- Email: [email protected]
A CASE OF LITHOTOMY.
230 the
Clinical Notes: MEDICAL, SURGICAL, OBSTETRICAL,
AND
THERAPEUTICAL. A CASE OF DISLOCATION OF THE FIRST PHALANX OF THE THUMB FORWARDS. BY HENRY E. HAYCOCK, L R.C.P. EDIN., M.R.C.S. ENG. _
AT 12.30
I was called to see G.
1st I
P-, July When a down aged twenty-seven, under-gardener. driving dark lane that night at 11.30 he ran the wheel of the cart against the hedge, and was thrown into the road, the cart falling upon him as he lay. In falling he alighted on his left hand, holding the reins, of course, and with his thumb doubled into the palm. The result was a dislocation of the first phalanx of the thumb forwards. He suffered extreme pain, and the position of the bones was as follows :-The A, M. on
patient in bed. In most cases the patient does better to continue his usual occupation, wearing a truss during the the time of treatment. This method is also adapted to herniae which cannot be retained by a truss, the latter being able to be worn, and keeping back the hernia after a course of treatment. In a few cases only toxic effects (alcoholism, urticaria, vertigo) were observed. This method of treatment is not entirely without danger; but accidents will be rare if due care is taken and regard paid to the anatomy of the respective parts. For particulars I must refer to Dr. Steffen’s paper in Nos. 12 and 13 of the Correspondenzbdat9 fiir Schweizer Aerzte. St. Moritz, Engadine. CASE OF GONORRHŒAL RHEUMATISM. BY T. CURTIS LEMAN, L.R.C.P. LOND., M.R.C.S.
IN the hope that some members of the profession may have met with a similar case, and that they will favour me with their views on the rather sudden fatal termination,i send this case to THE LANCET for publication. A. B-, young man aged twenty-six. When seen on thumb was much shortened, there was a broad and rounded prominence on the dorsal aspect, and a projection on the Sept. lst he was suffering from gonorrhcea, with gonorrhoea anterior surface of the member. Having knotted a piece of rheumatism complicating, particularly the fibrous structures bandage tightly around the first phalanx, reduction was of the left instep, where he complained of great pain. Heart effected by forcible adduction and flexion of the thumb across and lungs normal ; temperature normal, pulse rather feeble ; the palm to a right angle, followed by dragging the thumb tongue very white, but he admitted having been drinking. away from the wrist, when it at once returned to its place He was treated for the gonorrhoea by injection, and hob with a grating sound. Beyond slight stiffness and swelling poppy fomentations to the painful instep, the foot to be there was little discomfort afterwards. I might add the man enveloped in soft flannel.-Sept. 3rd : When seen, all rheusustained a bad simple fracture of the tibia and fibula as matic pains had disappeared, but he had developed symwell. The case is of interest from its rarity and the ease ptoms of delirium tremens, sleepless and wandering during the night, with hallucinations. with which reduction was accomplished. Tongue white, temWhitwell, Welwyn. perature normal, pulse feeble ; very thirsty, and takes nourishment well. Ordered pills, each composed of a, RESULTS OF TREATMENT OF REDUCIBLE HERNIA quarter of a grain of morphia hydrochlorate, one to be taken at once, another in six hours if the patient is not BY ALCOHOLIC INJECTIONS. quiet. To take beef-tea, with barley water to relieve BY THEODORE ZANGGER, M.D. his thirst, but no stimulants.-Sept. 4th : The first pill had no effect; so in six hours-i.e., at 5 A.M.