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A CASE OF AMŒBIC DYSENTERY IN A BOY AGED THREE.
122
Clinical Notes : MEDICAL, SURGICAL, OBSTETRICAL, AND THERAPEUTICAL.
by pressure on the nerve fibres. Clearly it was an instance of toxic degeneration of the peripheral nerves, though, as in so many unexplained forms of "toxic polyneuritis," the source and nature of the toxin remain obscure. rS-83 _________
A CASE OF
OPHTHALMIA NEONATORUM BEFORE BIRTH
A CASE OF
LEUKÆMIC POLYNEURITIS. BY WILFRED HARRIS, M.D.
CANTAB., F.R.C.P. LOND.,
SENIOR PHYSICIAN. ST. MARY’S HOSPITAL, LONDON.
BY GRACE H. GIFFEN D.P.H.
DUNDAS, F.R.C.S. IREL., CANTAB.,
MEDICAL OFFICER TO MATERNITY AND CHILD
WELFARE,
MIDDLESBROUGH.
Iz’ SEVERE forms of anaemia, cachexia, and senility Mrs. X., a 2-para, was admitted to the Municipal been stated occasionally to produce definite multiple Home, Middlesbrough, on Oct. 6th, 1920. Maternity neuritis, though the occurrence of well-marked poly- Labour pains had commenced ten hours previously. neuritis in lymphatic leukaemia has not, so far as I The child was born two hours after the mother was In haemophilia admitted. I saw it within five minutes of its can ascertain, hitherto been recorded. birth, neuritis has been ascribed to the pressure of the when it was found to have neonatorum. ophthalmia effused blood on nerve trunks, but the resultant The lids were red and oedematous, and pus was disneuritis would be local, asymmetrical, and quite unlike from both eyes. The obstetric sister who charging the usual form of toxic polyneuritis. Similarly, unithe delivery reported the case as left conducted lateral facial paralysis has been described in leukaemia. The case described below illustrates symmetrical occipito-anterior. The following history was obtained from the mother :polyneuritis as an early and prominent symptom in a ’ Her first child was born healthy; a creamy discharge " comcase of lymphatic leukaemia, before the definite menced before the second pregnancy and continued during the a fortnight before labour pains set in "the waters diagnosis of the blood condition was possible to pregnancy; began to come away, dribbling all the time," so that the patient establish. "never dry." The case was evidently one of intra-uterine was W. J., a youth aged 17, attended the out-patient department early infection made possible by the draining away of the liquor amnii, in April, 1920, on account of weakness of the legs, saying that for the and presumably the presentation had been a brow converted into past five weeks he had noticed that his legs were becoming stiff, an occipital during labour. Labour pains only lasted 12 hours, but followed two weeks later by unsteadiness on his feet, and numbness the brow must have been in contact with the infected cervix and tingling of his finger pads. The spleen was noticed to be for some time previous to the commencement of the pains. The definitely enlarged, about three fingers-breadth below the costal mother’s puerperiam was normal, and she left the home at the end margin, and the notch easily felt, A slight degree of anaemia was of a fortnight to be treated by her own doctor. The child’s eyes evident, and he was sent into the hospital, being admitted on April received the usual treatment, including hourly saline irrigation, 15th. His gait was weak and unsteady, and there was definite and the discharge began to clear up ; intracellular diplococci were weakness of dorsiflexion of the feet, the electrical reaction of the demonstrated in the pus. Apart from the eyes the child seemed leg muscles showing partial reaction of degeneration. Tests of healthy at birth and weighed 6 lb. 12 oz., but on the third day it sensation showed diminution to touch and pin-prick on the feet began to refuse its feeds, and was slightly cyanosed. The cry was and legs up to the knees, though the vibration sensation to a large feeble ; twitching of the facial muscles occurred several times; the tuning-fork placed on the tibias was normal. The knee-jerks, power to suck gradually disappeared, whereupon the child was Achilles, and forearm-jerks were all absent, nor could any plantar spoon-fed with the mother’s milk. The temperature remained reflexes be obtained, though the cremaster reflexes were present. subnormal; the child gradually became more feeble and more
have
"
eyes and discs normal. The blood examination showed a red cell count of 3,400,000, with haemoglobin content 60 per cent., the colour index being 0’88. There was a degree of leucopenia. the white cells numbering only 5800, though the differential count showed the polymorphs to be reduced to 23 per cent., the lymphocytes amounting to 68 per cent. Wassermann test negative. Numerous small lymphatic glands soon became palpable in the posterior triangles on both sides of his neck, and one of these was removed for microscopical examination. The healing of this wound was very troublesome, recurrent h2emorrhage occurring for several days, and his temperature, which previously had been normal, now began to show oscillations, with rises to 99’5° to 100° F. Gradually he became weaker, and he died on May 29th. Post mortem, the spleen was found considerably enlarged and soft, the liver fatty and weighing 74 oz., while microscopical examination revealed leukaemic infiltration of the liver, nerves, and kidneys, with lymphocytes. ’,
Sphincters normal ;
cyanosed, and died on the tenth day. Within 18 hours of the death I received permission to do a limited post-mortem. On removing the calvareum
The extreme intracranial congestion was found. sinuses were full of fluid blood, and injection of the pia mater was intense. When the brain was removed a purulent exudate was found on the middle of the base of the skull extending from the optic commissure backwards. There was no disintegration of the globe of either eye. The secondary condition was evidently due to infection by blood or lymph stream.
