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1003 began to be restless. The bowels were opened several times and ,he had vomited once since 11 30 P.M. She died at A.M on May 2nd. At the post-mortem examination the iLtMtines were found to be matted together with recent lymph, and there was also some purulent fluid in the peritoneal cavity. At the apex of the appendix there was a small perforation in the centre of a black slough. In the appendix there was a small hardened mass of fmces. There was no other lesion. CASE 3 -This was that of a man aged thirty-eight who was admitted into the infirmary on Jan. llth, 1891, suffering from acute peritonitis, with great abdominal distension and pain referred to the region of the cæcum. The following was the history given. He had previously had several attacks of pain in the abdomen, but never so severe as on that occasion. The attack had commenced suddenly on Jan. 4th with great pain over the hypogastrium and right side of the abdomen, and was supposed to be biliary colic ; it was accompanied by vomiting. The bowels were constipated until Jan. 9th, when they were freely moved seven times. On Jan. llth he was admitted into the infirmary at 9 30 P.M. The patient was emaciated and ansemic. The pulse was small and rapid. The abdomen was much distended. Rectal examination was negative. He complained of great pain, especially in the epigastrium and right side of the abdomen. At 10.30 P.:lII. abdominal section was performed. There was general purulent peritonitis, with a collection of stinking pus in the right lumbar region, which seemed to proceed from behind the liver, but no distinct cause could be made out The vermiform appendix was normal. The abdomen was washed out, a large drainage-tube was inserted, and the abdominal walls were then stitched up. The patient never rallied and died on Jan. 12th at 7 A. M. At the post-mortem examination purulent peritonitis was found to be present. The intestines were much distended. The cause of the peritonitis was discovered to be the perforation of an ulcer on the posterior surface of the pylorus ; the contents of the stomach had escaped therefrom and, together with pus &c thus produced, had passed underneath the liver and into the right lumbar region of the abdominal cavity. Renaarks by Mr. H. THMSON.- The difficulties experi- enced in diagnosing the causes of abdominal mischief are so well known that they have given rise to the phrase- first evolved, I believe, by Mr. Lawson Tait-"that you cannot tell of what wood a table is made until you remove the cloth." " In the first case the facts to be noted are the apparently previous perfect health of the patient, the severe blow over the abdomen, followed immediately by great pain, together with many of the symptoms of probable injury of intestine or other lesions, but which abdominal section demonstrated to be caused by the perforation of a previously diseased vermiform appendix of which there had been no symptoms, and which perforation was probably immediately caused by the blow, although it was liable to occur at any time without traumatism. In the second case it is to be noticed that there was a history of previous malaise for about a week, but on admission the diagnosis was most uncertain. When under chloroform there was such a distinct feeling of fulness in the left flank that, in spite of the absence of blood-stained mucus from the anus or of a tumour to be felt there, the case was looked upon as one of intussusception. This diagnosis seemed to be bome out by the results of the treatment adopted- the bowels were well moved, the swelling disappeared, and for a short time the patient seemed to go on favourably. Collapse, however, set in, and she died fifteen hours after admission. Of course, if the symptoms had not apparently improved so much I should have proceeded with abdominal section if the condition of the child would have admitted of it, which was very doubtful. The tumour felt on the left side of the abdomen, which disappeared under treatment, was no doubt a mass of faeces in the rectum and sigmoid I, flexure; but it was certainly remarkable that even under chloroform no thickening or enlargement could be felt in the region of the vermiform appendix. In the third case, the man only being seen for the first time when Mt extremis, the diagnosis was mere guesswork, and unfor- tunately was only clearly made out at the post-mortem exami- nation. Probably there had been, during one or more of the previous attacks of pain, slight leaking through the ulcer ; this had produced a local collection of purulent mateiial, which had become more or less encapsuled, and it was only on the giving way of this collection into the general cavity of the peritoneum that the serious symptoms developed. Medical Societies. MEDICAL SOCIETY OF LONDON. Some Less-known Factors in Graves’ Disease.