-he took THE original modits operandi of Schwalbe, who introduced another, since which time he has been quiet. Taken a. this form of treatment in 1871, is modified by Dr. good deal of beef-tea during the night, and at midday he Steffen of Regensdorf (Zurich). A 70 per cent. solution of regained consciousness for a time, and answered a few alcohol was used, and from two to four grammes of this fluid questions. Pulse weak; temperature 101°. Pupils respond to light ; very restless. From this time he sank into a were injected round the saccus herniosus (hernial sac) after state of muttering delirium, and died in the evening, dereposition of the hernia. The treatment was ambulatory; the administration of stimulants, and before death his first one or two injections a week were made, then at greater spite ran to 103°. No post-mortem examination temperature intervals. Before being dismissed from medical super- allowed. The up which presented itself to me was question vision the patient had to go without the truss which he whether to attribute his sinking into this form of delirium, used during the treatment. The time of treatment varied followed to the delirium tremens, or could death, by solely from one month to two years and a half, or more. In 293 the morbid which had suddenly left the fibrdu9 process cases there were 83 (62 per cent.) cures, 6 (48 per cent.) imstructures of various parts of his body have been accountprovements, 9 (9 per cent.) of negative results. A cure was able for his cerebral symptoms ? considered to have been obtained when, at least one year after Sodbury. Chipping dismissal of the patient, the hernia was neither to be seen nor felt during coughing or under intr? abdominal pressure, A CASE OF LITHOTOMY. and when the patients, most of whom belonged to the labourBY HURAND HAROOTUNE HEKIMIAN, M.D. ing class, had been at their usual work for six or seven months. In 10 per cent. of the cases dismissed as cured the hernia returned, owing to various causes. The age of the M. A- came under my observation on Aug. 2ndi, hernia (sit venia verbo) was not without influence as to the 1890. He gave a long history of seven or eight years of result obtained, as will be seen from the following list :bladder irritation and dysuria. The patient also called Duration of PerNo. of No of attention to the fact that he had a small fistulous opening disease. cases. cures. centage. Hernia incipiens ...... 11 100 somewhere between the rectum and penis, through which 11 100 10 Date, a few days...... 10 opening once quite a large stone had passed. 44 93-2 41 Under year As a preliminary step the urine was examined, and 91 45 41 " 1 found full of mucus, with chalky deposits and pus. Appa842 120 101 10 " rently the man had been suffering from chronic cystitis 65-4 52 34 " 30 and catarrh of the bladder for a long time, with symptoms 80 5 4 Over 30 rise to suspicion of stone in the bladder. An external giving 6 3 50 Date unknown examination revealed that the patient had a large swelling Dr. Steffen comes to the following conclusions :-About in the perineal region, with a fistulous opening, through four-fifths of small and medium-sized reducible hernise can which a large stone had once passed ; there was also conbe cured, the wearing of a truss becoming in most cases tinual dripping of urine from this point. Arectalexaminafsuperfluous. The prognosis improves the younger the indi- tion showed that the swelling was an enormous prostate, vidual, and the shorter the time the hernia has existed. which was as hard as stone to the touch. On soundIncipient cases should therefore be treated by injections, ing him I found that he had a few strictures along the course and not leftto the chance of a spontaneous cure under a truss. of the urethra, which, on inquiry, were the results of a Ambulatory treatment, with pauses of from four to seven previous attack of gonorrhoea. The sound, while passing with days, gives better results than daily injection whilst keeping difficulty through the prostatic portion of the urethra, gave ______________
slightly
______________
...
...
...
...
......
...
...
......
...
...
......
...
...
......
...
...
......
...
...
......
...
...
231 me
the sensation of solid matter
touching the point
n,nd sides of the instrument. I repeated my examination after the lapse of a few days, and concluded that the man Whether the was suffering from stone in the prostate. catarrhal condition of the blidder brought about the formation of stone, or the formation of stone was the cause of this state of the organ, was not plain to me. I also desire to direct particular attention to the following. The extremely irritable condition of the bladder and the severe
Feb.
7th, suffering from severe pain in the head and constanb
vomiting. seen
Mr.
