1
332 HOSPITAL MEDICINE AND SURGERY. required. There is a curious form of diarrhoea met with in elderly women, the etiology of which I do not quite under- stand. Before the proper time to get up and perhaps once or twice during dressing there occurs a mild form of diarrhoea. As this continues year after year it gradually impairs the health. I find it best treated by half a grain of codeia, or even two-thirds of a grain, about four o’clock in the morning. It should be given in the form of a pill. Sometimes chronic neuroses may be cured by breaking the continuity of the pain, for which purpose I have found this drug peculiarly suited. It is better in such cases to prescribe it in a rather large dose at a long interval, as two-thirds of a grain or a grain every twenty-four hours. This need not prevent other treat- ment being adopted if necessary. Codeia will not entirely take the place of morphia, for it is not so powerful. It will I not relieve an intense pain, but it has distinctly its own sphere of action. It is usually given in the form of pills, as it is so difficult to keep in solution. This answers very well in diabetes, in which disease, as is well known, it is invaluable. In many cases, however, a solution is decidedly preferable, and if it is dissolved by heat and a little spirit added it keeps very well except in cold weather, when it should be kept in a room with a fire. A small quantity only should be pre- pared at a time.. Cla,rendon.road, Leeds. A CASE OF INJURY TO THE THROAT AND HARD PALATE. BY SURGEON-CAPTAIN HOLMDEN, M.B., M.C. EDIN., BECHUANALAND BORDER POLICE. A NATIVE employed at a cattle post a few miles distant was brought into Macloutsie Fort, British Bechuanaland, on Dec. 14th, 1893. His companion stated that an ox had struck him beneath the chin with its horn about three hours before his arrival at the fort and that he had been bleeding from the wound, the nose, and the mouth. When I first saw the patient he was lying back in a chair, partly sensible, the mouth being slightly open. The pulse was 68 per minute, and respiration difficult ; the temperature was 98° F. There was an irregular wound about three-quarters of an inch in length, occupying the middle line between the symphysis of the lower jaw and the hyoid bone, and extending into the mouth ; there was slight haemorrhage. On examining the mouth it was seen that the horn had entered just to the left of the anterior attachment of the frsenum linguae, pushing the tongue to one side and fracturing the hard palate, and, entering the left nasal fossa, it had fractured the left inferior turbinate bone. The treat- ment consisted in the removal of spicula of bone from the hard palate and left nasal fossa, syringing the wounded parts with a 1 in 25 carbolic acid solution, and applying a wet anti- septic dressing to the external wound. On Dec. 15th the patient slept for a few hours and was able to take some fluid nourishment; the temperature was 101° and the pulse 84. On the morning of the 16th the patient was not so well, but he was still able to swallow fluids. The wounds were dusted with iodoform and boracic acid. The temperature was 101-5° and the pulse 87. Ten grains of compound ipecacuanha powder were ordered to be taken at bedtime. From this date the patient made an uninterrupted and uneventful recovery, returning to his work on Dec. 24th. NEURITIS SUPERVENING DURING THE TREATMENT OF CHOREA BY ARSENIC. BY JOHN A. ADAMS, B.A., M.B. R.U.I., SENIOR HOUSE SURGEON TO THE HALIFAX INFIRMARY. ON Sept. 15tb, 1893, a bright girl of eleven years of age was admitted into the Halifax Infirmary with well marked chorea. She had been ill for two weeks and was now unable to walk or feed herself. She was at once treated with ten- minim doses of liquor arsenicalis, B.P., three times a day. During the first week there was no change in her condition. The movements then began to get less and she continued to improve for a fortnight, during which time she had no sick- ness, diarrhoea, or other symptom of arsenical poisoning. At the end of this time she expressed herself as being much better, the choreic movements had almost ceased, she could feed herself and was permitted to get up. On Oct. 8th she complained of pain and difficulty in swallowing, when the arsenic was discontinued. Two days later she said her legs were painful and felt numb, and on examination there was found some paresis of the legs, and the calves were tender, sensa. tion was also impaired, and the patellar reflex was absent on both sides. A day or two later the arms became affected in a similar manner, and gradually all the limbs became power- less, the muscles becoming flaccid and extremely wasted. She was now unable to turn in bed or to help herself in any way. The temperature ranged from 99" F. in the morning to. 100° in the evening (on one occasion to 101°), and continued so for three weeks, when she gradually began to recover under the use of prepared food, cod-liver oil, tincture of nuxvomica, massage, and faradaism. On Jan. 12th, 1894, the patient had so far improved that she could feed herself and sit up in a chair, but could not walk properly. The numbness had dis- appeared, and the muscles had regained much of their strength and tone. The interesting point about this case is- in view of the present much-advocated use of large doses of arsenic in the treatment of chorea-the possibility of the occurrence of peripheral neuritis without any of the cardinal symptoms of arsenical poisoning, though the case be closely watched in hospital. A Mirror OF HOSPITAL PRACTICE, BRITISH AND FOREIGN. Nullaautem est alia pro certo noscendi via, nisi quamplnrimas etmor. borum et dissectionum historias, turn aliorum turn proprias collectay habere, et inter se compa.ra.re.—MORGASNI De Sed. et Caus. fort. lib. iv. Procemium. - MIDDLESEX HOSPITAL. A CASE OF CANCER OF THE THYROID GLAND; DEATH ; NECROPSY. (Under the care of Mr. HENRY MORRIS.) MALIGNANT disease of the thyroid gland may be either primary or secondary, and secondary disease by extension, from neighbouring structures, especially from the ceso- phagus, is the more common and less important. Most of our museums contain specimens which purport to be malig. nant disease of the thyroid gland, but it is not always possible to tell whether they are sarcomatous or carcinomatous, and unless they have been examined microscopically by some one known to be conversant with the occasional resemblance of innocent tumours of the thyroid gland to malignant ones, a statement that a particular tumour was cancerous-when its clinical characters were those of a simple growth-would be received with hesitation. These specimens are not numerous, nor are the cases recorded in surgical literature. Besides the rarity of the disease there are many points in this completed record which render it of unusual interest. There was no history of previous enlargement of the gland, and in the majority of such cases this is said to have been met with. Malignant goitre is more common in Switzerland, where goitre of simple cha- racter is frequent, and is more common in females. This case is a good example of the disease, on account of its rapidity of progress, severe pain, infiltration of parts, and the history of the attacks of dyspnoea early in the illness. Death ensued from suffocation, but the exact way in which it was brought about is not very evident, there being no growth in the air passages or hemorrhage into the substance of the tumour. At present the number of instances in which a successful treatment of malignant disease of the thyroid gland can be claimed is so small that operation is scarcely justified even in apparently favourable cases. There was no chance of attempting any- thing in the way of removal in this case. Dr. Koester has given the results of fifty cases of operation for "cancer "of the thyroid gland. Eight of the patients died within twenty- four hours of operation, five at the end of the first week and eight at the end of the second week. Only four remained free from recurrence at the end of six months. but one continued well at the end of at least four years after the operation. We are indebted for the following notes to Mr. G. H. A. Berkeley, house surgeon. A man forty years of age was admitted into the Middlesex