-Specimens of Exophthalmic Goirre. THE first ordinary meeting of this Society was held on Oct. 16th, the chair being taken by Dr. DE HAVILLAND HALL, Vice-President, in the unavoidable absence of the President, Dr. Bristowe. Mr. ARTHUR MAUDE read a paper on Some Less-known Factors in Graves’ Disease. He said that by watching cases very carefully and continuously he was convinced that some variation in the size of the thyroid gland was always present even in very early cases. There was little statistical evidence that Graves’ disease was unknown in districts where goitre was common, as was commonly stated, but it was rare in India. On the other hand, he had found 15 cases amongst 55 of enlarged thyroid gland in a small country district. Graves’ disease was said not to occur in previously goitrous persons, but he had collected 7 cases, of which he gave details. Attention was then turned to the connexion between Graves’ disease and mxyoedema, and to the results of operation on the thyroid gland for Graves’ disease, 20 of which were collected last year by him. He then reviewed the nervous disturbances of Graves’ disease which were not due to vaso-motor changes, beginning with the psychoses. He described two conditions as common : s (1) a hyper-sensitive notion of duty and (2) an incoherence of ideas ; and he described a disturbance of conscious- ness resembling ambulatory epilepsy. After mentioning the tremor as almost the commonest symptom of the disease, and touching briefly on the existence of convulsions, he described a peculiar form of clonic spasm. in a young woman. The bulbar signs and the numerous cases of ophthalmo- plegia were reviewed. It was claimed that many of the common symptoms were due to peripheral neuritis-e.g , cramps, hypersesthesia, symmetrical paresis of the legs, hyperaesthesia, pains and lowered patellar reflexes. Glyco- suria was never found in these cases. On the question of pathology Mr. Maude thought that no focal lesion in the sympathetic or medulla could possibly explain the condition, which must be due to some general nerve poison, probably to be found in the thyroid gland. The fact that the thyroid gland was already enlarged, that operations on that gland had neaily always relieved the symptoms, and the connexion with mygoedema were all evidence, he thought, in support of this theory Dr. DE HAVILLAND HALL said that Mr. Maude did not allude to the association of intra-nasal charges with Graves’ disease. Dr. Semon had removed a polypus from the nose with the actual cautery, which seemed to cure a liability to asthma, but was the starting point of unilateral enlargement of the thyroid gland. The fact that cases of Graves’ disease had been cured by intra-nasal treatment seemed to suggest a sympathetic origin in some cases at least. Dr. PASTEUR said that he had ascertained from a competent authority in Switzerland that, although ordinary goitre was extremely common, Graves’ disease was a comparatively rare affection. The general view of physicians there was against altitude having anything to do with the production of the condition. Dr. BOWLES said that he had met with two cases in which there had been Graves’ disease in early life and myxoedema developed afterwards. From personal obselva- tion he thought that Kocher was right in his assertion that removal of the thyroid gland produced myxœdema, though if a small portion of the organ was left myxoedema did not develop. Kocher had endeavoured to transplant pieces of the thyroid gland into various parts of the body, and he had seen that operator insert a piece of the thyroid gland of a healthy dog into the tunica vaginalis testis of a boy whose thyroid gland had been removed, and he likewise inserted a portion into the divided femoral artery of the same patient. Dr. BURNEY YEO had made some observations on exoph- thalmic goitre fifteen years ago. He showed one case in which there was a left exophthalmos and an enlarged thyroid gland on the right side ; on the left side the hairs of the eyebrow and eyelashes had disappeared. Later the thyroid on the left side enlarged, and this was followed by a baldness of the opposite eyebrow and eyelashes. The same crossed phenomena
Transcript
Page 1: MEDICAL SOCIETY OF LONDON

