ST. GEORGE'S HOSPITAL
Under the care of Mr. G. R. TURNER.) Nulla autem est alia pro certo noseendi via, nisi quamplurimas tt morborum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se comparare.—MoBaAeNi De Sed. et Caw. Jf<M'6., lib. iv. Prooemium. -CASE 1. Femoral herrtia in a boy, aged six years.-The patient was admitted into St. George's Hospital with a swelling of the size of a pigeon's egg in the left groin, seemingly reducible into the abdominal cavity and apparently with some
... arently with some slight impulse on coughing. There was enlargement of the inguinal glands above and below Poupart's ligament and the child had obviously been circumcised not long ago. Both testicles were in the scrotum ; the hernial swelling was said to be increasing in size. The hernia on operation proved to be of the femoral variety containing omentum. A radical cure was performed, a flap from the pectineus muscle being utilised in the way that Mr. Watson Cheyne has suggested. The boy made an uninterrupted recovery. CASE 2. Double femoral hernia in a rnan.-The patient, a z , labourer, aged 46 years, was admitted into St. George's Hospital on May 31st, 1898. He stated that he had had a reducible lump in the fold of the left groin for 12 months. This had increased in size somewhat suddenly of late. He was subject to bronchitis in the winter months, but otherwise he had enjoyed good health. He had neither lost nor gained flesh recently. He had never worn a truss. There was a smaller swelling in the right groin. On admission the patient was found to have a femoral hernia of about the size of a Tangerine orange which was readily reducible on the left side. He had a smaller right femoral hernia and both inguinal rings although unoccupied by hernia were very capacious. On June 3rd Mr. Turner operated on the left side, doing a radical cure of the femoral hernia and suturing the inguinal ring with kangaroo tendon at the same time. Three weeks later he did the same on the right side. The femoral hernise on both sides were omental ; no gut was down on the left side at the time of operation, although previously this had probably been the case. The patient was discharged wearing a double truss large enough to support both inguinal and femoral rings. Remarks by Mr. Tu]Ett-TER.-Femoral hernia in a boy, aged six years is sufficiently rare to be worthy of record. Double femoral hernia in an adult man is not often seen. It was associated in the case recorded above with dilatation of the inguinal rings, although no hernia was present in these situations. It is curious that on both sides the hernia should have selected the crural canals when an easy inguinal route was open to them. As a general rule after the operation for radical cure of a hernia I do not advocate the wearing of a truss, but in this case the rings were alone dealt with and the truss is worn as a matter of prevention of possible hernia in the future. GREAT YARMOUTH GENERAL HOSPITAL A CASE OF SUPPURATIVE OTITIS ; MASTOID DISEASE ; CEREBRAL ABSCESS ; NECROPSY. (Under the care of Dr. HENRY BLAKE.) FOR the notes of the case we are indebted to Dr. Alexander Goodall, house surgeon. A youth, aged 17 years, was admitted into Great Yarmouth General Hospital on Sept. 22nd, 1899, under the care of Dr. Blake. The patient complained of pain and discharge from the left ear of about three weeks' duration. His family history was good, his home surroundings were comfortable, and he had not suffered from any previous illness of importance. His intelligence was not of a high order and it was difficult to get an account of the onset of his illness. On admission the temperature was 100'4° F. There was a good deal of purulent discharge from the left ear and a small polypus could be seen growing from the posterior wall of the meatus. There was no tenderness over the mastoid. The pulse was 72 per minute and in other respects the patient seemed to be in good health. The ear was douched with boric lotion and insufflated with iodoform. Chromic acid was applied to the polypus. On Sept. 25th the temperature rose to 104'5°, but atter cold sponging it fell to 1000. For the next three weeks the temperature was very irregular, ranging from 98'40 to 103°, but the general condition seemed to improve and operation was deferred. On Oct. 2nd the patient vomited and he began to suffer from severe paroxysmal headaches. On the 16th the mastoid was trephined and a few drops of pus escaped. A communication was made between the. mastoid antrum and the meatus. The temperature, however, remained irregular, ranging from 100° in the morning to. 103° in the evening, and on the 24th the patient had a rigor. On the 28th the mastoid opening was enlarged and some bony detritus was cleared out. On the 30th the temperature. rose to 1020. There were swelling and tenderness along the line of the internal jugular. On the next day the swelling and tenderness had extended along the line of the subclavian vein. Carbolic fomentations were applied and in. two days these symptoms had subsided. On Nov. 1st, and again on the 3rd and the 5th, the patient vomited. On Nov. lst the temperature fell to 97°, but on the 2nd it rose to 102°. The patient was now rather drowsy and his cerebral processes became very slow. On the morning of the 6th the temperature was normal and the pulse rate was 60. At 10 A.M. the temperature fell to 96° and the pulse rate to 48. There were slight paresis of the right facial nerve and a slight tendency to ptosis of the left eyelid and the left pupil was dilated. The fundus oculi looked healthy. In the evening Dr. Blake trephined over the temporo-sphenoidal lobe, entering the trephine at a point about one and a quarter inches behind and above the centre of the external auditory meatus. An incision was made in the dura mater and an exploring needle was inserted inta the temporo-sphenoidal lobe. Pus was at once found and about one ounce escaped. The opening was enlarged with sinus forceps and a rubber tube was inserted and stitched to the scalp. On the next morning the temperature was 970' and the pulse was 64. To ensure better drainage the rubber tube was replaced by a silver cannula. In theevening the temperature had risen to 102° and the pulse-rate to 84. The following morning the temperature was 10!.° but it gradually rose to 1082° and the patient died in the afternoon. .cfy.—A post-mortem examination was made on the following day. There was a small ragged opening about the. middle of the inferior temporo-sphenoidal convolution where the tube had been inserted and around the opening there was an area of about a square inch where the brain substance was very thin and friable. On cutting into the brain an abscess containing a quantity of pus was found in the temporo-sphenoidal lobe. The cavity had a diameter of one and three-quarter inches and projected into the descending horn of the left lateral ventricle. The abscess cavity was. lined by a pyogenic membrane one-sixteenth of an inch in thickness, which was very easily detachable from the brain substance. There was no thrombosis of either the internal jugular vein or the lateral sinus and there was no indication of meningitis. Remarks by Dr. G01DALL.-The diagnosis when the patient first came under observation was septic absorption from purulent otitis and it was only the continuation of the symptoms after douching, &c , that indicated mastoid disease. After the second operation there was reason ta believe that there was venous thrombosis, and it was only the rapid extension of the condition that prevented operation. Subsequent events proved the decision to defer operation to have been fortunate. The most interesting feature of the case was the fact that the abscess, which had a thick pyogenic membrane, must have existed for weeks before it gave rise to any symptoms. The patient's mental processes. were certainly slow, but it so happened that his sister, who was in hospital at the same time suffering from chlorosis, showed much the same peculiarity. It was, therefore, impossible to determine when the slow cerebration became pathological. Definite symptoms of brain abscess only showed themselves two days before the boy died. I am indebted to Dr. Blake for his kindness in allowing me to. publish the case.