A CASE OF INJURY TO THE THROAT AND HARD PALATE

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332 HOSPITAL MEDICINE AND SURGERY.

required. There is a curious form of diarrhoea met with inelderly women, the etiology of which I do not quite under-stand. Before the proper time to get up and perhaps once ortwice during dressing there occurs a mild form of diarrhoea.As this continues year after year it gradually impairs thehealth. I find it best treated by half a grain of codeia, oreven two-thirds of a grain, about four o’clock in the morning.It should be given in the form of a pill. Sometimes chronicneuroses may be cured by breaking the continuity of the pain,for which purpose I have found this drug peculiarly suited.It is better in such cases to prescribe it in a rather largedose at a long interval, as two-thirds of a grain or a grainevery twenty-four hours. This need not prevent other treat-ment being adopted if necessary. Codeia will not entirelytake the place of morphia, for it is not so powerful. It will Inot relieve an intense pain, but it has distinctly its own sphereof action. It is usually given in the form of pills, as it isso difficult to keep in solution. This answers very well indiabetes, in which disease, as is well known, it is invaluable.In many cases, however, a solution is decidedly preferable,and if it is dissolved by heat and a little spirit added it keepsvery well except in cold weather, when it should be kept ina room with a fire. A small quantity only should be pre-pared at a time..Cla,rendon.road, Leeds.

A CASE OF INJURY TO THE THROAT AND HARDPALATE.

BY SURGEON-CAPTAIN HOLMDEN, M.B., M.C. EDIN.,BECHUANALAND BORDER POLICE.

A NATIVE employed at a cattle post a few miles distantwas brought into Macloutsie Fort, British Bechuanaland,on Dec. 14th, 1893. His companion stated that an oxhad struck him beneath the chin with its horn about threehours before his arrival at the fort and that he had beenbleeding from the wound, the nose, and the mouth.When I first saw the patient he was lying back in achair, partly sensible, the mouth being slightly open. The

pulse was 68 per minute, and respiration difficult ; thetemperature was 98° F. There was an irregular wound aboutthree-quarters of an inch in length, occupying the middleline between the symphysis of the lower jaw and the hyoidbone, and extending into the mouth ; there was slighthaemorrhage. On examining the mouth it was seen that thehorn had entered just to the left of the anterior attachmentof the frsenum linguae, pushing the tongue to one side andfracturing the hard palate, and, entering the left nasal fossa,it had fractured the left inferior turbinate bone. The treat-ment consisted in the removal of spicula of bone from thehard palate and left nasal fossa, syringing the wounded partswith a 1 in 25 carbolic acid solution, and applying a wet anti-septic dressing to the external wound.On Dec. 15th the patient slept for a few hours and was

able to take some fluid nourishment; the temperature was101° and the pulse 84. On the morning of the 16th thepatient was not so well, but he was still able to swallowfluids. The wounds were dusted with iodoform and boracicacid. The temperature was 101-5° and the pulse 87. Ten

grains of compound ipecacuanha powder were ordered to betaken at bedtime. From this date the patient made anuninterrupted and uneventful recovery, returning to his workon Dec. 24th.