1003

began to be restless. The bowels were opened several timesand ,he had vomited once since 11 30 P.M. She died atA.M on May 2nd. At the post-mortem examination the

iLtMtines were found to be matted together with recent lymph,and there was also some purulent fluid in the peritonealcavity. At the apex of the appendix there was a small

perforation in the centre of a black slough. In the appendixthere was a small hardened mass of fmces. There was noother lesion.CASE 3 -This was that of a man aged thirty-eight who

was admitted into the infirmary on Jan. llth, 1891, sufferingfrom acute peritonitis, with great abdominal distension andpain referred to the region of the cæcum. The following wasthe history given. He had previously had several attacksof pain in the abdomen, but never so severe as on thatoccasion. The attack had commenced suddenly on Jan. 4thwith great pain over the hypogastrium and right side of theabdomen, and was supposed to be biliary colic ; it was

accompanied by vomiting. The bowels were constipateduntil Jan. 9th, when they were freely moved seven times. OnJan. llth he was admitted into the infirmary at 9 30 P.M.The patient was emaciated and ansemic. The pulse wassmall and rapid. The abdomen was much distended. Rectalexamination was negative. He complained of great pain,especially in the epigastrium and right side of the abdomen.At 10.30 P.:lII. abdominal section was performed. There was

general purulent peritonitis, with a collection of stinking pusin the right lumbar region, which seemed to proceed frombehind the liver, but no distinct cause could be made outThe vermiform appendix was normal. The abdomen waswashed out, a large drainage-tube was inserted, and theabdominal walls were then stitched up. The patient neverrallied and died on Jan. 12th at 7 A. M. At the post-mortemexamination purulent peritonitis was found to be present. Theintestines were much distended. The cause of the peritonitiswas discovered to be the perforation of an ulcer on the posteriorsurface of the pylorus ; the contents of the stomach had

escaped therefrom and, together with pus &c thus produced,had passed underneath the liver and into the right lumbarregion of the abdominal cavity.Renaarks by Mr. H. THMSON.- The difficulties experi-

enced in diagnosing the causes of abdominal mischief areso well known that they have given rise to the phrase-first evolved, I believe, by Mr. Lawson Tait-"that you cannottell of what wood a table is made until you remove thecloth." " In the first case the facts to be noted are the

apparently previous perfect health of the patient, the severeblow over the abdomen, followed immediately by great pain,together with many of the symptoms of probable injury ofintestine or other lesions, but which abdominal sectiondemonstrated to be caused by the perforation of a previouslydiseased vermiform appendix of which there had been nosymptoms, and which perforation was probably immediatelycaused by the blow, although it was liable to occur at anytime without traumatism. In the second case it is tobe noticed that there was a history of previous malaisefor about a week, but on admission the diagnosis wasmost uncertain. When under chloroform there was sucha distinct feeling of fulness in the left flank that, in

spite of the absence of blood-stained mucus from theanus or of a tumour to be felt there, the case was lookedupon as one of intussusception. This diagnosis seemedto be bome out by the results of the treatment adopted-the bowels were well moved, the swelling disappeared, andfor a short time the patient seemed to go on favourably.Collapse, however, set in, and she died fifteen hours afteradmission. Of course, if the symptoms had not apparentlyimproved so much I should have proceeded with abdominalsection if the condition of the child would have admitted ofit, which was very doubtful. The tumour felt on the leftside of the abdomen, which disappeared under treatment,was no doubt a mass of faeces in the rectum and sigmoid I,flexure; but it was certainly remarkable that even underchloroform no thickening or enlargement could be feltin the region of the vermiform appendix. In the thirdcase, the man only being seen for the first time whenMt extremis, the diagnosis was mere guesswork, and unfor-tunately was only clearly made out at the post-mortem exami-nation. Probably there had been, during one or more of theprevious attacks of pain, slight leaking through the ulcer ;this had produced a local collection of purulent mateiial,which had become more or less encapsuled, and it was onlyon the giving way of this collection into the general cavity ofthe peritoneum that the serious symptoms developed.