Remarks.
A CASE OF
admission presented a diagnosis pretty problem. Splenic anaemia with combined sclerosis was negatived by the fact of the absent reflexes, normal vibration sense on the legs, with no involvement of the sphincters, while the clinical picture was indeed characteristic of polyneuritis. The recognition of the type of anaemia was more difficult, the leucopenia being suggestive of splenic anaemia, but the greatly inverted lymphocytic preponderance was against this diagnosis, and was more suggestive of One of lymphatic leukaemia or lymphadenoma. the slightly enlarged glands was therefore excised for microscopical examination, but the pathological report was that it was normal, and again we were The troublesome haemorrhage from the at fault. small wound in the neck made by the surgeon was more suggestive of leukaemia than of lymphadenoma, but the diagnosis of leukaemia was not established until the tissues were microscoped after the post mortem. The extremely rare combination of wellmarked polyneuritis with leukaemia makes it desirable to place this case on record. What exactly is the association between the two conditions is perhaps hard to say. The symmetry of the polyneuritis and its resemblance to many forms of toxic polyneuritis preclude the possibility of the neuritis being due to leukaemic infiltration of the nerves producing paralysis
AMŒBIC DYSENTERY IN A BOY AGED THREE.
The
of the
case on
BY M. L. HOUSE
YOUNG, M.B., B.CH. CANTAB.,
PHYSICIAN, PADDINGTON GREEN HOSPITAL, LONDON.
CHILDREN’S
THE age of the patient and the absence of any obvious source of infection are noteworthy features of this case. Stanley K., aged 3 years, was admitted to the Paddington Green Children’s Hospital Ion Nov. 3rd, 1920, with the following history, During the six weeks prior to admission he had suffered from persistent diarrhoea, sometimes passing as many as seven stools in the 24 hours, and during the latter four weeks streaks of bright red blood and some slime had been noticed by the mother in almost every stool. Throughout this period of six weeks the boy had been bright and happy, and there had been no complaint of pain or discomfort. When admitted to the hospital he looked a perfectly healthy and unusually high-spirited boy. During the first 24 hours four loose stools were passed containing a large amount of mucus, well streaked with bright red blood, but very little fascal matter. Laboratory examination of a stool revealed the presence of the Entamaeba histolytica, much blood and mucus, and a relatively small amount of pus; no dysentery bacilli were found. It was then decided to proceed with a course of emetine hydrochloride by hypodermic injectton : 1/12th gr. was given on the first occasion, and during the following 24 hours one loose stool was passed containing much mucus but less blood. A second injection of 1/6 gr. was then given, and resulted in further improvement. Two more injections of 1/6th gr. at intervals of 24 hours were given, and a semi-solid partially formed stool was examined and found to contain a considerable quantity of mucus, a few red blood cells, and
123 two amoebae. At this time the diarrhoea, was entirely checked. After two further injections of l/6th gr., at intervals of 24 hours, the child was constipated. Examination of a stool revealed no blood, no amoebae, and no cysts.
