1065HOSPITAL MEDICINE AND SURGERY.

as usual." If we accept this statement we have a right toassume that, the great cooling mechanism of the body beingrelatively inactive while heat production was excessive, theremust have been hyperpyrexia and a condition not unlike someforms of heat apoplexy. If there was hyperpyrexia, wehave a condition, in addition to the exercise, which certainlywould exert an influence over the nature and quantityof the tissue waste. I think there is no evidence whateverthat the attack was in any degree attributable to heartfailure. The heart has always appeared strong and in everyway normal, and the vigorous struggles of the patient duringhis unsonsciousness negative the idea of cardiac exhaustion.It is possible, however, that the copious draught of waterwhich he took in the dressing tent may have caused a flow ofblood into the abdominal vessels and have indirectly pro-duced sufficient cerebral anaemia to determine the suddenonset of unconsciousness. You will have gathered from theseremarks that there were three conditions which, so to say,made for unconsciousness-viz., (a) waste products circulatingin the blood, (b) hyperpyrexia, and (e) sudden cerebralanaemia. A very important point is the prognosis. Is thisman’s career as an athlete at an end ? Or may we tell him togoon attempting to add to the :E140 worth of prizes which hestates he has won in the last three years ? 7 Is this attack apure accident, or is it liable to recur ? 7 These are questionsto which an answer is expected. It would be safest, perhaps(for ourselves), to tell him on no account to run again, butby giving such safe advice we may deprive him of a notinconsiderable income, which he may still be quite competentto earn with safety. Certain it is that the man is organi-cally quite sound, and before advising him to give up usinghis fine body in manly exercises let us look to his historyand see if there be any circumstance which may havean important bearing upon the matter. First the patientstated that he felt out of sorts" when he started for

his race, and although all one can say of being "outof sorts" is that it indicates some derangement in theworking of the machinery of the body, it is impossiblenot to believe that such derangement must have had animportant bearing on the contretemps for which he wasadmitted here. I am inclined to attach considerable impor-tance to his diet on the day of the race. At 6.30 A. M. he hadtwo eggs, two cups of tea, and some toast, and at 11 30 A, M.he had a mutton chop and dry toast, but nothing to drink. Acup of tea was put before him at the midday meai, but hedid not like it and put it aside. The amount of food takenon the day of the race seems small in its relation to the manand his work, and it is almost certain that the amount offluid taken was too small, and I am inclined to attach con-siderable importance to the fact that, owing to an acci-dental circumstance, he took no fluid with his midday meal.If a man starts on such a race with too little fluid in himthe excretion by the skin and kidneys will be hampered andhis risk of auto-intoxication and hyperpyrexia be increased.In the Turkish bath, when a bather does not sweat the atten-dants offer him some tepid water, and in the majority ofcases the body will bead with perspiration within a fewseconds of taking it. If a normal amount of diaphoresis hadbeen started in our patient it is possible that his attacks ofinsensibility might not have occurred. In his work on

bodily exercise Lagrange touches upon the subject ofauto-intoxication, and he asserts that, although not verycommon in human beings (unless we include many ofthe cases of so-called I I sunstroke " occurring in soldiers aftera long march), it is far from uncommon in hunted animals,which, he says, are not seldom found dead in their lairs onthe day following a prolonged Itunt. It is to be regrettedthat no careful examination of the patient was made in thehours immediately succeeding the race. A record of tem-perature and an analysis of the first urine secreted mighthave thrown considerable light on the case, but the circum-stances were obviously such as to preclude such investiga-tions. After his admission here the highest temperaturerecorded was 99° F., the urine was high coloured, but other-wise normal, and the one other point of note is that thebreath was "foul," a fact which tends to justify one inranging the case alongside of I I uroemia ". and diabetes. "

MANCHESTER ROYAL INFIRMARY.TWO CASES OF PERSISTENT THYREOCLOSSAL DUCT.

