% JJlirror of iospiia! |inclirf. SURGICAL CASES.

By G. P. BKANKIjIN, b.a., v.p., Ji.o. (Cantab.), m.r.c.p. (Lond >ii),

Captain, i.m.s., ^

Aijencij Surgeon in CUyii,

The following crscs, which \Vere 0])SP1.ve(i at

Meshed, appear to be worthy of record : -

(1) Dermoid Cyst of an Undescended Testicle. The patient, a Persian of 35, complained of a

movable tumour in his abdomen. He had noticed it for several years and thought that it was

growing larger. It gave him 1>ain occasionally. On examination a hard rounded tumour was

detected, freely movable in all directions. The

patient himself pushed it up out of the pelvis, remarking that it was more easily felt up above ! The diagnosis was in considerable doubt till it was discovered that there was n0 rj0],t testicle either in the scrotum or in the in<minal canal

when it was conjectured that the tumour miu'ht have some connection with the missing or<?'an. On opening the abdomen a rounded tumour

with a long pedicle was discovered and removed. Both kidneys were present. The wound was

closed in the usual manner and the patient made an uneventful recovery, in spite of the fact that he was found walking about the hospital on the

third day! The tumour measured some 7 by 4 inches and retained the shape of a normal

testicle. The pedicle consisted of the vas and vessels (greatly enlarged) and a covering of

peritoneum. The wall of the tumour was thick and the cavity unilocular, the contents including hair and bone in addition to the ordinary dermoid material.

(2) Dermoid Cyst of tlce Right Orbit. A man of 40 presented himself with a bulging

swelling to the inner side of his right eye and with his right eye displaced outwards, downwards and forwards. His appearance was grotesque. He complained of the latter and of failing vision. On examination a fluctuating tumour was found filling up the greater part of the right orbit and apparently adherent to the inner wall. At operation, an elliptical incision was made over the tumour and a dark-walled cyst came into view. This was gently separated on its outer side and found to lie extending towards the apex of the orbit. The cyst wall was easily separated on its outer side from the capsule of the eye, but on the nasal side it was firmly adherent and very thin and unfortunately burst during the manipulations. After evacuation the cyst was found to extend to the apex of the orbit. As much as possible of the cyst wall was then removed, and the remainder, a deep portion adherent to the bone, was thoroughly scraped. The patient made a

good recovery, and on his discharge the position of the right eye had nearly approximated to that of the left and his appearance had much improv- ed.

(3) Ninety-six Calculi in a Pouch of the Urethra.

A boy, aged 8, was brought to the hospital by his parents. They stated that the child, did not

pass water through the proper channel and that there was a hard swelling at the base of his penis. On examination a swelling was seen on the under surface of the penis of the size of a small orange. The swelling extended from the scrotum to within half an inch of the glans and inclined to the left. A urethral fistula opened at the lower end of the tumour through which all the urine passed. The swelling felt exactly like a bau' full of stones. The meatus was patent and a sound was passed into the bladder, no stone being detected there. A director inserted through the fistula passed straight into the swelling and numerous stones were felt. At operation the fistula was slit up and a saccular dilatation of the penile urethra discovered, troin this dilatation 96 calculi were removed. The calculi varied in size from that of a marble to that of a fig seed. An attempt was then made to obliterate the dilatation and to close the fistula, but only the latter part was successful. On his discharge, further treatment being refused, urine was passed through the meatus only, but the swelling reap- peared unless pressure was exercised at the moment of urination.

394 THE INDIAN MEDICAL GAZETTE. [Oct., 1912.

(4) Fibroma of the Floor of the Mouth. A woman, aged 28, presented herself at the

hospital with a large red swelling, the size of a

polo ball, protruding from her mouth. She

stated that she had had a tumour there for

twenty years and that it was gradually enlarging. On examination the tumour was found to be of

moderate firmness, covered in the upper part by the thinned-out tongue in an advanced stage of

glossitis, and for the remainder of its extent by the everted mucous membrane of the floor of

the mouth. Her mouth was permanently propped open by the tumour. The lower jaw, from the

pressure of the tumour, was prolonged down- wards, thinned-out and toothless. There was

great impediment of speech and much difficulty in eating. The tumour was shelled out without

difficulty and proved to be a soft fibroma. After

the operation the condition of the tongue and mouth rapidly improved, the tongue contracting down to almost its normal size. The resultant

deformity was not very marked and talking and

eating much improved. (5) Fibroma of the Left Shoulder.

This case was noteworthy on account of the

age of the patient and the size of the tumour.

The patient was an Afghan from Kandahar, aged 70, and the tumour was of the shape and size of

a Rugby football. The old man stated that he

had carried it in a sling over his chest for years. At operation flaps were dissected up from the base of the tumour which was adherent to various fascias and ligaments in the neighbourhood of

the clavicle. There was considerable bleeding, but the old man stood the operation well and

made a good recovery. \j (6) Effects of a Fall fi 'om a Hoof. The patient, a Persian, aged 27, fell some 40

feet off the roof of a house. He was picked up unconscious and brought to hospital. He quickly recovered consciousness, and on examination he was found to have sustained, in addition to numerous cuts and bruises, a compound fracture of the nose, a fracture of the superior maxilla, a dislocation of

the lower jaw on the left side and simple fractures of both forearms. The fracture of the superior maxilla was the interesting point, it extended from between the middle incisor teeth straight back through the palate, and the left superior maxilla and palate bone were lying parallel, but one inch nearly posterior to those of the right side. The left maxilla was brought forward and wired in position, the wire being passed through the palate bone of each side and brought out

above the lateral incisor teeth. The dislocation was reduced with some difficulty, and the other

injuries attended to in the ordinary way. An ex- cellent recovery was made, but the patient refused to have the wire removed, and 1 met him in the street some months later with it still in position.

(7) Fracture of the Arm in two places by Stabs from a Knife.

I record this case as I do not remember bearing of a similar one. An Afghan of 25 was

attacked in the street one evening by a man with a dagger. The Afghan was unarmed except for a stick, and he put lip his left arm to protect his face. He received two blows from the dagger on his arm before his assailant was beaten off and fled. One blow severed the external condyle of

the humerus from the shaft and the other cut tbe ulnar diagonally across three inches above the wrist. The fractures were both wired with, success.

(8) Persian Judicial Surgery. Two cases came for treatment after mutilation

at the hands of the public executioner. One

was a man of 22 whose four fingers of the right hand had been cut off through the meta-carpo- plialangeal joints. The patient applied for treat-

ment four days afterwards, and the heads of the four metacarpals were projecting in the midst of a sloughing and gangrenous mass. Partial ampu- tation was done at the level of the wrist joint, and there was a good recovery, the thumb which

it was found possible to save, having fair move-

ment. The man had been mutilated as a punish- ment for murder.

The second case was a highway robber, both of whose heels had been cut through above the os calcis. The cut was a dee}) one and the

tendon of the tibialis posticus severed in addi-

tion to the Achilles tendon. The tendons of the

posticus were easily secured, but a long incision

had to be made to reach the upper end of the

Achilles tendon. The patient made a fair

recovery, resumed his old occupation and was

ultimately hanged. I interviewed the executioner one day and

he told me that he had been brought up in his

trade by his father. He used a triangular shaped bluntish knife and displayed considerable

knowledge as to the line of incision to be taken

so as to hit the various joints. He added that

he never had any difficulty about stopping the

bleeding as his practice was to apply at once a

mixture oi lime and earth to the wound.