come across cases where this point had been overlooked and the results had been most disastrous. The patient would probably live only a few weeks after The child was kept under observation in the hospital the operation. He also urged on those who were for another fortnight, and then discharged apparently thinking of taking up the surgery of the thyroid gland knowledge of completely cured. At no time during his stay in hospital the importance of a sound and extensive of specimens did the child appear in the least unwell. The father its pathological anatomy. The hundreds has never been out of England, and no source of in the London museums gave those who lived in London infection has been established. As this is the only case ample opportunity for study. Mr. Berry demonstrated his method of removing an of amoebic dysentery which has been detected at the tumour. intrathoracic the it be to since would learn Having cleared the tumour war, interesting hospital around the base of the neck, he levers it up by means the experience of other children’s hospitals. I am indebted to Dr. G. A. Sutherland for permission of a spoon about the size of a dessert-spoon bent to an angle and thrust through the thoracic inlet and beneath to publish’the case. the tumour. At the same time the tumour is pulled, Removal of intrafrom above by means of forceps. thoracic goitres was rendered possible by the fact that,. in growing downwards, they carried their vessels with them. In the case of intrathoracic tumours he usually employed light general anaesthesia. If local anaesthesia ROYAL SOCIETY OF MEDICINE. only were used the patient was apt to move at the most dangerous time-when the tumour was being pulled out of the thorax. Nevertheless, there were certain cases SECTION OF SURGERY. where local anaesthesia alone might be advisable. A Fzcrther Series of 500 Goitre Operations. Mr. Berry said that he nearly always drained by A IEET1NG of this section of the Royal society of means of a short glass tube reaching just below the Medicine was held on Jan. 5th, Mr. W. G. SPENCER, the muscles. This was practically always infra-hyoid President, being in the chair, when Mr. JAMES BERRY removed within 24 hours. Of the two deaths which contributed a paper on a Further Series of 500 Goitre occurred among patients with simple goitre, one was a Operations, with special reference to the after-results. lady of 38 who had glycosuria. She died of pneumonia, Numerous charts were exhibited showing the age and ten days after the operation without gross evidence of sex incidence, the type of tumour, reasons for operaThe other case was that of a pregnant woman sepsis. tion, the lobes affected, the after-results, &c. Many of 41, on whom the operation was performed on account patients were present and a large number of patho- of dyspnoea. There were 78 patients who had had logical specimens were on view. On the epidiascope operation for true exophthalmic goitre (one being were shown photographs of patients, and photographs operated upon twice) with three deaths, all of which and coloured drawings of the tumours which had been were due to heart failure within a few hours. Among 14 had been traced, I the cases shown was a removed. Of the 500 cases all but professional singer, who conand Mr. Berry said that from a study of these 14 cases i sulted Mr. Berry because she was losing her voice and he had no reason to suppose that the after-results were thus her means of livelihood. After operation she had anything but satisfactory. He commented upon the regained her voice completely. She demonstrated tocomparatively large number (7 out of 63 men) of men the meeting her ability to sing sustained notes. there were no over 70 years of age in his series; DismLs8’ion and Reply. A large proportion of his cases women over 70. In the course of the discussion Sir STCLAIR THOMSON were women, and this he attributed to the fact that men sought operation only when the tumour was suggested that the word " stridor " should be used causing discomfort or when it was so enormously large instead of " dyspnoea." Stridor was an objective as to produce inconvenience or such unsightliness as symptom, but dyspnoea was a subjective