Frampton
of Gloucester-terrace had already or other intracranial blister at the back of the neck.
her, and suspecting meningeal
wrong had
applied a large
Her temperature was 101° F. ; she was violently delirious at times, and always seemingly unconscious of her surroundings ; the head was greatly retracted, and the right pupil was much larger than the left. These were the main symptoms and this was her history. For four years she pain during micturition, with the points revealed by the had had a discharge, frequently offensive, from the sound and the facts derived from the history of the patient, right ear, but six months ago the discharge began in conjunction with the probability of these conditions to lessen, and presently it almost ceased. A fortnight bringing on organic renal diseases, haematuria, or ursemic before admission she began to complain much of headache poisoning at the end, induced me to come to the conclu- and to feel tired and ill, and after seven days she awoke sion to operate. On opening the prostate I found the one morningwith the headache, which throughout was organ calcified as well as enlarged, and pressing against the almost entirely frontal, much more severe. She vomited urethra. I probed the bladder, and although large stones directly after her breakfast, and from that time onward were not found I took out a considerable amount of sandy continued to vomit incessantly. Furthermore, she was d6bris, and small masses of sand of a calcic nature; besides said to have been delirious, and to have had a rigor on the these there was much mucus and pus. Finally I washed evening of Jan. 31st. There had been no convulsion. the bladder out with antiseptic solution and dressed There was no difficulty in tracing a connexion between her the wound. The operation was attended with no more condition and the chronic disease of the ear, and her symhaemorrhage than usual, and no secondary haemorrhage ptoms were in the aggregate distinctly suggestive of cerefollowed. The patient was told to keep his bed, but after bellar abscess or of cerebellar meningitis. Two of the the second day he occasionally got up and walked about. symptoms, however, were not so clear as could have been Wine and cardiac stimulants were ordered, but he refused wished-namely, the retraction of the head, which it was to take them. After a period of five weeks, I again saw thought might in large measure be due to the sore from the the patient. He was quite well, his micturition easy, and very severe blister at the back of the neck ; and secondly, the wound entirely closed, but still at times he experienced the inequality of the pupils, which Mr. Page thought might be a natural peculiarity, for the reason that both reacted a little burning sensation during the act, with occasional equally well to light and darkness. Moreover, there pain, which was due to the catarrhal state of the bladder. was no local tenderness other than that from the Constantinople. blister, which had reached behind the ear, and whenever an answer could be got from her she said that her forehead and her neck were the seats of her pain. Her pulse was 120, and she looked wasted, pale, and ill. Mr. Page saw her for the OF first time on the 9th, and learned that, having been HOSPITAL freely purged, she was then very decidedly better than upon admission-that is to say, she was mentally much clearer BRITISH AND FOREIGN. and no fresh symptoms had supervened. Her morning temtoo, had fallen to 99°. On the 10th, however, she perature, Nulla autem est alia pro certo noscendi via, nisi quamplurimas et mor- was not so well, and by the advice of Dr. Broadbent, and borum et dissectionum historias, tum aliorum tum proprias collectae with the full et inter De Sed. et se Caus. approval of his surgical colleagues, Mr. Page Morb., habere, comparare.-MORGAGNI determined to explore the cerebellar region in the first place, Mb. iv. Prooemium. and afterwards to act as occasion might suggest. Half the scalp ST. MARY’S HOSPITAL. having been shaved and cleansed, a large semicircular flap TWO CASES OF MIDDLE EAR DISEASE IN WHICH OPERATION was accordingly turned forwards from behind the ear, and the muscles having been separated from the occipital bone, WAS RESORTED TO FOR THE RELIEF OF CEREBRAL an opening with a half-inch trephine was made at a point an COMPLICATIONS ; REMARKS. inch and a half below and behind the external auditory of HERBERT the care Mr. W. (Under PAGE. ) (bony) meatus. The meninges over the cerebellum were EVERYONE knows how serious and urgent are the com- found perfectly healthy, and a small opening through the plications which may occur in the course of chronic disease dura mater gave the same information. The next step in the of the middle