Medical Societies.MEDICAL SOCIETY OF LONDON.

Some Less-known Factors in Graves’ Disease.-Specimens ofExophthalmic Goirre.

THE first ordinary meeting of this Society was held onOct. 16th, the chair being taken by Dr. DE HAVILLAND HALL,Vice-President, in the unavoidable absence of the President,Dr. Bristowe.

Mr. ARTHUR MAUDE read a paper on Some Less-knownFactors in Graves’ Disease. He said that by watching casesvery carefully and continuously he was convinced that somevariation in the size of the thyroid gland was always presenteven in very early cases. There was little statistical evidencethat Graves’ disease was unknown in districts where goitrewas common, as was commonly stated, but it was rare inIndia. On the other hand, he had found 15 cases amongst55 of enlarged thyroid gland in a small country district.Graves’ disease was said not to occur in previously goitrouspersons, but he had collected 7 cases, of which he gavedetails. Attention was then turned to the connexionbetween Graves’ disease and mxyoedema, and to the resultsof operation on the thyroid gland for Graves’ disease, 20of which were collected last year by him. He thenreviewed the nervous disturbances of Graves’ disease whichwere not due to vaso-motor changes, beginning with thepsychoses. He described two conditions as common : s

(1) a hyper-sensitive notion of duty and (2) an incoherenceof ideas ; and he described a disturbance of conscious-ness resembling ambulatory epilepsy. After mentioning thetremor as almost the commonest symptom of the disease,and touching briefly on the existence of convulsions, hedescribed a peculiar form of clonic spasm. in a young woman.The bulbar signs and the numerous cases of ophthalmo-plegia were reviewed. It was claimed that many of thecommon symptoms were due to peripheral neuritis-e.g ,cramps, hypersesthesia, symmetrical paresis of the legs,hyperaesthesia, pains and lowered patellar reflexes. Glyco-suria was never found in these cases. On the question ofpathology Mr. Maude thought that no focal lesion in the

sympathetic or medulla could possibly explain the condition,which must be due to some general nerve poison, probablyto be found in the thyroid gland. The fact that the thyroidgland was already enlarged, that operations on that glandhad neaily always relieved the symptoms, and the connexionwith mygoedema were all evidence, he thought, in support ofthis theory

Dr. DE HAVILLAND HALL said that Mr. Maude did notallude to the association of intra-nasal charges with Graves’disease. Dr. Semon had removed a polypus from the nosewith the actual cautery, which seemed to cure a liability toasthma, but was the starting point of unilateral enlargementof the thyroid gland. The fact that cases of Graves’ diseasehad been cured by intra-nasal treatment seemed to suggest asympathetic origin in some cases at least.

Dr. PASTEUR said that he had ascertained from a competentauthority in Switzerland that, although ordinary goitre wasextremely common, Graves’ disease was a comparatively rareaffection. The general view of physicians there was againstaltitude having anything to do with the production of thecondition.

Dr. BOWLES said that he had met with two cases inwhich there had been Graves’ disease in early life andmyxoedema developed afterwards. From personal obselva-tion he thought that Kocher was right in his assertion thatremoval of the thyroid gland produced myxœdema, thoughif a small portion of the organ was left myxoedema did notdevelop. Kocher had endeavoured to transplant pieces of thethyroid gland into various parts of the body, and he had seenthat operator insert a piece of the thyroid gland of a healthydog into the tunica vaginalis testis of a boy whose thyroidgland had been removed, and he likewise inserted a portioninto the divided femoral artery of the same patient.