symptom. In would prevent them from getting employment. Women, his opinion there were three conditions of stridor which demanded operation-stridor when at rest, stridor when on the other hand, often came largely for operation for cosmetic reasons, the goitre being usually more in asleep, and stridor on exertion. Fixation of the vocal cord was also an indication for operation, and recovery evidence with them than was the case with men. With regard to the immediate reason for operation, sometimes followed successful operative treatment. in more than half of the cases of this series (274) Paralysis of the vocal cord was rarely due to cutting of operation was performed for dyspnoea. He was anxious the recurrent laryngeal nerve. Voice change often came to hear opinions as to the suitability of intra-tracheal on some weeks after operation, and was probably due ether as a mode of anaesthesia for operations of this kind. to slight suppuration and fibrosis. Mr. A. J. WALTON gave his opinion as to the indicaHe urged the importance of the anaesthetic in goitre operations, and said that he never used chloroform but tions for operation. Operation should be performed on nearly always very light open ether. The intra-tracheal well-defined adenomata, but if the adenoma was soft and method always seemed to him to be dangerous for ill-defined, immediate operation was not necessary and just those operations where he would like to use it- the condition often improved under medical treatment. namely, cases of extreme dyspnoea with very narrow When a goitre was complicated by pregnancy he would trachea. So far he had not ventured to try it always postpone operation until the pregnancy was with goitre operations of this class. In these over, unless the tumour was enormous. In " parenchypatients the trachea was so narrowed from pressure matous " goitre there was not a true increase of by the tumour that its lumen was a mere chink. parenchyma, but much increase of colloid. He preThe deep anaesthesia and extreme extension of the ferred to call this type " colloid goitre." Apart from head, both of which appeared to be necessary for the dyspnoea, no colloid goitre should be operated upon, a& introduction of the tube in intra-tracheal anaesthesia, the condition usually disappeared. Operation should be he thought most dangerous in goitres with extreme performed in cases of extreme dyspnoea. He said suffocative dyspnoea. The pressure of a tube, however that cases sometimes occurred in which atrophy of soft, in the trachea in contact with the delicate lining cartilage was so great that tracheotomy had to be of the already narrow trachea, seemed to him not performed after thyroidectomy. He considered that unlikely to produce a dangerous post-operative swelling. operation was the treatment for exophthalmic goitre of For these reasons he had never employed it. On the longer standing than about six months. He had never other hand, it might safely be employed in the less seen any permanent benefit from X rays in this consevere cases, but here there seemed no particular dition. He had had 11 cases in which prolonged X ray in it. treatment had been carried out elsewhere. Two of advantage With regard to malignant growths, he urged very these had squamous carcinoma, and there was much strongly that operation should never be performed scarring in the other cases. None appeared to have unless the thyroid not only moved up and down with the benefited. In relapsing cases X ray treatment also trachea, but was also movable on the trachea. He had appeared to be unsuccessful. one or
Medical Societies.
’
Clinical Notes : MEDICAL, SURGICAL, OBSTETRICAL, AND THERAPEUTICAL.
by pressure on the nerve fibres. Clearly it was an instance of toxic degeneration of the peripheral nerves, though, as in so many unexplained forms of "toxic polyneuritis," the source and nature of the toxin remain obscure. rS-83 _________
A CASE OF
OPHTHALMIA NEONATORUM BEFORE BIRTH
A CASE OF
LEUKÆMIC POLYNEURITIS. BY WILFRED HARRIS, M.D.
CANTAB., F.R.C.P. LOND.,
SENIOR PHYSICIAN. ST. MARY’S HOSPITAL, LONDON.
BY GRACE H. GIFFEN D.P.H.
DUNDAS, F.R.C.S. IREL., CANTAB.,
MEDICAL OFFICER TO MATERNITY AND CHILD
WELFARE,
MIDDLESBROUGH.