ear. We place on record two cases in which operation was to expose the lateral sinus, for although on turning up the scalp flap the mastoid vein had bled freely, symptoms of cerebral mischief arose, not only because of the record of published cases has shown that plugging of their own special interest, but also with the view of adding the lateral sinus is of frequent occurrence, and it clearly something to the knowledge which, in this country, we owe was the right thing to examine it. Its bony groove was more especially to Barker by his Hunterian Lectures of 1889, opened, therefore, with chisel and mallet; but beyond slight that relief from impending danger may be very surely averted i roughness, such as might have been due to exuded lymph ’by timely resort to operative measures. Recorded cases are on the wall of the sinus, nothing abnormal was found at this hitherto comparatively few in number, but there is, perhaps, stage of the procedure. The next step was to explore the surface of the temporo-spenoidal lobe by an inch trephine no department of surgery in which, under the protection of perfect cleanliness, there is such promise of good from at a point an inch and three-quarters above and behind the operation under conditions of greatest danger. And in no external bony meatus. Nothing whatever amiss was case is it more true that prevention is better than cure, and found, and there seemed no call for opening the dura. The that, as Mayo Collier has recently advocated, the early end of the search for that which was unquestionably operative treatment, on ordinary surgical principles, of present somewhere had not yet come, and examining again chronic disease of the middle ear and its accessory with a probe in the upper wall of the lateral sinus in the tone cavities is imperatively necessary to save the direction of the mastoid antrum, pus was found, which patient from risks which are at all times imminent, welled into the lateral groove, and accordingly Mr. Page and from which in no other way can he be freed. proceeded with chisel and mallet to cut into the antrum, The two cases here related had this in common, that at a point just above the level of the upper border the disease had lasted a long time and that the chronic of the meatus and close behind it. Evaluation was symptoms were ic:entical ; but operation in the first of them given to several drops of stinking pus. There seemed was resorted to after the onset of acute symptoms suggestive a grave risk that the other openings which had been of serious intracranial mischief. In the second case there made might be septically contaminated, and more than was happily the opportunity of operating before any such ordinary care was therefore taken in cleansing and irrisymptoms had arisen, yet nevertheless in the presence of gating the parts with perchloride solution. The flap was indications which pointed to the real peril in which the now brought into apposition, and through a small orifice in it, just above and behind the meatus, a silver tube-a patient lived. CASE 1.—Alice -, aged sixteen, was admitted to piece of a cannula-was inserted to the depth of threeSt. Mary’s Hospital under the care of Dr. Broadbent on quarters of an inch into the region of the antrum. __
A Mirror
PRACTICE,
-
Clinical Notes: MEDICAL, SURGICAL, OBSTETRICAL,
AND
THERAPEUTICAL. A CASE OF DISLOCATION OF THE FIRST PHALANX OF THE THUMB FORWARDS. BY HENRY E. HAYCOCK, L R.C.P. EDIN., M.R.C.S. ENG. _
AT 12.30
I was called to see G.
1st I
P-, July When a down aged twenty-seven, under-gardener. driving dark lane that night at 11.30 he ran the wheel of the cart against the hedge, and was thrown into the road, the cart falling upon him as he lay. In falling he alighted on his left hand, holding the reins, of course, and with his thumb doubled into the palm. The result was a dislocation of the first phalanx of the thumb forwards. He suffered extreme pain, and the position of the bones was as follows :-The A, M. on
patient in bed. In most cases the patient does better to continue his usual occupation, wearing a truss during the the time of treatment. This method is also adapted to herniae which cannot be retained by a truss, the latter being able to be worn, and keeping back the hernia after a course of treatment. In a few cases only toxic effects (alcoholism, urticaria, vertigo) were observed. This method of treatment is not entirely without danger; but accidents will be rare if due care is taken and regard paid to the anatomy of the respective parts. For particulars I must refer to Dr. Steffen’s paper in Nos. 12 and 13 of the Correspondenzbdat9 fiir Schweizer Aerzte. St. Moritz, Engadine. CASE OF GONORRHŒAL RHEUMATISM. BY T. CURTIS LEMAN, L.R.C.P. LOND., M.R.C.S.