Dr. BURNEY YEO had made some observations on exoph-thalmic goitre fifteen years ago. He showed one case in whichthere was a left exophthalmos and an enlarged thyroid glandon the right side ; on the left side the hairs of the eyebrowand eyelashes had disappeared. Later the thyroid on theleft side enlarged, and this was followed by a baldness of theopposite eyebrow and eyelashes. The same crossed phenomena

Page 2: MEDICAL SOCIETY OF LONDON

1004

he bad observed in another case. He urged, then, that thegeneral phenomena of the disease, which were probably dueto lesion of the central nervous system, had been overlookedin the study of the local manifestations.

Dr. SAVAGE said that his experience led him to believethat ordinary goitre and exophthalmic goitre very rarelyoccurred together, nor did he accept on purely theo-retical grounds the idea that it was due to peripheralneuritis. Most of them were of a general rather than ofa, local neurotic origin. It was very rarely associated withinsanity. In one type of recurrent insanity there was anassociated prominence of eyes, enlargement of throat andincreased pulsation during an attack, and it was noticed thatthe remedies which benefited exophthalmic goitre relievedthe recurrent mania,. In a very few cases of general paralysisbe had seen some or all of the symptoms of exophthalmicgoitre.

Dr. HEBON had noticed two associations with this disease-namely, that the thyroid gland was always more or lessenlarged and that patients usually had one of two kinds ofbad temper, either an almost insane fury or a kind of sullensavageness. Such persons in these states might lapse intocrime, and then a medico-legal question of responsibilitymight arise.

Dr. MURRAY (Newcastle) said that the thyroid gland wasnearly always affected. It was a, secreting gland, and if it wasremoved in a monkey the cachexia strumapriva developed,but the glycerine extract of thyroid gland would removethese symptoms, and the same thing occurred in the treat-ment of myxoedema. If the gland underwent enlargementhyper-secretion might take place, and this might help toproduce the symptoms of Graves’ disease; and if this were soany measures which tended to diminish the secretion shouldtend to improve the symptoms of that malady. In practice thisoccurred, for inunction of the red iodide of mercury, which ’’,tended to diminish the size of the thyroid gland, was accom- I

panied by a beneficial effect on the affection ; belladonna, by I,checking secretion, also was of use. In like manner pilo- ’,carpine was beneficial in myxœdema because it promotedover-secretion of the small portion of thyroid gland left. Iftoo large a dose of thyroid gland extract was given in ’Imyxoedema the pulse-rate was raised, and it was accom-panied by tremor of the hands and sweating of the skin, andin larger doses muscular wasting and weakness followed. Ifthe symptoms of Graves’ disease and of myxœdema were compared they for the most part were in contrast.

Mr. BERRY showed specimens from two cases of Graves’disease under the microscope to demonstrate the completeabsence of all colloid secretion from sections of thyroidgland, and he showed two other sections from ordinaryparenchymatous goitre showing a large excess of colloid inthe alveoli. The thyroid gland in Graves’ disease was muchmore homogeneous on section.

Dr. ORD did not regard exophthalmic goitre as more com-mon than formerly, but thought that it was more observed.He was inclined to agree with Mr. Maude as to the relationsbetween exophthalmic goitre and myxoedema ; in the formermalady there was too much vascularity and too great a pro-liferation of the secreting structure, which led to a destruc-tion of the gland. He had seen the gland too rapidlyreduced by treatment, and the symptoms of myxoedemaproduced.

Dr. GUTHRIE held that there was increased vascularisationin the early stages of Graves’ disease, and quoted instancesto show how the gland might vary in size. He believed thatpulsating aorta was often associated with an abdominal formof Graves’ disease.

Dr. HECTOR MACKENZIE insisted on the necessity for pro-longed observation in these cases, and he was not convincedthat the disease was due to change connected with thethyroid gland. The relation between goitre and Graves’disease required collective investigation. He had given largedoses of thyroid gland extract in cases of Graves’ disease,and no bad result followed; this was against the change inthe thyroid being at the root of the disease, which tendedgradually to subside of itself.

