On some rarer factors in Graves's disease.

  • Maude, Arthur.
Date:
[1893]
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Licence: Public Domain Mark

Credit: On some rarer factors in Graves's disease. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    suffering from this disease and I can confirm Trousseau’s remark that enlarged thyroid is more frequent in females than in males. Though Graves’s disease is supposed not to be common in goitrous patients I found that out of 55 cases of enlarged thyroid 12 presented symptoms of Graves’s disease at the time or subsequently. In respect of the incidence of the disease 1 may point out that the number of deaths grouped by the Registrar General under the head of “ bronchocele ” has steadily increased between the years 1881 and 1891 and as all the increase has been in female deaths they were probably largely due to Graves’s disease. The number of admissions under this head in St. Bartholomew’s Hospital has also increased since 1870. I have collected seven instances of Graves’s disease supervening in goitrous patients and one of the patients was the child of a myxoedematous mother. Last year I col- lected a number of cases of Graves’s disease in which partial or complete thyroidectomy was performed and I refer to them now in order to point to the improvement that has ensued in nearly all. Among the psy- choses we get incoherence of idea, a tendency to melancholia with vertigo, tinnitus and throbbing in the head, the latter being probably due to interference with the blood supply. Tremor is perhaps the most frequent symptom of the disease most marked in the flexors of the arms, the interossei escaping. This tremor resembles that produced in animals after removal of the thyroid and its character is much more uniform than that of hysterical tremor. Sometimes there are eclamptic convulsions possibly induced by the disturbed cardiac action. Clonic spasms of the face and chorea are also frequent concomitants. There is often slight difficulty in swallowing akin to that observed in myxoedema, with possibly some drawling of the speech. Many cases of facial paralysis are on record and most patients exhibit some enfeeblement of the facial nerve. The ocular symptoms I believe to be due to paresis of the temporal division of the temporo-facial nerve. There is often general muscular weakness possibly culminating in paraplegia. In addition to the foregoing there are a number of symptoms which in my opinion are attributable to peripheral neuritis such for example as cramps, general hyperesthesia, symmetrical paresis of the legs, lessening or abolition of the patellar reflexes, etc. I conclude that the condition known as Graves’s disease is a general nerve poisoning of which the stress falls most heavily on the medulla, the poisoning resembling clinically that caused by alcohol, lead and beri beri. All attempts to account for the symptoms by focal lesions in the sympathetic, medulla or elsewhere are quite unproven and unsatisfactory. We do not know what this poison may be, nor how it is produced but the constant presence of goitre, the connexion with myxcedema and the results of operation on the thyroid point to that gland as the origin of the miscnief. Dr. F. de Havilland Hall.—There are a number of cases on record in which the symptoms of Graves’s disease have subsided on the treat- ment of concomitant intra-nasal conditions. In a case brought forward by Dr. Semon some time since, a woman from whose nostril some nasal polypi had been removed, developed unilateral enlargement of the thyroid with some proptosis. I should like to know if the author has observed any intra-nasal troubles in this association. Dr. W. Pasteur.—I have ascertained that in Switzerland, where goitre is common enough, exophthalmic goitre is comparatively rare. Swiss practitioners, moreover, are generally of opinion that altitudes have no effect in determining the disease. Dr. Bowles (Folkestone).—I know of two cases in which patients, after suffering for some years from Graves’s disease, have developed symptoms of myxoedema.' For some years past I have followed Pro- fessor Kocher’s practice at Berne, and have witnessed a certain number of thyroidectomies and attempts to prevent the supervention of myxce- dematous symptoms, as the consequence of the removal of the gland, by the transplantation of healthy portions of the gland and of portions of the thyroid of animals. Dr. Burney Yeo.—I remember the case of a woman who, to begin with, presented exophthalmos on the right side in association with en- largement of the thyroid gland on the left. The eyelashes and eye- brows on the side corresponding to the thyroid enlargement were shed. Later on the gland underwent enlargement on the other side, and then exophthalmos occurred on the opposite side and the lashes and eyebrows fell in their turn. It seems to me that we direct too much attention to the striking local symptoms and lose sight of the general nervous affection. Dr. Savage.—-I hold with others that exophthalmic goitre does not often occur in association with ordinary goitre. 1 did not meet with a single instance of Graves’s disease in a thousand cases of goitre collected by me in a district in Cumberland. I do not believe either that the malady is caused by peripheral neuritis, this being met with under so many different conditions. In fact the neurotic features are general rather than local. It is worthy of note, however, that there is a form of acute recurring mania associated with the symptoms of myxcedema and in these cases benefit is derived from the remedies for myxcedema. I have seen at least a dozen of such cases. In some of them the exoph- thalmos was more marked on one side than on the other. Dr. Heron— 1 have noticed that the thyroid is always enlarged more or less in Graves’s disease. The temper is peculiarly affected in the subjects of the latter affection, in some cases so much so as to suggest a taint of insanity and this long before the symptoms of Graves’s disease make their appearance. It is an interesting question whether such persons could properly be held legally responsible, if they gave way to crime under the influence of one of these attacks of anger. Dr. G. Murray (Newcastle).