IN the hope that some members of the profession may have met with a similar case, and that they will favour me with their views on the rather sudden fatal termination,i send this case to THE LANCET for publication. A. B-, young man aged twenty-six. When seen on thumb was much shortened, there was a broad and rounded prominence on the dorsal aspect, and a projection on the Sept. lst he was suffering from gonorrhcea, with gonorrhoea anterior surface of the member. Having knotted a piece of rheumatism complicating, particularly the fibrous structures bandage tightly around the first phalanx, reduction was of the left instep, where he complained of great pain. Heart effected by forcible adduction and flexion of the thumb across and lungs normal ; temperature normal, pulse rather feeble ; the palm to a right angle, followed by dragging the thumb tongue very white, but he admitted having been drinking. away from the wrist, when it at once returned to its place He was treated for the gonorrhoea by injection, and hob with a grating sound. Beyond slight stiffness and swelling poppy fomentations to the painful instep, the foot to be there was little discomfort afterwards. I might add the man enveloped in soft flannel.-Sept. 3rd : When seen, all rheusustained a bad simple fracture of the tibia and fibula as matic pains had disappeared, but he had developed symwell. The case is of interest from its rarity and the ease ptoms of delirium tremens, sleepless and wandering during the night, with hallucinations. with which reduction was accomplished. Tongue white, temWhitwell, Welwyn. perature normal, pulse feeble ; very thirsty, and takes nourishment well. Ordered pills, each composed of a, RESULTS OF TREATMENT OF REDUCIBLE HERNIA quarter of a grain of morphia hydrochlorate, one to be taken at once, another in six hours if the patient is not BY ALCOHOLIC INJECTIONS. quiet. To take beef-tea, with barley water to relieve BY THEODORE ZANGGER, M.D. his thirst, but no stimulants.-Sept. 4th : The first pill had no effect; so in six hours-i.e., at 5 A.M.-he took THE original modits operandi of Schwalbe, who introduced another, since which time he has been quiet. Taken a. this form of treatment in 1871, is modified by Dr. good deal of beef-tea during the night, and at midday he Steffen of Regensdorf (Zurich). A 70 per cent. solution of regained consciousness for a time, and answered a few alcohol was used, and from two to four grammes of this fluid questions. Pulse weak; temperature 101°. Pupils respond to light ; very restless. From this time he sank into a were injected round the saccus herniosus (hernial sac) after state of muttering delirium, and died in the evening, dereposition of the hernia. The treatment was ambulatory; the administration of stimulants, and before death his first one or two injections a week were made, then at greater spite ran to 103°. No post-mortem examination temperature intervals. Before being dismissed from medical super- allowed. The up which presented itself to me was question vision the patient had to go without the truss which he whether to attribute his sinking into this form of delirium, used during the treatment. The time of treatment varied followed to the delirium tremens, or could death, by solely from one month to two years and a half, or more. In 293 the morbid which had suddenly left the fibrdu9 process cases there were 83 (62 per cent.) cures, 6 (48 per cent.) imstructures of various parts of his body have been accountprovements, 9 (9 per cent.) of negative results. A cure was able for his cerebral symptoms ? considered to have been obtained when, at least one year after Sodbury. Chipping dismissal of the patient, the hernia was neither to be seen nor felt during coughing or under intr? abdominal pressure, A CASE OF LITHOTOMY. and when the patients, most of whom belonged to the labourBY HURAND HAROOTUNE HEKIMIAN, M.D. ing class, had been at their usual work for six or seven months. In 10 per cent. of the cases dismissed as cured the hernia returned, owing to various causes. The age of the M. A- came under my observation on Aug. 2ndi, hernia (sit venia verbo) was not without influence as to the 1890. He gave a long history of seven or eight years of result obtained, as will be seen from the following list :bladder irritation and dysuria. The patient also called Duration of PerNo. of No of attention to the fact that he had a small fistulous opening disease. cases. cures. centage. Hernia incipiens ...... 11 100 somewhere between the rectum and penis, through which 11 100 10 Date, a few days...... 10 opening once quite a large stone had passed. 44 93-2 41 Under year As a preliminary step the urine was examined, and 91 45 41 " 1 found full of mucus, with chalky deposits and pus. Appa842 120 101 10 " rently the man had been suffering from chronic cystitis 65-4 52 34 " 30 and catarrh of the bladder for a long time, with symptoms 80 5 4 Over 30 rise to suspicion of stone in the bladder. An external giving 6 3 50 Date unknown examination revealed that the patient had a large swelling Dr. Steffen comes to the following conclusions :-About in the perineal region, with a fistulous opening, through four-fifths of small and medium-sized reducible hernise can which a large stone had once passed ; there was also conbe cured, the wearing of a truss becoming in most cases tinual dripping of urine from this point. Arectalexaminafsuperfluous. The prognosis improves the younger the indi- tion showed that the swelling was an enormous prostate, vidual, and the shorter the time the hernia has existed. which was as hard as stone to the touch. On soundIncipient cases should therefore be treated by injections, ing him I found that he had a few strictures along the course and not leftto the chance of a spontaneous cure under a truss. of the urethra, which, on inquiry, were the results of a Ambulatory treatment, with pauses of from four to seven previous attack of gonorrhoea. The sound, while passing with days, gives better results than daily injection whilst keeping difficulty through the prostatic portion of the urethra, gave ______________
slightly
______________
...
