19,3 Maxwell: Filariasis in China 315 
The fourth cause of fever is pneumonia. The utmost care 
must be taken at the time of operation that the patient does not 
get chilled. If he should be so unfortunate as to get pneumonia, 
the case must be carefully watched and treated on ordinary 
principles. 
So much for the complications of convalescence, but there are 
yet to be discussed the complications of operation. 
Hernia.—In the principal writings on elephantiasis scroti, so 
little notice is taken of this complication that one is led to believe 
it does not greatly increase the risk of operation. It is nearer 
the truth to say that a large hernia is the most serious com- 
plication one can meet, for two reasons: first, that it is some- 
times difficult to tell the size and contents of the hernia, owing 
to the thickness and hardness of the skin covering the parts; 
and, secondly, because the dragging of the tumor on the muscles 
of the abdominal wall, combined with the length of time the 
hernia has been down, has diminished the capacity of the abdo- 
men, leaving little room for reduction. 
It may be that I have been extremely unfortunate in the cases 
that I have had, but two of them gave me an anxious time. 
The first was a case in which there was a right inguinal hernia 
that had existed for years and was apparently reducible. 
Radical cure was performed on that side, the right testicle being 
removed and the scrotum amputated. Great difficulty was ex- 
perienced in reducing the bowel, and the abdomen when the 
wound was sewn up was as tight as a drum. This case did well 
after looking unfavorable for the first few days. 
The second case was more unfortunate. The patient was a 
man of 44 years, with elephantiasis scroti which weighed, after 
removal, 18 pounds (8.2 kilograms). He had a large right in- 
guinal hernia, the size of which was hard to estimate accurately, 
owing to the very thick skin that extended well up on the ab- 
dominal wall. I was strongly of the opinion that it was not all 
reducible, and, owing to the risk, was rather unwilling to operate. 
However, the man was unable to work, and he was urgent in 
his request that the operation should be done at all risks; so it 
was finally undertaken. I found myself confronted with a huge 
hernia, in which some of the bowel had evidently been long out 
of the abdomen. After removing 0.5 pound (0.226 kilogram) 
of omentum, and puncturing the bowel in three places to let out 
gas, it was reduced, but the abdomen was so tight that there 
was danger of the stitches giving way. For three days the 