(Under the care of Mr. WHITEHEAD and Mr. HARDIE.)THESE cases are excellent examples of the effects of per-

sistence of the thyreoglossal duct, and should be read in I

connexion with the account of a paper by Mr. H. K. Durhamrecently given before the Royal Medical and ChirurgicaSociety and published in THM LANC&bgr;T.J As the modeof formation of this duct may perhaps not be remembereby all our readers, we give the following account froma recent text-book. 2 "In the human embryo the thyroidremains for some time as a bifid hollow vesicle, whichis connected with the upper surface of the tongue bya small duct (ductus thyreoglossus) ; subsequently, how-ever, the vesicle becomes solid, and the duct is obliteratedand disappears, with the exception of a small portionnear the orifice, which becomes converted into the foramencascum of Morgagni. Occasionally even in the adult a

comparatively long duct is found, leading downwards andbackwards from the foramen caecum. This, which hatbeen called the ductus lingualis, is the remains of the

original thyrolingual duct connecting the median part of thethyroid with the tongue. It may further happen that thelower part of this connexion also remains in the shape of atubular prolongation of the median portion of the thyroidtowards the root of the tongue (ductus tbyroideus, when weKdeveloped this forms the pyramid)." For the notes of thesecases we are indebted to Mr. P. R. Cooper and Mr. S. ColleySalter, house surgeons.CASE 1 (under the care of Mr. Whitehead).-A woman

twenty years of age was admitted to the ManchesterRoyal Infirmary on Jan. 12th, 1894, for the removal ofa small fistula situated close above the thyroid isthmus,and respecting which the following history was elicited.Seven years previously she first noticed a round lumpthe size of a hazel nut, situated in the middle line ofthe neck just below the larynx. This lump, although fairlytense, was not painful, and at first gave her no trouble. It

gradually enlarged, however, and at the end of six monthsshe sought medical relief. Painting the swelling with iodinewas tried for several months, but without effect. Thetumour was next punctured, and its viscid yellowish con-tents squeezed out, a small aperture subsequently remainingand discharging glairy fluid for nearly two years. An

attempt was then made to close the fistula by operation.After this it remained quiescent for four years. Three months

ago, however, another smaller and more painful swellingappeared in the site of the former one. At the lower part df.this a little blue bleb soon formed. This bleb was pricked,more mucoid material evacuated, and the fistula had sincebeen constantly "making up and breaking down again.’’’On admission to hospital the patient was a healthy lookingcountry girl. She complained of nothing except the " placeon her neck," which annoyed her both by its unsightlinessand its continual discharge. Situated in the medianline of the neck, and immediately above the thyroidisthmus, was a small reddish opening, about a quarterof an inch in diameter, the floor and margins of whichwere lined by a velvety red mucous membrane, looking atfirst sight like granulation tissue. From this mucous surfacewas seen oozing, drop by drop, a colourless glairy secretion. On probing, a passage was found to lead directlyupwards for about two inches under the skin, ending blindlybehind the hyoid bone. Inferiorly an impervious cord couldbe felt extending for about half an inch downwards an’slightly to the right side to join the substance of the thyroidisthmus. The fistula was surrounded by a concentric scaithe size of a florin. On swallowing tension was exerted onthe scar at the mouth of the fistula. In Mr. Whitehead’scase, however, the cyst formed from the thyreoglossal ducthad opened externally, and a fistula had thus become estab.lished. On Jan. 12th the patient wa,s anæsthetised, and theneck having been well cleaned, Mr. Whitehead laid open thefistula with a scalpel, and then with scissors dissected away

every visible trace of mucous membrane. There was moderatelyfree hbemorrhage, especially from the lower part, where themucous membrane appeared to be in continuity with thyroidtissue. The haemorrhage was arrested by pressure. Th(wound was then flushed out with hot water, dried, dustedwith iodoform, accurately sutured, and dressings were appliedso as to exert firm and equable pressure on the wound. Theeffects of the anaesthetic were soon recovered from. Thetemperature and general condition after the operation werenormal. The head was kept between sand-bags and theneck perfectly at rest for ten days. Slight pain on swallowing was felt for the first few days, otherwise the patient wasquite comfortable. On the tenth day the dressings wereremoved, the wound was found to be completely healed by

