while for weeks, or months, or years it is grasp, trying to get into the most inaccessible place which it can get the common duct-there, to set up the tortures of the damned, to say nothing of the terrible risks he lets his patient

run.

Remember the number of cases quoted where a distended gall bladder has been ruptured by a slight tap, and set up a fatal peritonitis; of cases where ulceration has taken place, and death followed while the stone has been waiting for the surgeon to remove it, to say nothing of malignant disease which is so often set up. Are we to wait until all this happens, when an early operation, which is simple and safe, could be done, and all the danger and suffering obviated?

A great deal depends upon the physician and general practitioner who see these cases early, and who, if not certain that he can feel the gall bladder, should place the patient under an anæsthetic and make sure and, if it is enlarged and painful, should have it operated upon without loss of time, and not wait and watch and give oil, while the patient either dies or becomes a morpho-maniac, with the risk of dying at any time.

Most general practitioners now recognise the fact that a person who has had two attacks of appendicitis-why two I don't know, but that is somewhat towards the right path-should be operated upon. Why not give the other poor wretches who have had two attacks of gall stone colic or cholecystitis the same chance of relief and safety. If one had a patient with stone in the bladder would one give him oil to lubricate his passages, and wait until he passed the stone per urethram? I think the most conservative would hardly do that, and I see but little difference; or would one wait for very a stone to work its pleasant and invigorating passage from the kidney to the bladder before interfering with it? It may pass some day of

course.

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A CASE OF DIAPHRAGMATIC HERNIAOPERATION-DEATH.

By C. P. B. Clubbe, M.R.C.S., L.R.C. P. Lecturer in Clinical Surgery and Hon. Surgeon Prince Alfred Hospital, Sydney;

And

Sinclair Gillies, M.D. (Lond.) Hon. Assist. Physician Prince Alfred Hospital.

M.G., æt. 70, a hale-looking old man, walked into Prince Alfred Hospital on 28th September, 1901, complaining that his bowels had not acted for a week. He was living in a tent at Marrickville, and had just come into an old-age pension. As he had been vomiting he was admitted for observation.

He gave the following history:-Has always been a healthy man, but always subject to constipation. Twenty years ago he fell from a height, fracturing three ribs on the left side and injuring his head. He was very ill at that time, but completely recovered. His occupation until recently had been that of a gardener. Four days before admission, while lying in bed sewing, he was seized with sudden pain in the left side of the abdomen. The pain was very severe, and kept him awake all night. It has persisted till admission. Vomiting commenced on the same evening, and has continued. Two days before the pain came on he noticed that his stomach was swelling. He has had a cough for two months past. He gave no history of sudden onset of dyspnoea.

His bowels had not acted for a week before admission, but he could not say whether he had passed flatus or not. No history of further illness or injury was obtainable.

On the afternoon of admission he vomited fæculent material. He was given calomel gr. v., and an enema by the house physician, which resulted in a motion accompanied by flatus. Later in the evening his bowels acted spontaneously, but vomiting continued. Next morning he had two more enemata, followed by passage of flatus, but no motion. Fæcal vomiting continued.

When seen by us for the first time on the afternoon of the 29th September his condition was noted as follows:-Patient is a well developed, muscular old man. He lies in bed in evident pain. His face is bronzed and shows no signs of anxiety. His tongue is coated with thick dirty fur, his breath is very offensive. His chest is barrel-shaped, and on inspection the right side is seen to move better than the left. Vocal vibrations are diminished on the left side. The percussion note is hyper-resonant over the left front of

the chest, especially below the nipple. The cardiac dulness is absent, but on the right side there is a dull area bounded above by the fourth rib, to the right by a line just internal to the nipple, to the left by a line one inch to the right of the sternum. There is some indistinct impulse over the dull area, but no distinct apex beat is made out. The heart sounds are best heard over this dull area, the maximum being along its inner edge. Below the level of the nipple on the left side of the front of the chest a markedly tympanitic percussion note is present, and this is continued uninterruptedly on to the much distended abdomen.

Breath sounds are vesicular on the right side On the left they are very faint at the apex, and absent below the second rib. From the second rib downwards there is well-marked metallic tinkling, which is of a more gurgling character than that usually heard in pneumothorax. It is heard better in some parts of the left side of the chest than in others, notably below and outside the left nipple. It can be traced uninterruptedly on to the distended epigastrium, where it assumes a deeper pitch. Bruit d' airain is heard all over the left side below the level of the third rib and over the epigastrium Behind, the percussion note and breath sounds are normal over the right side. On the left the note is hyper-resonant, and the side moves less than the right. Breath sounds are very weak over the left back. At the base metallic tinkling is occasionally heard, and bruit d' airain is present.