Iz’ SEVERE forms of anaemia, cachexia, and senility Mrs. X., a 2-para, was admitted to the Municipal been stated occasionally to produce definite multiple Home, Middlesbrough, on Oct. 6th, 1920. Maternity neuritis, though the occurrence of well-marked poly- Labour pains had commenced ten hours previously. neuritis in lymphatic leukaemia has not, so far as I The child was born two hours after the mother was In haemophilia admitted. I saw it within five minutes of its can ascertain, hitherto been recorded. birth, neuritis has been ascribed to the pressure of the when it was found to have neonatorum. ophthalmia effused blood on nerve trunks, but the resultant The lids were red and oedematous, and pus was disneuritis would be local, asymmetrical, and quite unlike from both eyes. The obstetric sister who charging the usual form of toxic polyneuritis. Similarly, unithe delivery reported the case as left conducted lateral facial paralysis has been described in leukaemia. The case described below illustrates symmetrical occipito-anterior. The following history was obtained from the mother :polyneuritis as an early and prominent symptom in a ’ Her first child was born healthy; a creamy discharge " comcase of lymphatic leukaemia, before the definite menced before the second pregnancy and continued during the a fortnight before labour pains set in "the waters diagnosis of the blood condition was possible to pregnancy; began to come away, dribbling all the time," so that the patient establish. "never dry." The case was evidently one of intra-uterine was W. J., a youth aged 17, attended the out-patient department early infection made possible by the draining away of the liquor amnii, in April, 1920, on account of weakness of the legs, saying that for the and presumably the presentation had been a brow converted into past five weeks he had noticed that his legs were becoming stiff, an occipital during labour. Labour pains only lasted 12 hours, but followed two weeks later by unsteadiness on his feet, and numbness the brow must have been in contact with the infected cervix and tingling of his finger pads. The spleen was noticed to be for some time previous to the commencement of the pains. The definitely enlarged, about three fingers-breadth below the costal mother’s puerperiam was normal, and she left the home at the end margin, and the notch easily felt, A slight degree of anaemia was of a fortnight to be treated by her own doctor. The child’s eyes evident, and he was sent into the hospital, being admitted on April received the usual treatment, including hourly saline irrigation, 15th. His gait was weak and unsteady, and there was definite and the discharge began to clear up ; intracellular diplococci were weakness of dorsiflexion of the feet, the electrical reaction of the demonstrated in the pus. Apart from the eyes the child seemed leg muscles showing partial reaction of degeneration. Tests of healthy at birth and weighed 6 lb. 12 oz., but on the third day it sensation showed diminution to touch and pin-prick on the feet began to refuse its feeds, and was slightly cyanosed. The cry was and legs up to the knees, though the vibration sensation to a large feeble ; twitching of the facial muscles occurred several times; the tuning-fork placed on the tibias was normal. The knee-jerks, power to suck gradually disappeared, whereupon the child was Achilles, and forearm-jerks were all absent, nor could any plantar spoon-fed with the mother’s milk. The temperature remained reflexes be obtained, though the cremaster reflexes were present. subnormal; the child gradually became more feeble and more
have
"
eyes and discs normal. The blood examination showed a red cell count of 3,400,000, with haemoglobin content 60 per cent., the colour index being 0’88. There was a degree of leucopenia. the white cells numbering only 5800, though the differential count showed the polymorphs to be reduced to 23 per cent., the lymphocytes amounting to 68 per cent. Wassermann test negative. Numerous small lymphatic glands soon became palpable in the posterior triangles on both sides of his neck, and one of these was removed for microscopical examination. The healing of this wound was very troublesome, recurrent h2emorrhage occurring for several days, and his temperature, which previously had been normal, now began to show oscillations, with rises to 99’5° to 100° F. Gradually he became weaker, and he died on May 29th. Post mortem, the spleen was found considerably enlarged and soft, the liver fatty and weighing 74 oz., while microscopical examination revealed leukaemic infiltration of the liver, nerves, and kidneys, with lymphocytes. ’,
Sphincters normal ;
cyanosed, and died on the tenth day. Within 18 hours of the death I received permission to do a limited post-mortem. On removing the calvareum
The extreme intracranial congestion was found. sinuses were full of fluid blood, and injection of the pia mater was intense. When the brain was removed a purulent exudate was found on the middle of the base of the skull extending from the optic commissure backwards. There was no disintegration of the globe of either eye. The secondary condition was evidently due to infection by blood or lymph stream.
Remarks.
A CASE OF
admission presented a diagnosis pretty problem. Splenic anaemia with combined sclerosis was negatived by the fact of the absent reflexes, normal vibration sense on the legs, with no involvement of the sphincters, while the clinical picture was indeed characteristic of polyneuritis. The recognition of the type of anaemia was more difficult, the leucopenia being suggestive of splenic anaemia, but the greatly inverted lymphocytic preponderance was against this diagnosis, and was more suggestive of One of lymphatic leukaemia or lymphadenoma. the slightly enlarged glands was therefore excised for microscopical examination, but the pathological report was that it was normal, and again we were The troublesome haemorrhage from the at fault. small wound in the neck made by the surgeon was more suggestive of leukaemia than of lymphadenoma, but the diagnosis of leukaemia was not established until the tissues were microscoped after the post mortem. The extremely rare combination of wellmarked polyneuritis with leukaemia makes it desirable to place this case on record. What exactly is the association between the two conditions is perhaps hard to say. The symmetry of the polyneuritis and its resemblance to many forms of toxic polyneuritis preclude the possibility of the neuritis being due to leukaemic infiltration of the nerves producing paralysis
AMŒBIC DYSENTERY IN A BOY AGED THREE.