1 THE LANCET, April 14th, 1894.2 Quain, Embryology, p. 110.

1068 ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

first intention, the stitches were taken out, and the patientreturned to her home.CASE 2 (under the care of Mr. Hardie).-A boy thirteen

years of age was admitted to the Manchester RoyalInfirmary on Feb. 4th for the removal of a small cherry-like projection in the middle line of his neck. The patientwas said to have been born with a swelling in the positionindicated, which was thought by his parents to be aprominent Adam’s apple." It was about the size of ahazel nut, covered with normal skin and quite painless ;consequently it did not excite much attention until abouttwo years previously, when, apparently owing to the frictionof the collar-stud, it became red and inflamed. It was thenpoulticed for some time, with the result that the swellingburst and discharged a small quantity-about half a tea-spoonful—of "thin yellow matter." After discharging fora time it became closed over by a thin reddish pellicle,which, on one or two subsequent occasions, broke down, thesame kind of " matter being discharged. " Local applicationsof iodine paint were also tried, but, appearing to have no effecton the condition, surgical interference was sought. Thefollowing is a description of the cyst on the patient’s admis-sion to hospital. Exactly in the middle line of the neck, justbelow the cricoid cartilage, was a small reddish cystic pro-jection about the size of, and closely resembling, a cherry,and moving up and down in the act of deglutition. It wascovered by a thin shining epithelial-like pellicle, which

abruptly terminated in the surrounding skin. The skinimmediately above was puckered in a crescentic manner. On

grasping and making traction on the projection it wasfound to move freely from side to side below, but leadingup from it in the middle line above was felt a firm fibrouscord, which, on being rendered tense, could be traced asfar as the thyro-hyoid space, where it seemed to dipbackwards and disappear behind the hyoid bone. Whilstmaking traction on it the patient experienced the sensationof something pulling on the back of the tongue. Onintroducing a probe a few drops of transparent, slightlyyellowish, glairy fluid escaped, and the probe passed aboutone inch and a half along the before-mentioned fibrous cord.On Feb. 24th Mr. Hardie passed a director along the duct,and, having laid it open, dissected it out with its fibrousinvestment to its full extent by means of scissors. The lengthof the part removed was about two inches and a half. Itwas submitted to microscopic examination and was found toconsist chiefly of firm fibrous tissue, with inflammatory cell-formation, lined by mucous membrane having columnarciliated epithelium. The mucous membrane was absent fromthe cystic portion, and was replaced by granulation tissue.No thyroid tissue was found. The operation wound healedby primary union, and the patient was discharged in aboutten days.

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL

SOCIETY.

Case of Extra-Peritoneal Vesical Hernia.-Operationfor Cureof Cleft of Hard and Soft Palate.

AN ordinary meeting of this society was held on April 24th,the PRESIDENT, Mr. Hutchinson, being in the chair.A paper on a case of Extra-Peritoneal Vesical Hernia by

Dr. ERNST MICHELS was communicated by Mr. R. W. PARKER.A man forty-eight years of age was admitted into the GermanHospital suffering from inguinal hernia on both sides. Onthe left side radical operation was done without any diffi-culty. On the right side the operation was more compli-cated, owing to the matting together of the different layers.At last what appeared to be the empty sac was reached,isolated with some difficulty, tied at its neck, and cut away ;the stump was put back into the abdomen, and the inguinalring closed. Twenty-four hours after the operation the patientbegan to complain of pain in the hvpogastrium, and theurine contained a large admixture of blood. It was evidentnow that what had been taken for and treated as an emptyhernial sac was in reality an extra-peritoneal diverticulum ofthe bladder. The abdomen was opened at once, the bladderfully exposed, and a wound discovered in its extra-peritonealpart, which was closed by a double row of sutures. AJacques’ catheter was passed into the bladder and retained

for six days. The patient made an uninterrupted recovery.From an examination of the hitherto published cases