...
...
...
......
...
...
......
...
...
......
...
...
......
...
...
......
...
...
......
...
...
231 me
the sensation of solid matter
touching the point
n,nd sides of the instrument. I repeated my examination after the lapse of a few days, and concluded that the man Whether the was suffering from stone in the prostate. catarrhal condition of the blidder brought about the formation of stone, or the formation of stone was the cause of this state of the organ, was not plain to me. I also desire to direct particular attention to the following. The extremely irritable condition of the bladder and the severe
Feb.
7th, suffering from severe pain in the head and constanb
vomiting. seen
Mr.
Frampton
of Gloucester-terrace had already or other intracranial blister at the back of the neck.
her, and suspecting meningeal
wrong had
applied a large
Her temperature was 101° F. ; she was violently delirious at times, and always seemingly unconscious of her surroundings ; the head was greatly retracted, and the right pupil was much larger than the left. These were the main symptoms and this was her history. For four years she pain during micturition, with the points revealed by the had had a discharge, frequently offensive, from the sound and the facts derived from the history of the patient, right ear, but six months ago the discharge began in conjunction with the probability of these conditions to lessen, and presently it almost ceased. A fortnight bringing on organic renal diseases, haematuria, or ursemic before admission she began to complain much of headache poisoning at the end, induced me to come to the conclu- and to feel tired and ill, and after seven days she awoke sion to operate. On opening the prostate I found the one morningwith the headache, which throughout was organ calcified as well as enlarged, and pressing against the almost entirely frontal, much more severe. She vomited urethra. I probed the bladder, and although large stones directly after her breakfast, and from that time onward were not found I took out a considerable amount of sandy continued to vomit incessantly. Furthermore, she was d6bris, and small masses of sand of a calcic nature; besides said to have been delirious, and to have had a rigor on the these there was much mucus and pus. Finally I washed evening of Jan. 31st. There had been no convulsion. the bladder out with antiseptic solution and dressed There was no difficulty in tracing a connexion between her the wound. The operation was attended with no more condition and the chronic disease of the ear, and her symhaemorrhage than usual, and no secondary haemorrhage ptoms were in the aggregate distinctly suggestive of cerefollowed. The patient was told to keep his bed, but after bellar abscess or of cerebellar meningitis. Two of the the second day he occasionally got up and walked about. symptoms, however, were not so clear as could have been Wine and cardiac stimulants were ordered, but he refused wished-namely, the retraction of the head, which it was to take them. After a period of five weeks, I again saw thought might in large measure be due to the sore from the the patient. He was quite well, his micturition easy, and very severe blister at the back of the neck ; and secondly, the wound entirely closed, but still at times he experienced the inequality of the pupils, which Mr. Page thought might be a natural peculiarity, for the reason that both reacted a little burning sensation during the act, with occasional equally well to light and darkness. Moreover, there pain, which was due to the catarrhal state of the bladder. was no local tenderness other than that from the Constantinople. blister, which had reached behind the ear, and whenever an answer could be got from her she said that her forehead and her neck were the seats of her pain. Her pulse was 120, and she looked wasted, pale, and ill. Mr. Page saw her for the OF first time on the 9th, and learned that, having been HOSPITAL freely purged, she was then very decidedly better than upon admission-that is to say, she was mentally much clearer BRITISH AND FOREIGN. and no fresh symptoms had supervened. Her morning temtoo, had fallen to 99°. On the 10th, however, she perature, Nulla autem est alia pro certo noscendi via, nisi quamplurimas et mor- was not so well, and by the advice of Dr. Broadbent, and borum et dissectionum historias, tum aliorum tum proprias collectae with the full et inter De Sed. et se Caus. approval of his surgical colleagues, Mr. Page Morb., habere, comparare.