The
of the
case on
BY M. L. HOUSE
YOUNG, M.B., B.CH. CANTAB.,
PHYSICIAN, PADDINGTON GREEN HOSPITAL, LONDON.
CHILDREN’S
THE age of the patient and the absence of any obvious source of infection are noteworthy features of this case. Stanley K., aged 3 years, was admitted to the Paddington Green Children’s Hospital Ion Nov. 3rd, 1920, with the following history, During the six weeks prior to admission he had suffered from persistent diarrhoea, sometimes passing as many as seven stools in the 24 hours, and during the latter four weeks streaks of bright red blood and some slime had been noticed by the mother in almost every stool. Throughout this period of six weeks the boy had been bright and happy, and there had been no complaint of pain or discomfort. When admitted to the hospital he looked a perfectly healthy and unusually high-spirited boy. During the first 24 hours four loose stools were passed containing a large amount of mucus, well streaked with bright red blood, but very little fascal matter. Laboratory examination of a stool revealed the presence of the Entamaeba histolytica, much blood and mucus, and a relatively small amount of pus; no dysentery bacilli were found. It was then decided to proceed with a course of emetine hydrochloride by hypodermic injectton : 1/12th gr. was given on the first occasion, and during the following 24 hours one loose stool was passed containing much mucus but less blood. A second injection of 1/6 gr. was then given, and resulted in further improvement. Two more injections of 1/6th gr. at intervals of 24 hours were given, and a semi-solid partially formed stool was examined and found to contain a considerable quantity of mucus, a few red blood cells, and
123 two amoebae. At this time the diarrhoea, was entirely checked. After two further injections of l/6th gr., at intervals of 24 hours, the child was constipated. Examination of a stool revealed no blood, no amoebae, and no cysts.
come across cases where this point had been overlooked and the results had been most disastrous. The patient would probably live only a few weeks after The child was kept under observation in the hospital the operation. He also urged on those who were for another fortnight, and then discharged apparently thinking of taking up the surgery of the thyroid gland knowledge of completely cured. At no time during his stay in hospital the importance of a sound and extensive of specimens did the child appear in the least unwell. The father its pathological anatomy. The hundreds has never been out of England, and no source of in the London museums gave those who lived in London infection has been established. As this is the only case ample opportunity for study. Mr. Berry demonstrated his method of removing an of amoebic dysentery which has been detected at the tumour. intrathoracic the it be to since would learn Having cleared the tumour war, interesting hospital around the base of the neck, he levers it up by means the experience of other children’s hospitals. I am indebted to Dr. G. A. Sutherland for permission of a spoon about the size of a dessert-spoon bent to an angle and thrust through the thoracic inlet and beneath to publish’the case. the tumour. At the same time the tumour is pulled, Removal of intrafrom above by means of forceps. thoracic goitres was rendered possible by the fact that,. in growing downwards, they carried their vessels with them. In the case of intrathoracic tumours he usually employed light general anaesthesia. If local anaesthesia ROYAL SOCIETY OF MEDICINE. only were used the patient was apt to move at the most dangerous time-when the tumour was being pulled out of the thorax. Nevertheless, there were certain cases SECTION OF SURGERY. where local anaesthesia alone might be advisable. A Fzcrther Series of 500 Goitre Operations. Mr. Berry said that he nearly always drained by A IEET1NG of this section of the Royal society of means of a short glass tube reaching just below the Medicine was held on Jan. 5th, Mr. W. G. SPENCER, the muscles. This was practically always infra-hyoid President, being in the chair, when Mr. JAMES BERRY removed within 24 hours. Of the two deaths which contributed a paper on a Further Series of 500 Goitre occurred among patients with simple goitre, one was a Operations, with special reference to the after-results. lady of 38 who had glycosuria. She died of pneumonia, Numerous charts were exhibited showing the age and ten days after the operation without gross evidence of sex incidence, the type of tumour, reasons for operaThe other case was that of a pregnant woman sepsis. tion, the lobes affected, the after-results, &c. Many of 41, on whom the operation was performed on account patients were present and a large number of patho- of dyspnoea. There were 78 patients who had had logical specimens were on view. On the epidiascope operation for true exophthalmic