Succussion splash is made out at the base behind.

Respirations are twenty per minute, and only slightly embarrassed.

Heart.-Dulness is present on the right side of the chest as described above. Sounds are weak and irregular. Pulse is 80, feeble, very irregular in force and rhythm.

The abdomen is much and irregularly dis tended, the epigastrium and both iliac regions presenting prominences due apparently to distended bowel.

The tympanitic chest note, bruit d'airain, and metallic tinkling can be traced uninterruptedly from the left side of the chest on to the epigastric bulging. The percussion note is tympanitic all over the abdomen. The upper part of the abdomen moves well on respiration, the lower part very slightly. Liver dulness is one inch and a half in the right nipple line. Inguinal and femoral rings are normal. A peritoneal rub is palpable over the epigastrium. The extremities are normal.

Urine, specific gravity 1020, slight haze of albumen.

Temperature, 99o.

The left side of the thorax was tapped by a fine needle and air withdrawn, which was odourless.

The patient obviously had intestinal obstruction, and in addition the physical signs of a pneumothorax of an abnormal nature. This abnormality consisted in the fact that metallic tinkling could be traced continuously from the thorax on to the upper part of the abdomen, increasing in loudness as the abdomen was approached, and that it was heard with considerably varying intensity on areas close to one another on the chest wall. The same variation was noted in the bruit d'airain.

The most probable explanation seemed that these sounds, both in the chest and abdomen, were produced in widely dilated bowel, the variations in intensity being determined by the limits of the distended viscera. A diagnosis of diaphragmatic hernia with strangulation was therefore made, and it was decided to attempt its relief though the patient's condition was very bad.

The patient having been anesthetised, Mr. Clubbe made an incision from the ensiform cartilage to the umbilicus. Hugely diluted small intestine presented. On inserting his hand he found that he could pass it up through a fissure in the left side of the diaphragm into the thoracic cavity where a much dilated stomach and intestines were found firmly fixed.

Following the advice of Trauman (the patient being in too collapsed a condition to allow of ribs being excised, and a hand introduced into the pleural cavity) the left side of the chest was tapped by a large trocar, and an attempt made to draw the viscera into the abdomen. This was found impossible and the trocar was withdrawn. A second attempt at reduction was made, and the trocar was again inserted through the same wound. This time it pierced the stomach wall and the stomach contents drained through the tube. Further attempt at reduction being deemed useless the wound was closed, the trocar left in situ, and the patient sent back to bed. He died fourteen hours later.

Post-mortem.-On opening the thorax, the greater part of left side of the chest was occupied by a much dilated stomach, the left lung being pressed upwards and inwards, where it was firmly fixed by adhesions to the pleura around and to the stomach below. The lower and half the upper lobe were much compressed, only the apex of the upper lobe appearing to be functional.

The heart and pericardium were displaced to the right, so that only one-third of the left ventricle lay to the left of the sternum. The right lung was everywhere adherent to the pleura by fine adhesions.

On opening the abdomen masses of widely dilated small intestine presented. There was no peritonitis present.

We have here the contents of the thorax and abdomen, with the diaphragm, ribs, and vertebræ complete. Sufficient dissection has been carried out to shew the relations of the various organs. This has involved breaking down the dense adhesions which bound the organs to one another and to the pleura.

In the left side of the diaphragm is a large oval opening about four inches in longest diameter. It begins close to the vertebral attachment and its anterior edge, which is sharp and thick, curves outwards to the ninth rib, where it turns backwards towards the vertebræ. At the ninth rib only about half an inch of diaphragm intervenes between the opening and the ribs. Through this opening the hand can be passed, and no sign of constriction exists here. Through it and through the pleura covering the diaphragm has passed the stomach, which was much dilated, and occupied the whole of the front of the chest as high as the third rib. It had pressed the left lung upwards and inwards against the mediastinum, which, with the heart, was displaced to the right. The stomach was densely adherent to the parietal pleura and to the outer and under surface of the lung. Part of the pleura is left to shew the denseness of the adhesions.

Extending up behind the stomach lay twelve to eighteen inches of collapsed transverse colon, which could be traced through the opening to the collapsed colon in the abdomen.

Behind the colon and well above the diaphragm lay the spleen, packed tightly by dense adhesions against the pleura covering the upper part of the ninth and tenth ribs. So closely adherent was it to the pleura that it was discovered only late in the dissection. Along its hilum it was adherent to the posterior edge of the diaphragmatic opening and from its lower end an adhesion passed to the outer edge of the opening.