-MORGAGNI determined to explore the cerebellar region in the first place, Mb. iv. Prooemium. and afterwards to act as occasion might suggest. Half the scalp ST. MARY’S HOSPITAL. having been shaved and cleansed, a large semicircular flap TWO CASES OF MIDDLE EAR DISEASE IN WHICH OPERATION was accordingly turned forwards from behind the ear, and the muscles having been separated from the occipital bone, WAS RESORTED TO FOR THE RELIEF OF CEREBRAL an opening with a half-inch trephine was made at a point an COMPLICATIONS ; REMARKS. inch and a half below and behind the external auditory of HERBERT the care Mr. W. (Under PAGE. ) (bony) meatus. The meninges over the cerebellum were EVERYONE knows how serious and urgent are the com- found perfectly healthy, and a small opening through the plications which may occur in the course of chronic disease dura mater gave the same information. The next step in the of the middle ear. We place on record two cases in which operation was to expose the lateral sinus, for although on turning up the scalp flap the mastoid vein had bled freely, symptoms of cerebral mischief arose, not only because of the record of published cases has shown that plugging of their own special interest, but also with the view of adding the lateral sinus is of frequent occurrence, and it clearly something to the knowledge which, in this country, we owe was the right thing to examine it. Its bony groove was more especially to Barker by his Hunterian Lectures of 1889, opened, therefore, with chisel and mallet; but beyond slight that relief from impending danger may be very surely averted i roughness, such as might have been due to exuded lymph ’by timely resort to operative measures. Recorded cases are on the wall of the sinus, nothing abnormal was found at this hitherto comparatively few in number, but there is, perhaps, stage of the procedure. The next step was to explore the surface of the temporo-spenoidal lobe by an inch trephine no department of surgery in which, under the protection of perfect cleanliness, there is such promise of good from at a point an inch and three-quarters above and behind the operation under conditions of greatest danger. And in no external bony meatus. Nothing whatever amiss was case is it more true that prevention is better than cure, and found, and there seemed no call for opening the dura. The that, as Mayo Collier has recently advocated, the early end of the search for that which was unquestionably operative treatment, on ordinary surgical principles, of present somewhere had not yet come, and examining again chronic disease of the middle ear and its accessory with a probe in the upper wall of the lateral sinus in the tone cavities is imperatively necessary to save the direction of the mastoid antrum, pus was found, which patient from risks which are at all times imminent, welled into the lateral groove, and accordingly Mr. Page and from which in no other way can he be freed. proceeded with chisel and mallet to cut into the antrum, The two cases here related had this in common, that at a point just above the level of the upper border the disease had lasted a long time and that the chronic of the meatus and close behind it. Evaluation was symptoms were ic:entical ; but operation in the first of them given to several drops of stinking pus. There seemed was resorted to after the onset of acute symptoms suggestive a grave risk that the other openings which had been of serious intracranial mischief. In the second case there made might be septically contaminated, and more than was happily the opportunity of operating before any such ordinary care was therefore taken in cleansing and irrisymptoms had arisen, yet nevertheless in the presence of gating the parts with perchloride solution. The flap was indications which pointed to the real peril in which the now brought into apposition, and through a small orifice in it, just above and behind the meatus, a silver tube-a patient lived. CASE 1.—Alice -, aged sixteen, was admitted to piece of a cannula-was inserted to the depth of threeSt. Mary’s Hospital under the care of Dr. Broadbent on quarters of an inch into the region of the antrum. __
A Mirror
PRACTICE,
-