goitre (one being were shown photographs of patients, and photographs operated upon twice) with three deaths, all of which and coloured drawings of the tumours which had been were due to heart failure within a few hours. Among 14 had been traced, I the cases shown was a removed. Of the 500 cases all but professional singer, who conand Mr. Berry said that from a study of these 14 cases i sulted Mr. Berry because she was losing her voice and he had no reason to suppose that the after-results were thus her means of livelihood. After operation she had anything but satisfactory. He commented upon the regained her voice completely. She demonstrated tocomparatively large number (7 out of 63 men) of men the meeting her ability to sing sustained notes. there were no over 70 years of age in his series; DismLs8’ion and Reply. A large proportion of his cases women over 70. In the course of the discussion Sir STCLAIR THOMSON were women, and this he attributed to the fact that men sought operation only when the tumour was suggested that the word " stridor " should be used causing discomfort or when it was so enormously large instead of " dyspnoea." Stridor was an objective as to produce inconvenience or such unsightliness as symptom, but dyspnoea was a subjective symptom. In would prevent them from getting employment. Women, his opinion there were three conditions of stridor which demanded operation-stridor when at rest, stridor when on the other hand, often came largely for operation for cosmetic reasons, the goitre being usually more in asleep, and stridor on exertion. Fixation of the vocal cord was also an indication for operation, and recovery evidence with them than was the case with men. With regard to the immediate reason for operation, sometimes followed successful operative treatment. in more than half of the cases of this series (274) Paralysis of the vocal cord was rarely due to cutting of operation was performed for dyspnoea. He was anxious the recurrent laryngeal nerve. Voice change often came to hear opinions as to the suitability of intra-tracheal on some weeks after operation, and was probably due ether as a mode of anaesthesia for operations of this kind. to slight suppuration and fibrosis. Mr. A. J. WALTON gave his opinion as to the indicaHe urged the importance of the anaesthetic in goitre operations, and said that he never used chloroform but tions for operation. Operation should be performed on nearly always very light open ether. The intra-tracheal well-defined adenomata, but if the adenoma was soft and method always seemed to him to be dangerous for ill-defined, immediate operation was not necessary and just those operations where he would like to use it- the condition often improved under medical treatment. namely, cases of extreme dyspnoea with very narrow When a goitre was complicated by pregnancy he would trachea. So far he had not ventured to try it always postpone operation until the pregnancy was with goitre operations of this class. In these over, unless the tumour was enormous. In " parenchypatients the trachea was so narrowed from pressure matous " goitre there was not a true increase of by the tumour that its lumen was a mere chink. parenchyma, but much increase of colloid. He preThe deep anaesthesia and extreme extension of the ferred to call this type " colloid goitre." Apart from head, both of which appeared to be necessary for the dyspnoea, no colloid goitre should be operated upon, a& introduction of the tube in intra-tracheal anaesthesia, the condition usually disappeared. Operation should be he thought most dangerous in goitres with extreme performed in cases of extreme dyspnoea. He said suffocative dyspnoea. The pressure of a tube, however that cases sometimes occurred in which atrophy of soft, in the trachea in contact with the delicate lining cartilage was so great that tracheotomy had to be of the already narrow trachea, seemed to him not performed after thyroidectomy. He considered that unlikely to produce a dangerous post-operative swelling. operation was the treatment for exophthalmic goitre of For these reasons he had never employed it. On the longer standing than about six months. He had never other hand, it might safely be employed in the less seen any permanent benefit from X rays in this consevere cases, but here there seemed no particular dition. He had had 11 cases in which prolonged X ray in it. treatment had been carried out elsewhere. Two of advantage With regard to malignant growths, he urged very these had squamous carcinoma, and there was much strongly that operation should never be performed scarring in the other cases. None appeared to have unless the thyroid not only moved up and down with the benefited. In relapsing cases X ray treatment also trachea, but was also movable on the trachea. He had appeared to be unsuccessful. one or
Medical Societies.
’