aged 28, had suffered from indigestion for six years. Pain occurred from half to one hour after meals; vomiting, which had been particularly frequent during the last few months, relieved the pain. In 1910 she had a severe attack of haematemesis, after which she was kept in bed for some weeks, but the pain did not disappear completely. In 1913 she was again treated for gastric ulceration for eight weeks but
M., AGED 26, a fitter, was admitted into Guy's for a tumour, the size of an orange, in the right Scarpa's triangle. Four years previously he had a blow in this position with a crowbar, and a year ago. he had rheumatic fever; he had had gonorrhoea. He had noticed the lump for eight months; it had gradually increased, and had been painful for three months.The right external iliac artery was enlarged, and pressure over it did not entirely stop the pulsation in the tumour, which was " expansile"; the right posterior tibial pulse was delayed and small. There were no signs of syphilis or cardiac disease. On March 30 the right external iliac artery was exposed and trebly ligatured with No. 4 French catgut; the lowest ligature was placed about 1V in. above Poupart's ligament, as below this the artery was dilated. Pulsation in the aneurysm was diminished but did not cease, so the deep epigastric was ligatured and the incision was continued downwards and the superficial femoral artery tied. The aneurysmal sac was dissected out, the anterior crural nerve being peeled off it externally, and, behind, the superficial femoral vein was separated from it to a point at which it joined the deep vein, where its wall became so thin that it was thought necessary to ligature both veins; the deep femoral artery was ligatured, and the whole aneurysm then came away, the external iliac rupturing below the ligatures as it was pulled down. After the deep circulmflex iliac vessels had been exposed and tied, the common femoral vein was tied just below Poupart's ligament, and the wound was sutured with drainage. There was slight superficial gangrene at the inner edge of the wound, and a small blister formed on the heel. The leg and foot presented a mottled aspect for forty-eight hours, after which sensation and power pf movement returned, but the pulse in the tibial vessels could not be felt a month after operation.The aneurysm sac measured 2 2 in. vertically, 3i in. antero-posteriorly, and 2-in. transversely; it is distinctly "fusiform," two-thirds of its circumference projecting behind a line joining the external iliac and superficial femoral arteries; the origins of both the superficial and deep femoral arteries are involved by the sac, from which they arise at an
free passage to the nose. On the 20th the sac was swollen and hard ; it extended to the middle line of the lower lid and was probably full of blood. On the 23rd the sac was dissected out. It was as large as a pigeon's egg and its walls were from 1' 5 millimetres to 2 millimetres thick. The operation cured the case. ' CASE 3.-A female Arab, aged 30 years. This case was almost exactly similar to the last cited. The sac was enormous and contained two drachma of pus ; it was syringed out and a little per cent. silver nitrate solution was left in situ. This caused great œdema and pain. The sac was syringed out daily for 14 days with no result. A No. 4 probe found a tight stricture and bare bone. The canaliculus was now slit up by a colleague and the neck of the sac was divided with Stilling's knife, a large conical probe was passed into the nose, a counter puncture was made in the skin, and a drain inserted. This treatment had no effect. Ultimately the sac was extirpated and the patient was cured. Both these patients had old cicatricial trachoma ; the sacs were of large size with thick walls. Silver salts were not tolerated. CASE 4.-A Jew, aged 26 years. On Nov. 10th, 1904, there was a discharge of pus from the left lacrymal sac. The condition was said to have been present for some time but the patient could not say how long. On the llth the sac was syringed out with boric acid and a few. drops of a 10 per cent. solution of protargol were left in the sac. On the 12th the left side of the nose and both lids were oedematous and there was much pain. This cedema cleared op in two days and treatment was continued with 5 per cent. protargol solution which was well tolerated. A month's treatment was without result. In this case 10 per cent. protargol caused irritation. Parsons recommends that from 10 to 15 per cent. be used, and I have personally often used 15 per cent. in England. In Palestine in trachomatous cases even 10 per cent. is never tolerated, Coventry.
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