Between this adhesion the attached hilum and the edge of the diaphragm between them, a knuckle of small intestine had passed and become strangulated. It lay in a small pouch bounded by the diaphragm below, and the parietal pleura externally, and the spleen above, from which it

The

8

The

was separated by a piece of omentum. entering portion of the gut can be traced through the diaphragmatic opening as distended coil continuous with the dilated small intestine, duodenum, and stomach. distal portion is continuous with the collapsed small intestine and colon seen in the abdominal cavity. Death was, therefore, due to strangulation of a knuckle of small intestine by a band within the thorax, and not directly to the hernia itself.

About an inch of dilated duodenum beyond the pylorus was found in the thorax. Behind the collapsed colon, and between the stomach and posterior edge of the spleen, three inches of pancreatic tail lay vertically.

The left kidney lay just below, but did not ass through the opening.

The relationship of the viscera in the opening was as follows:-Internally was the duodenum, externally and in front the dilated and contracted portions of small intestine, passing in front of the contracted large intestine behind and internal to which lay the pancreas.

No trace of old fracture was detected in the ribs.

Remarks. The case is remarkable in several

repects. The hernia was evidently of long standing, and must have existed for years without causing symptoms. It may have dated from the injury twenty years before, but no sign of old fracture could be detected in the ribs.

Though 72 years of age, the man was active, and had till recently worked for his living. Close questioning failed to elicit any cause for onset, except perhaps, the accident mentioned above.

Death was due, not to theh ernia, but to strangulation by a band within it. Operation might have relieved the strangulation had its seat been discovered, but no operation could have reduced the hernia owing to the number and denseness of the adhesions between the viscera and the parietal layer of pleura.

The risk of tapping the pleural cavity to equalise pressure in such cases is well shewn by the results of tapping of the stomach in this

case.

Doubtless the right procedure in such cases is to resect several ribs and attempt reduction through the thorax.

No pleural covering existed over the hernia between it and the lung. It therefore belongs to the class of false hernia, which, according Leichtenstein, are ten times more common than the true. According to the same authority, out of 250 cases collected by him the condition was diagnosed on five occasions only.

We think the case worthy of record as the literature on the subject is scanty and the number of cases few in which a diagnosis has been made during life and an operation attempted for its relief.

AN ARTIFICIAL LARYNX.

By G. T. Hankins, M. R.C.S., Surgeon to the Nose, Ear and Throat Department, Prince Alfred Hospital, Sydney.

THIS apparatus is for use in those cases of total extirpation of the larynx where all sinuses between the oral cavity and the external air are closed, and all direct communication between the lungs and upper air-passages cut off. It consists, essentially, of a small three-necked Wolff's bottle. Through a perforated cork in the middle neck passes a tube bearing the reed which hangs downwards in the centre of the bottle, the outer end of the tube being connected with a No. 14 (English) soft rubber catheter cut off obliquely at the end.

To one of the necks of the bottle is fitted a stiffish rubber tube four inches long and quarterinch internal diameter, ending in a vulcanite nipple for plugging into the tracheal tube. The third neck of the bottle is left open.

The reed is one taken from a penny toy known as a "screecher." It is of the "beating variety, on the same principal as the clarionet reed, and made of metal. Unlike the "free" reed of the harmonium, or mouth organ, it is of very strong tone, and cannot be over-blown. The long narrow tube of the catheter to which it is attached merely lowers the pitch without stopping the vibrations, as would be the case with the harmonium reed. The tongue of the "screecher" reed requires a little manipulation before a satisfactory effect can be obtained, but when obtained the result is permanent.

In using this apparatus the patient smears the catheter with vaseline, and passes it along the nose for six inches, where it is fixed in position by a vulcanite olive through which the catheter and which is plugged into the passes, orifice of the nostril.

The patient next inserts the nipple at the end of the short tube into the trachea opening on to the skin of the neck. He can then breathe easily and without noise so long as the third neck of the bottle is open.

When he wishes to speak this opening is closed by the forefinger of the hand holding the bottle, and on expiration the air is forced

through the reed and enters the pharynx in a state of vibration just below the uvula, producing a bass note in fair imitation of the male voice.