it appeared that there were two distinct kinds ofvesical hernia. In the great majority of cases theintra-peritoneal kind was found, a hernial sac descendingthrough the inguinal ring and drawing down the intra-peri.toneal part of the bladder, which in these cases was placedbehind the sac. The descent of the extra-peritoneal part ofthe bladder, of which the case recorded above was an instance,was much rarer, only five cases having been hitherto published.In both varieties it was extremely difficult to recognise thenature of the structure, no symptoms pointing to the presenceof the bladder in the hernial sac, and in almost all the casesthe bladder had been wounded; even then in a number ofcases the true state of things was not discovered until sometime had elapsed, and signs of injury to the bladder haddeveloped. The correct treatment consisted, of course,in full exposure of the wounded bladder, and closureof the wound by sutures. Under these circumstancesthe prognosis seemed fairly good.-Mr. PARKER said thatnow that such a number of operations were being dailyperformed for the radical cure of hernia the possibilityof this accident was worth bearing in mind. It appearedfrom the published records of cases that when earlyrecognised and efficiently treated it was not such a for-midable complication. He stated that he had performeda large number of radical cures in young children beforethe hernia had become large and the relations of theparts much altered ; the patients were thus saved from allthe grave disadvantages of hernia in later life. He showeda large hernial sac which he had removed from a manwho had been much inconvenienced by the presence of therupture. In another instance, in a child, a hernia sud.denly appeared in the canal of Nuck, and its appearance wasaccompanied by vomiting, but there was diarrhoea insteadof constipation. The infant, which was very weak, shortlyafterwards died, and the hernial swelling was found to con-tain a right ovary tightly strangulated and gangrenous.-Mr. MACREADY remarked that the accidental opening of thebladder in these cases had been done by many accomplishedsurgeons, and he was, therefore, not ashamed to confess thatan instance had happened in his own practice. The patient wasa woman aged sixty-seven, who had been ruptured since theage of fifty, but had been always able to return the rupturetill the time of her admission with strangulation. The rupturewas femoral, and on the right side. The sac was opened andthe gut returned ; the sac was then isolated, transfixed, tiedin two parts, and the fundus cut off. Three days later therewas a sanio-purulent discharge from the wound, staining thedressings. On the ninth day a clear fluid was found tricklingfrom the wound, and, a tube being passed into the orifice,three ounces of urine were drawn off from the groin. Thebladder being emptied, some Condy’s fiuid was injected intothat viscus, and it returned through the wound. A catheterwas tied into the bladder and the urinary fistula in the woundsoon closed, the patient making a good recovery. The presenceof the bladder in an inguinal rupture was rare, but in afemoral rupture still rarer. The classification adopted byDr. Michels, while unusual, was yet judicious. It was

advisable in practice to trace back the neck of every thicksac and make manifest the point of origin of the thickening.In cases of hernia of the intra-peritoneal portion of thebladder it would be difficult to miss detecting the presenceof the bladder in the hernia if the finger was passed alongthe neck of the sac into the ring. Though excellent resultsmight follow the immediate closure of the wound in thebladder, yet it was better practice to avoid the accident.-Mr. KEETLEY said that he believed vesical hernia to be muchmore common than most surgeons imagined. He had him-self seen the bladder three times in a hernial sac, and he hadonce punctured that viscus with a suture needle while closingthe ring. In that case he knew that the bladder was in thewall of the sac, but he was tempted to go a little higher upwith his suture than was safe. He sewed up the punctureand the patient did well. If in the wall of the sac beside orbehind the neck a thick cushion of fat was found thebladder might be suspected to be near at hand. The morefrequent occurrence of the bladder in hernias had not hithertobeen recognised because until comparatively recently but littleattention had been paid to the contents of hernias in theinguinal canal. He believed that in the great majorityof cases in which the bladder was present it was neitheraltogether intra- nor extra-peritoneal, but a’ mixture ofthe two. When operating recently on a case in whichthis condition was present two of the medical men present