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AN UNUSUAL CASE OF DIAPHRAGMATIC HERNIA.
1782
greatly distended, and the latter showing signs of strangulaAN UNUSUAL CASE OF DIAPHRAGMATIC tion. These practically filled the left side of the thorax, except for about ten ounces of blood-staiued fluid which were. HERNIA. present. The left lung was firmly pressed back against the BY H. B. G. NEWHAM, M.R.C.S. ENG., L.R.C.P. LOND., spinal column ; it was quite airless, small, and deeply pigmented. The heart was healthy, though small, and pushed D.P.H. CANTAB. The right lung was over well to the right of the sternum. and was wit]&, adhesions down bound by pleuritic THE patient was a plasterer’s labourer; he was :a completely The lung on this. removed from the body. difficulty steady, hard-working man with no history of previous side was rather smaller than usual and somewhat congested. illness. On July llth, 1904, he was engaged in taking dowr. On examination of the diaphragm an opening slightly to the some scaffolding when he overbalanced and fell to thE left of the middle line, with smooth edges and easily the index finger, was found, through which thesome He of 30 feet. was a distance admitting immediately ground, and intestine had escaped into the thoracic cavity. stomach removed on an ambulance to the David Lewis Northern The liver was of average size and healthy, but somewhat Hospital and I am enabled, through the courtesy of Dr. more to the right side than usual. All the other organs, T. J. Barry, the house surgeon, under whose care he was, including the brain, were quite healthy. to give a few notes of his condition on admission and also to The hole in the diaphragm appears undoubtedly to have
been made at the time of the accident and was probably case whilst he was in that institution. When admitted (at 3.30 P.M.)he was found caused by sudden violent muscular contraction. It seems, to have sustained a fracture of the left femur through the however, almost incredible that such a large hernia, which middle third of the shaft of that bone accompanied by must have existed for some time to produce such pressure be comconsiderable bruising of the chest and abdomen but without symptoms-e.g., compression of lung, &c.-could with life. He patible of fracture of the was also and ribs. signs any vomiting Liverpool. in a generally greatly collapsed condition. On examination of the abdomen some dulness was made out in the flanks which shifted on moving the patient. The diagnosis was made of probably ruptured spleen, but owing to the general A CASE OF CONGENITAL HYPERTROPHIC grave condition of the patient operative interference was out STENOSIS OF THE PYLORUS IN WHICH of the question. Minim doses of iodine were successfully PYLOROPLASTY WAS UNSUCCESSemployed to control the vomiting and later in the day, the to in the a FULLY PERFORMED. abdomen, owing great pain hypodermic injection of morphine (a quarter of a grain) with atroRUTHERFORD MORISON, F.R.C.S. ENG. AND EDIN., pine was administered. Towards midnight his condition SURGEON TO THE ROYAL INFIRMARY, NEWCASTLE-ON-TYNE. became more serious, with small pulse, great collapse, and a temperature of 102° F. To meet this two pints of normal saline solution were transfused. This revived him AT the present time when so much attention is being paid somewhat but an hour later he had a rigor. On the next to the subject of congenital stenosis of the pylorus, and morning (the 12th) the patient was found to be somewhat improved and the temperature was normal, at which especially when its treatment by operation is prominently it practically remained throughout his stay in the hospital. before the profession, it seems proper to report every case The vomiting started again on the 13th and did not cease of surgical intervention irrespectively of the result. I was until towards the evening of the following day in spite asked to see the following case with Mr. A. Dryden. He of the administration of suitable remedies. On the 18th the had made a correct diagnosis and, recognising the inpatient complained of a good deal of pain in the lower part efficiency of hygienic and medicinal means, was anxious of the abdomen, accompanied by diarrhoea. Hypodermic injections of morphine (a quarter of a grain) were employed I that an operation should be performed. The patient was a male infant, seven weeks old. The to relieve the pain. Towards evening vomiting again started and persisted for four days in spite of the fact that nothing parents were healthy and there was no history of was given by the mouth, the patient being fed with nutrient syphilis. Delivery was assisted by forceps and at birth enemata. From this time onwards until his discharge on the child appeared to be quite healthy. He vomited Sept. 16th he progressed fairly favourably, except for some more