The patient for whom the apparatus was made, can now articulate, not very clearly in this case on account of one-sided paralysis of the tongue, but he can recite the only piece he knows, ie, the Lord's Prayer, and make himself well understood. I know the idea of getting access to the pharynx through the nose is not original, it having been carried out by Glück and mentioned in the Berliner Klinischer Wochenschrift for March, 1900. I have not been able to obtain access to the article, but I understand the reed was contained in the olive which fitted the nostril. By this plan an ordinary "free" reed could be used, as the column of air to be set in vibration would be only six inches long, but the tone of such a reed is very unnatural and doll-like.

By placing the reed in a bottle it is kept perfectly free from contact with secretions and condensed moisture, and the whole apparatus can be easily taken to pieces and kept clean.

NOTES ON PARTIAL HEPATECTOMY, WITH THE REPORT OF A SUCCESSFUL CASE. By W. J. Stewart McKay, M.B., M Ch., B.Sc. Syd.' Senior Surgeon, Lewisham Hospital for Women, Sydney.

THE patient, a female, aged 36, suffering from phthisis, consulted me four years ago on account of a swelling in the epigastric region. I considered it to be a hydatid of the liver, and advised an operation.

The patient returned to me three months later and said that she had been operated on at the Sydney Hospital for "floating kidney;" but on examining her I again found a tumour, and advised an operation. The woman readily consented, because she was in great pain; so great, in fact, that I expected to find that an abscess had formed. On percussion, I discovered that the tumour was situated to the left of the median line, in the epigastric region, and that its lower border was well defined and reached to the umbilicus; but there was a distinct tympanitic zone between the liver and the tumour, which made me think that I was about to deal with a growth in the transverse colon.

The patient was operated on at the Lewisham Hospital. An incision was made in the median line, beginning 2in. above the umbilicus and extending down to the lower border of the mass. On coming down to the peritoneum it was seen that the great pain that she had suffered was due to a very extensive local peritonitis. After separating the adhesions, which bled very freely, the tumour was found to be about the size of two fists, and to be part of the left lobe of the liver; there was, however, no pedicle. The tumour was delivered through the abdominal incision, and I proceeded to pass silk ligatures through the liver well beyond the growth, which could be distinguished by its firmer consistence. When, however, I began to tighten up these ligatures they cut through the liver substance so easily that it was evident that they would not control the hæmorrhage if I attempted to remove the growth. I accordingly transfixed the liver with some hat pins, and then passed the ends of the silk ligatures through the abdominal wall and tied them, and by these means I was able to firmly anchor the tumour, which was dusted with tannic acid and boracic acid and covered with gauze.

The patient suffered great pain from the dislocation of the liver, but otherwise she exhibited no alarming symptoms. On the third day after the operation I took a large amputating knife

and removed half the tumour; there was considerable oozing, which I checked with the cautery; the cutting of the liver gave the patient no pain whatever. Each day after this a slice was removed, and by the seventh day after the operation I had reached almost to the pins.

As the liver appeared to be firmly adherent to the abdominal walls, I removed the silk ligatures, as one of them had become infected by the stump and had caused a stitch abscess. The stump was kept as sweet as possible by washing it with peroxide of hydrogen. The patient returned home after six weeks, and I have seen her from time to time during the last three years and nine months.

Two years after the operation her legs and abdomen swelled very much, and she was forced to take to her bed; but after some months the dropsy and the ascites disappeared, and she has now no sign of any swelling in the legs.

The growth was examined by Dr. Camac Wilkinson, who pronounced it to be a sarcoma. I believe that the growth has returned, for the liver is now very enlarged and the patient much wasted. Other cases have been recorded where the patient lived for some time after the removal of a malignant neoplasm of the liver: Hochenegg's and Lüke's cases were alive after three years, while Schrader's case was well seven years after the operation.

One point may be noted about this case, i.e., that she was first operated upon under the impression that the tumour was a floating kidney; while, when I came to deal with the case I thought that the growth was in the transverse colon.

These mistakes have been made by others in dealing with solid tumours of the liver. Thus, Eiselberg thought that he was about to operate on an omental tumour, but it turned out to be an angioma of the liver; Israel diagnosed a renal tumour, and found a vascular sarcoma of the liver; Keen diagnosed a floating kidney, and found an adenoma of the liver. These mistakes occur because a very marked tympanitic area occurs between the tumour and the liver, and Terrier and Auvray record six cases illustrating this point.

I have not recorded this case because I am in favour of this method of treating neoplasms of the liver, for we must always regard the extra-peritoneal method of treating a pedicle, whether of the uterus, the liver, or any other organ, as an indication that we have adopted a safe, but a primitive and imperfect method.

Turning, now, to the reports of cases of partial hepatectomy, it appears that the operation