_____

NEURITIS SUPERVENING DURING THE TREATMENTOF CHOREA BY ARSENIC.

BY JOHN A. ADAMS, B.A., M.B. R.U.I.,SENIOR HOUSE SURGEON TO THE HALIFAX INFIRMARY.

ON Sept. 15tb, 1893, a bright girl of eleven years of agewas admitted into the Halifax Infirmary with well markedchorea. She had been ill for two weeks and was now unableto walk or feed herself. She was at once treated with ten-minim doses of liquor arsenicalis, B.P., three times a day.During the first week there was no change in her condition.The movements then began to get less and she continuedto improve for a fortnight, during which time she had no sick-ness, diarrhoea, or other symptom of arsenical poisoning. Atthe end of this time she expressed herself as being muchbetter, the choreic movements had almost ceased, she could

feed herself and was permitted to get up. On Oct. 8th shecomplained of pain and difficulty in swallowing, when thearsenic was discontinued. Two days later she said her legs werepainful and felt numb, and on examination there was foundsome paresis of the legs, and the calves were tender, sensa.tion was also impaired, and the patellar reflex was absent onboth sides. A day or two later the arms became affected ina similar manner, and gradually all the limbs became power-less, the muscles becoming flaccid and extremely wasted.She was now unable to turn in bed or to help herself in anyway. The temperature ranged from 99" F. in the morning to.100° in the evening (on one occasion to 101°), and continuedso for three weeks, when she gradually began to recover underthe use of prepared food, cod-liver oil, tincture of nuxvomica,massage, and faradaism. On Jan. 12th, 1894, the patienthad so far improved that she could feed herself and sit up ina chair, but could not walk properly. The numbness had dis-appeared, and the muscles had regained much of theirstrength and tone. The interesting point about this case is-in view of the present much-advocated use of large doses ofarsenic in the treatment of chorea-the possibility of theoccurrence of peripheral neuritis without any of the cardinalsymptoms of arsenical poisoning, though the case be closelywatched in hospital.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

Nullaautem est alia pro certo noscendi via, nisi quamplnrimas etmor.borum et dissectionum historias, turn aliorum turn proprias collectayhabere, et inter se compa.ra.re.—MORGASNI De Sed. et Caus. fort.lib. iv. Procemium. -

MIDDLESEX HOSPITAL.A CASE OF CANCER OF THE THYROID GLAND;

DEATH ; NECROPSY.

(Under the care of Mr. HENRY MORRIS.)MALIGNANT disease of the thyroid gland may be either

primary or secondary, and secondary disease by extension,from neighbouring structures, especially from the ceso-

phagus, is the more common and less important. Most ofour museums contain specimens which purport to be malig.nant disease of the thyroid gland, but it is not always possibleto tell whether they are sarcomatous or carcinomatous, andunless they have been examined microscopically by some oneknown to be conversant with the occasional resemblance ofinnocent tumours of the thyroid gland to malignant ones, astatement that a particular tumour was cancerous-whenits clinical characters were those of a simple growth-would bereceived with hesitation. These specimens are not numerous,nor are the cases recorded in surgical literature. Besides therarity of the disease there are many points in this completedrecord which render it of unusual interest. There was no historyof previous enlargement of the gland, and in the majority ofsuch cases this is said to have been met with. Malignant goitreis more common in Switzerland, where goitre of simple cha-racter is frequent, and is more common in females. This caseis a good example of the disease, on account of its rapidity ofprogress, severe pain, infiltration of parts, and the history of theattacks of dyspnoea early in the illness. Death ensued fromsuffocation, but the exact way in which it was brought about isnot very evident, there being no growth in the air passages orhemorrhage into the substance of the tumour. At presentthe number of instances in which a successful treatment ofmalignant disease of the thyroid gland can be claimed is sosmall that operation is scarcely justified even in apparentlyfavourable cases. There was no chance of attempting any-thing in the way of removal in this case. Dr. Koester hasgiven the results of fifty cases of operation for "cancer "ofthe thyroid gland. Eight of the patients died within twenty-four hours of operation, five at the end of the first weekand eight at the end of the second week. Only fourremained free from recurrence at the end of six months.but one continued well at the end of at least four yearsafter the operation. We are indebted for the followingnotes to Mr. G. H. A. Berkeley, house surgeon.A man forty years of age was admitted into the Middlesex