or less from birth. From the first he was fed considerable pain over the cardiac region, somewhat in- on Mellin’s food from a screw-stoppered bottle. The creased on taking his food which consisted of milk, bread- bowels were very constipated and they never acted without medicine. Enemata, castor oil, magnesia and, and-butter, and milk pudding. After leaving the hospital he still continued to complain of alterative powders were successively used, but without any pain over the cardiac region, which increased on taking food benefit. Up to the age of five weeks the vomiting only but was unaccompanied by any vomiting. In consequence of occurred as a rule every two or three days, but sometimes this he took very little nourishment and wasted consider- more frequently. During the sixth week the child proably. On Nov. 16th he was suddenly seized with most severe gressively lost flesh. A one-cow milk diet was tried and pain in the abdomen, accompanied by dry retching and there was no vomiting for two days; at the end of this intense thirst, and was taken by his wife to see a medical time it restarted and occurred regularly every 24 hours man who. on examining him, advised him to go to hospital; between 4 and 5 A.M. In the seventh week the child was this, however, he refused to do and remained in his own home. very ill ; he vomited after every meal and rapidly lost The medical man gave him some medicine and ordered him flesh. At the time of the operation he was extremely castor oil, on taking which he became much worse and, as emaciated and lethargic. The stomach was seen to be dishis wife expressed it, " quite writhed in agony." After tended and was every now and then mapped out by a wave of application of hot fomentations, however, he became some- contraction. No mass could be felt at the pylorus. The what easier. The symptoms continued more or less severe condition was so desperate that an immediate operation all the next day and on the 18th he suddenly became un- seemed to offer the only chance of recovery. Shortly before conscious and died in about half an hour. From the 16th, the operation two ounces of normal saline solution were when he was taken ill, till the 18th, when he died, he had injected under the skin of the chest wall just below the no movement of the bowels and the only nourishment taken clavicles. Great pains were taken to prevent shock and aswas a little milk. little chloroform as possible was used. A median incision - ’
BY J.
,
greatly distended, and the latter showing signs of strangulaAN UNUSUAL CASE OF DIAPHRAGMATIC tion. These practically filled the left side of the thorax, except for about ten ounces of blood-staiued fluid which were. HERNIA. present. The left lung was firmly pressed back against the BY H. B. G. NEWHAM, M.R.C.S. ENG., L.R.C.P. LOND., spinal column ; it was quite airless, small, and deeply pigmented. The heart was healthy, though small, and pushed D.P.H. CANTAB. The right lung was over well to the right of the sternum. and was wit]&, adhesions down bound by pleuritic THE patient was a plasterer’s labourer; he was :a completely The lung on this. removed from the body. difficulty steady, hard-working man with no history of previous side was rather smaller than usual and somewhat congested. illness. On July llth, 1904, he was engaged in taking dowr. On examination of the diaphragm an opening slightly to the some scaffolding when he overbalanced and fell to thE left of the middle line, with smooth edges and easily the index finger, was found, through which thesome He of 30 feet. was a distance admitting immediately ground, and intestine had escaped into the thoracic cavity. stomach removed on an ambulance to the David Lewis Northern The liver was of average size and healthy, but somewhat Hospital and I am enabled, through the courtesy of Dr. more to the right side than usual. All the other organs, T. J. Barry, the house surgeon, under whose care he was, including the brain, were quite healthy. to give a few notes of his condition on admission and also to The hole in the diaphragm appears undoubtedly to have
been made at the time of the accident and was probably case whilst he was in that institution. When admitted (at 3.30 P.M.)he was found caused by sudden violent muscular contraction. It seems, to have sustained a fracture of the left femur through the however, almost incredible that such a large hernia, which middle third of the shaft of that bone accompanied by must have existed for some time to produce such pressure be comconsiderable bruising of the chest and abdomen but without symptoms-e.g., compression of lung, &c.