless night in spite of opium. Pulse scarcelyfelt at wrist, 90 to 100. She complained of feeling cold allthe morning. The dyspnoea increased during the day. Shevomited again. The temperature gradually fell from 104°at 11 A.M. yesterday, to 99.4° at 2 P.M. to-day, when she died.A post-mortem examination was made by Dr. Hadden on

the following day. " Rigor mortis present. A sinus ran

upwards under the healed incision for about three inches.The abdominal cavity contained a considerable quantity ofyellow fluid. There was acute peritonitis, with adherentlymph on both surfaces, most marked in the pelvis, and overthe intestines in the lower half of the abdomen. The in-flammation was most intense near the resected gut. Theuterus was large, extending three or four inches above thebrim of the pelvis. A knuckle of small intestine was prettyfirmly adherent to the under surface of the incision. Theposition of the resected bowel was made out with somedifficulty, on account of the adherent coils, and on trying toseparate what were apparentlytwo coilswhich were adherent,two ends of small intestine were found separated. It isdifficult to say certainly whether they were united, andlacerated during manipulation, or whether they were un-united. At any rate the greater part was pretty firmlyunited. The position of the resection was in the ileum, nearto the ileo-cteal valve. The lungs were emphysematous.The heart was large and flabby, the right auricle andventricle being dilated and hypertrophied. The liver andspleen were large and soft. The stomach and intestines,excepting the seat of operation, were healthy. The uteruswas very large, with much adherent dark clot on the mucousmembrane. The right ovary was adherent to the smallintestine rather firmly, near the resected portion."

ALEXANDRA HOSPITAL FOR CHILDREN,BRIGHTON.

CASE OF BRONCHO-PNEUMONIA WITH HIGH TEMPERATURES,LOWERED BY WARM BATHING.

(Under the care of Dr. EDWARD MACKEY, M.R.C.P.)F. S-, a rachitic boy two years old, was admitted into

the Alexandra Hospital on July 15th, 1885, with his fourthattack of bronchitis, then of three days’ duration. He hadbeen suckled for three months, then fed mainly on tea-biscuits ; later with gravy, bread, and vegetables. He cut thelower incisor at fifteen months; when admitted he had all the’incisors and two first molars. The fontanelle was widely open,the abdomen large, the forearms bent, and the ribs beaded.There was cough, and also quickened breathing (50 perminute) ; retraction of lower cartilages, with some lividityof tint, a very quick pulse, and temperature 103° F. Harshbreathing with some stridor was the main physical sign; gthere was not definite dulness on percussion. Ordered anipecacuanha emetic, to be followed by half a grain of iodideof potassium in a saline mixture; poultices to be appliedafter a counter-irritant liniment, and steam.July 16th.—Rhonchus over both lungs, with dry rales and

sibilus at the bases ; cough short and hacking; respirationpanting. Temperature 101’80, going up to 104° in the after-noon. Stimulating expectorants ordered.17th.-No sleep. Condition feeble; muco-crepitant rales

all over the chest; respiratory sounds louder on the rightside in front than on the left, with rhonchal fremitus;breathing shallow, with recession of the lower ribs. Tem-

perature 104°, going up to 105° in the afternoon.18th.-4 A.M.: Has dozed. Sibilus at left apex; less

retraction of ribs. Temperature 105-20; 8 A.M., 105.4°.The temperature of the room varied from 65° to 75°. At9 A.M. the child was placed in a bath at a temperature of 94°for about twenty minutes, the head only being supported-out. He became easier, and the temperature (always takenin rectum) fell two degrees. At noon, however, it reached106°; at 5.30 P.M. 106’20, when there were slight convulsions ;and the bath was given at 90°, reducing the temperature to101’80. Three hours afterwards it was, however, 105.8°,which the bath reduced to 99’40. At midnight it was again105’20, falling after the bath to 101’40.19th.-3 A.31:.: Temperature 106°; after bath, 102.8°.—

6 A.M.: Temperature 105’20; after bath at 7.30, 101’60.10 A.M.: Temperature 105°; after bath at 11, 98.6°.—2 P.M.: --Temperature 105’80; after bath, 100.8°.—5.30 P.M.: Tempera-ture 105’60; after bath, 100.4.°—9 P.M.: Temperature 106’60;after bath, 100-8°. During the day the cough became looser;no convulsion, but opening and shutting of hands. In the

evening the colour was better and breathing more regular ;coarse crepitation at bases ; no marked dulness over lung ;liver an inch and a half below the costal margin.

20th, 2 A.M.—Temperature 105-6°; after bath, 101°.—7 A.M. : Temperature 105’60; after bath, 99.6°; slight con-vulsion ; is very pale and restless ; respiration panting (88)of Cheyne-Stokes character, much more regular when inthe bath; skin moist; cough "loose"; fontanelle more

depressed; is pale, not livid (?); has taken food well.-11.30 A.M.: Temperature 106°; after bath, 100°4°.-4 P.M. :Temperature 105°; at 7 P.M. 105.4°; after bath, 103° ;respiration 72. Less reaction to bath.-9.30 P.M.: Tempera-ture 106° ; some shivering in bath, after which temperaturewas 103° ; respiration 94; hands opening and shutting ;pulsation of fontanelle; muco-crepitant rales general; de-ficient resonance in parts, especially apices ; the apex beatof the heart is about half an inch outside and below thenipple, and the area of dulness is increased near sternum ;there is epigastric pulsation.-11 p.ns. : Some vomiting andtendency to collapse ; has a little brandy at intervals.21st.-Frequent cough; much distress; tongue thickly

coated; stools offensive; lies on back with eyes partly open,dilated nostril and open mouth; starts in sleep ; colour

dusky. Ordered one leech to epigastric region; air entersall over lung; rales as before; skin now dry; pulse 140,becoming very feeble, but strengthening in the bath; thetemperature, which was 106° in the morning, remainedbetween that point and 105° till 5 P.M.; a hot bath (100°)was given, which reduced the temperature to 102-2°; it con-tinued to rise gradually to 1070 in the morning of July 22nd,when the warm bath reduced it to 104°; respiration being 58,pulse 140; it was again used at 9 A.M. with the effect of