—There is strong evidence in favour of the thyroid being a secreting gland and in view of the constant relation- ship of enlargement of the gland in Graves’s disease, I cannot help think- ing that the symptoms may, in part at least, be due to hypersecretion on the part of the gland. This idea is supported by the benefit often derived in cases of Graves’s disease by measures having for their object either to diminish the size of the gland or to curtail its functional acti- vity, such for instance as removal of the gland, counter-irritation by the inunction of the red iodide of mercury ointment and from the use ot belladonna. It is also worthy of note that the administration of too large doses of thyroid extract to myxoedematous patients is followed by the acceleration of the pulse, the moist perspiring skin and the mental excitability and muscular weakness observed in Graves’s disease. This fact has been observed by myself and by others. If we compare the clinical pictures of Graves’s disease and myxoedema we cannot but be struck by the opposite nature of the symptoms. Dr. Berry.—I am enabled to show you microscopical preparations from cases of ordinary goitre and of exophthalmic goitre. In the one you will see that there is an absence of colloid secretion, the alveoli being filled with small cell formation while in the other there is an abundance of colloid. Macroscopically one sees that the enlargement in cases of parenchymatous goitre is more homogeneous than in the ordin- ary form. Dr. Ord.—The apparent increase in the proportion of cases of Graves’s disease is probably due to our eyes having been opened on the subject. 1 certainly think there is a connection between myxcedema and Graves’s disease. The latter probably commences as a hyper-vascularisation of the gland and this may be followed by atrophy or destruction of the essential glandular secreting substance and the supervention of symptoms of myxcedema. In some cases treatment directed to diminishing the size of the gland in Graves’s disease has been followed by very rapid diminu- tion of size and ultimately by symptoms of myxcedema. I have noticed the occurrence of these various affections in collateral members of the same family, one member having Graves's disease, another mere enlargement ot the thyroid, while a third developed symptoms of myxoedema. Dr. Guthrie.—I remember dining at the house of a newly married lady who was giving her first dinner, when I was struck by the fact that she presented a well-marked, throbbing, goitre. Later on in the evening this had entirely disappeared. In a well-marked case of Graves’s disease with thyroid enlargement which 1 wished to have photographed, I found that the enlargement had quite subsided on the patient’s arrival at the photographer’s. 1 do not think that the theory of the sympathetic being involved can be dismissed as suggested by the author, for if there is increased vascularity this points to an affection of the sympathetic. Patients in the early stages of Graves’s disease often present one or several abdominal phenomena, among others a pulsating abdominal aorta. Dr. Hector Mackenzie.—It is only by observing these cases of Graves’s disease over long periods of time that we can form a precise and reliable idea of their natural course and so judge the value of a medicinal or sur- gical treatment. In my own experience these cases exhibited a tendency to spontaneous amelioration with one or two exceptions and this evi- dently militates against the reports of operations. If the disease were due to hypersecretion I should have expected to witness disastrous results from the experimental administration of thyroid extract but this was not so in one or two cases under my own observation. This point is important because if we adopt the idea of the disease being due to thyroidal changes we shall be too disposed to accede to the suggestion for surgical intervention. Mr. Maude.—In my opinion the neurotic manifestations are central rather than peripheral and are secondary to intestinal intoxication. I do not think that we can safely draw firm conclusions from microscopical appearances in respect of a gland of which we know so little. I quite agree that we shall require long series of operations before any safe conclusion can be based thereon. PATHOLOGICAL SOCIETY. Tuesday, October rytb, 1893. Double Ureter, one terminating in the Urethra. Mr. Leopold Hudson.—The specimen which 1 am enabled to show you was taken from a female patient aged 58, who was admitted into the Middlesex Hospital on November 5th 1889, with a neglected strangu- lated hernia on the left side. Her condition was so precarious that no- thorough examination of the abdomen was admissible. In spite of treat- ment directed to the relief of her condition she succumbed on the 12th. On dissecting the right renal region I found the following curious condition of things. The lower half of the right kidney formed a bag containing 32 fluid ounces of pus, and presenting all the characters of a pyonephrosis. The ureter from this sac passed down along the bladder and opened into the urethra just within the sphincter vesicas. A second ureter was found proceeding from the upper half of the right kidney which terminated in the bladder in the usual position. The kidney and ureter on the right side were perfectly normal. The bladder itself was healthy and no other abnormality was discovered in the abdomen or elsewhere. There was nothing in the history of the patient so far as it could be made out to throw any light upon the renal condition. This abnormality is very difficult to account for from an embryolo- gical point of view. It is indeed always more difficult to account for redundancies than for other malformations. It occurs to one that the duplicate ureter may possibly be a persistent Wolffian duct. This duct, it will be remembered, is normally persistent in the male and opens, as the vas deferens, at a point corresponding to this. The fact, however, that this ureter springs from the lower part of the kidney is against that hypothesis because a persistent Wolffian duct ought to come from the mesonephron at the upper part of the kidney. Mr. Bland Sutton.—Double ureters are by no means rare and there is no need to indulge in embryological speculations in order to explain their presence. The conversion of the lower part of the kidney into a pus sac is certainly an interesting feature and renders the specimen almost unique. The specimen would have been still more interesting had it