-could with life. He patible of fracture of the was also and ribs. signs any vomiting Liverpool. in a generally greatly collapsed condition. On examination of the abdomen some dulness was made out in the flanks which shifted on moving the patient. The diagnosis was made of probably ruptured spleen, but owing to the general A CASE OF CONGENITAL HYPERTROPHIC grave condition of the patient operative interference was out STENOSIS OF THE PYLORUS IN WHICH of the question. Minim doses of iodine were successfully PYLOROPLASTY WAS UNSUCCESSemployed to control the vomiting and later in the day, the to in the a FULLY PERFORMED. abdomen, owing great pain hypodermic injection of morphine (a quarter of a grain) with atroRUTHERFORD MORISON, F.R.C.S. ENG. AND EDIN., pine was administered. Towards midnight his condition SURGEON TO THE ROYAL INFIRMARY, NEWCASTLE-ON-TYNE. became more serious, with small pulse, great collapse, and a temperature of 102° F. To meet this two pints of normal saline solution were transfused. This revived him AT the present time when so much attention is being paid somewhat but an hour later he had a rigor. On the next to the subject of congenital stenosis of the pylorus, and morning (the 12th) the patient was found to be somewhat improved and the temperature was normal, at which especially when its treatment by operation is prominently it practically remained throughout his stay in the hospital. before the profession, it seems proper to report every case The vomiting started again on the 13th and did not cease of surgical intervention irrespectively of the result. I was until towards the evening of the following day in spite asked to see the following case with Mr. A. Dryden. He of the administration of suitable remedies. On the 18th the had made a correct diagnosis and, recognising the inpatient complained of a good deal of pain in the lower part efficiency of hygienic and medicinal means, was anxious of the abdomen, accompanied by diarrhoea. Hypodermic injections of morphine (a quarter of a grain) were employed I that an operation should be performed. The patient was a male infant, seven weeks old. The to relieve the pain. Towards evening vomiting again started and persisted for four days in spite of the fact that nothing parents were healthy and there was no history of was given by the mouth, the patient being fed with nutrient syphilis. Delivery was assisted by forceps and at birth enemata. From this time onwards until his discharge on the child appeared to be quite healthy. He vomited Sept. 16th he progressed fairly favourably, except for some more or less from birth. From the first he was fed considerable pain over the cardiac region, somewhat in- on Mellin’s food from a screw-stoppered bottle. The creased on taking his food which consisted of milk, bread- bowels were very constipated and they never acted without medicine. Enemata, castor oil, magnesia and, and-butter, and milk pudding. After leaving the hospital he still continued to complain of alterative powders were successively used, but without any pain over the cardiac region, which increased on taking food benefit. Up to the age of five weeks the vomiting only but was unaccompanied by any vomiting. In consequence of occurred as a rule every two or three days, but sometimes this he took very little nourishment and wasted consider- more frequently. During the sixth week the child proably. On Nov. 16th he was suddenly seized with most severe gressively lost flesh. A one-cow milk diet was tried and pain in the abdomen, accompanied by dry retching and there was no vomiting for two days; at the end of this intense thirst, and was taken by his wife to see a medical time it restarted and occurred regularly every 24 hours man who. on examining him, advised him to go to hospital; between 4 and 5 A.M. In the seventh week the child was this, however, he refused to do and remained in his own home. very ill ; he vomited after every meal and rapidly lost The medical man gave him some medicine and ordered him flesh. At the time of the operation he was extremely castor oil, on taking which he became much worse and, as emaciated and lethargic. The stomach was seen to be dishis wife expressed it, " quite writhed in agony." After tended and was every now and then mapped out by a wave of application of hot fomentations, however, he became some- contraction. No mass could be felt at the pylorus. The what easier. The symptoms continued more or less severe condition was so desperate that an immediate operation all the next day and on the 18th he suddenly became un- seemed to offer the only chance of recovery. Shortly before conscious and died in about half an hour. From the 16th, the operation two ounces of normal saline solution were when he was taken ill, till the 18th, when he died, he had injected under the skin of the chest wall just below the no movement of the bowels and the only nourishment taken clavicles. Great pains were taken to prevent shock and aswas a little milk. little chloroform as possible was used. A median incision - ’
BY J.
,