Mr. MAUDE, in reply, said he had found that the questionof altitude had no bearing on the etiology of the affection,in which the liability to crime was, he considered, the sameas that of any neurosis producing a tendency to acute mania.He had applied a cold coil over the thyroid gland with advan-tage. He had noticed a variation in the size of the thyroidgland in early cases of myxcedema. He thought that no reliableconclusion as to the secretion could be drawn from microscopic

sections. The malady was very chronic in its duration, anda larger series of cases must be awaited before the effectof operation could be properly appreciated.

CLINICAL SOCIETY OF LONDON.

Presidential Address.-Abdominal Section for Pyloric Adhe-sions.-Excision of Malignant Turmour from LargeIntestine.

THE first ordinary meeting of this Society for the presentsession took place on Oct. 13th.Mr. HULKE, the newly-elected President, on taking the

chair for the first time, delivered his inaugural address. He

began with a historical sketch of the progress of the Society,and recalled some impressions of its first President, SirThomas Watson, whose election he held to be a happy auguryof future success. During the twenty-six years that hadelapsed since the foundation of the Society in 1867 manyadvances in surgery and medicine had been made-advancesin which the Clinical Society had ever been found in the fore-most marching rank. He mentioned the flourishing conditionof the Society at the present time from the numerical pointof view, and he then approached the subject of his addressby referring to communications in the first volume of theSociety’s Transactions from Mr. Durham and the late Mr.Campbell de Morgan in illustration of the value of anti-

septics in surgery, which value was at that time much dis-cussed and even questioned. He gave some reminiscencesof his own early work to show that strict asepsis was imper-fectly understood in those days by a few and completelyignored by most surgeons. As an example of the defects inhospital construction, then so common, he gave a graphicaccount of the insanitary condition of the old hospital inCarey-street-formerly a workhouse, but which in his studentdays was attached to King’s College-where a charnelhouse existed under the male accident ward and the sametheatre was used for operations and necropsies. He held thatfor the attainment and maintenance of asepsis a strictattention to method and a scrupulous observance of detailwere of nearly as great moment as the selection of the agentemployed. In the last few volumes issued by the Societythere was recorded a series of notable instances of the

adoption of surgical measures for treating certain disordersand injuries of the digestive canal which would well repayattentive study. The heavy mortality attending some of theseoperations, and especially of those for relieving a slowly pro-gressive narrowing of some part of the digestive canal, was toooften due to the fact that the malady was allowed to reachsuch a stage that the greatly lessened strength of the patientmaterially diminished the prospect of obtaining relief fromoperation. Referring to cases in which excision of the vermi-form appendix was practised, he held that in many instancesit was better not to attempt a methodical excision of theappendix, but to be content with freely opening, emptying,and draining the abscess. He thought, in conclusion, thatthe chief progress of medicine had been in the direction ofexact diagnosis, rather than in that of treatment, and hequoted the disorders of the nervous system as being aptillustrations of this lagging of medical therapeutics behinddiagnosis. Though the physician appreciated an exact dia-gnosis, this did not satisfy the patient, who craved for aremedy, and pharmacological research was doing somethingtowards supplying this great want. In this connexion -helaid much stress on the value of the reports which were fromtime to time issued by specially appointed committees of theClinical Society.Mr. MAYO ROBSON read a paper on Dilatation of theStomach and Severe Pain dependent on Pyloric Adhesions,treated by abdominal section and separation of abnormalattachments, with general remarks on visceral adhesions as acause of obscure abdominal pain. Two cases had been sentto him for operative treatment on account of extreme emacia-tion dependent on dilatation of the stomach and severe painin the epigastrium and right hypochondrium. Medicaltreatment had been previously tried without affording relief.In both cases the same treatment-namely, separation ofadhesions of the stomach and pylorus-was carried out

successfully, the original cause of the adhesions being inthe one case gall-stones and in the other ulceration ofthe stomach. The cases were brought forward because,although it was known that simple adhesions might produce


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