On some rarer factors in Graves's disease.

  • Maude, Arthur.
Date:
[1893]
Catalogue details

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.

    5/10 (page 503)
    which I found a malignant tumour, which 1 could not remove, in the ascending colon, so I brought up the distended ileum and opened it at the end of twelve hours. The patient found the discharge of liquid faeces from the open end a great trial, so a month later 1 again opened the abdomen and fixed the ileum to the sigmoid flexure thus excluding the whole of the large intestine. The patient did remarkably well and is in such good health that he is unwilling to submit to any further intervention. Dr. Edmunds.—The divided ends were brought outside. The faeces escaped from the ileum and were quite liquid. The function of the large intestine is probably to convert the liquid motions into solid ones. In the first case there was a good deal of excoriation but this got well spontaneously though the discharge continued. 1 agree that where there is no distension it is well to suture immediately. NEW YORK. ACADEMY OF MEDICINE. Thursday, October 5th, 1893. Therapeutic Reflections. Dr. Simon Baruch read a paper in which he referred to the fact that enthusiasm in therapeutics was unwarranted, because the history of medicine abounds in the rise and fall of the most brilliant structures, in the explosion of the most plausible theories, and in the overthrow of remedies that seemed to be so firmly intrenched in the armamentarium of the foremost physicians that they seemed to be impregnable against attacks. Look where venesectiort stands to-day, look at the dethrone- ment of opium as a remedy for peritonitis ! Lawson Tait has urged that it is even dangerous for this condition, and to-day we give saline purgatives. Let us confess that the materia medica consists chiefly of medicinal agents whose action on the human body is uncertain and whose effect upon disease is either neutral or unreliable. How often can we say that we have accomplished by means of any medicinal agent, or combination of such agents, the cure or removal of any disease? With the exception of quinine, mercury and the iodides there is not a single medicinal agent that may be regarded as actually cura- tive. Faith in drugs is almost as frequent among physicians as is faith in being drugged among patients. In a recent consultation in a case of infantile diarrhoea, the abolition of a milk diet and the substitution of intestinal irrigation for salol, bismuth and Dover's powder, secured prompt recovery; and this illustrates the difference between medicinal and non-medicinal remedies, or rather the neglect of those non-medicinal agents whose action in disease is so simple, rational and clinically effective. The rock upon which therapeutics has always split is the treatment of symptoms. When a student, venesection was then in its last gasp, and veratrum viride was administered to control the rapid pulse of fever; in the speaker's first case of pneumonia in the hospital, veratrum was administered with perseverance, the pulse was reduced frcm 140 to 80, yet the pulmonary consolidation continued and the patient died. History repeats itself in the coal-tar products of to-day. In gastrec- tasia we have a condition that is the consequence of long continued functional insufficiency; the early recognition of the causes, the adap- tation of diet, mode of life, manner of eating, lavage, etc., to each indi- vidual case will conduce far more to cure than all medicinal agents from ancient gentian to modern strychnine, from muriatic acid to pepsin. It must be obvious to the most enthusiastic polypharmacist that he accomplishes only an amelioration or removal of certain mani- festations of disease, a result which may and probably does facilitate a restoration to health but is rarely, if ever, the direct means of such restoration. There is too often a tendency to treat a case of appendicitis as localised peritonitis, and to meet the symptoms by prescribing morphine to subdue the pain, ice or poultices locally To relieve the inflammation, food to satisfy the bug-bear of coming failure of the vital powers, and antipyretics to reduce the temperature. It is better that the patient suffer some discomfort than that his life be jeopardized by remedies that obscure the real issue of the case, and lull the physician into a false sense of security. Preferably keep such a case under the influence of chloroform until a decision for or against operative measures can be reached. Vis medicatrix naturae is an old rallying cry of the profession, but one that did not gather many steadfast defenders. At one time a complete therapeutic nihilism, emanating from the Vienna school, threatened to become prevalent. But when the chemist evolved those potent thera- peutic sledge hammers that could beat down symptoms, the gentle hand maiden—Nature—was thrust aside and the patient was beaten down as well as the symptoms. Happily to-day a reaction is setting in; once more are heard warning voices that bid us follow nature's promptings. To join these and to re-echo them in this hall was the author’s purpose. Rest is the first prompting of nature in diseased con- ditions; as the surgeon puts an inflamed joint in a splint, why may not the physician treat an acutely inflamed kidney in a similar way? Unlike the joint, the kidney’s function must go on; but the intelligent physi- cian so arranges diet that urea excretion is reduced to a minimum, and the skin and the bowels are made to act vicariously for the kidney. Far more actual curative results may be obtained from watching and cautiously following the tendencies of a disease and applying those agents that are potent in maintaining the system in health, viz, rest, exercise, diet, baths, changes of environment, etc., than from the most intelligent application of medicinal agents. The judicious application of ventilation and diet are pretty well known by the profession, the judi- cious application of water is unfortunately still a terra incognita to the large majority. The speaker then reviewed the pathology of typhoid fever, and the futility of drug treatment was compared with the’ results obtained by the Brand method. He also referred to the conditions causing, and existing in, anaemia and the failure of iron and other drugs to cure the disease, while removing the patient to the country, or the use of hydro- therapy and diet, would speedily cause improvement. He urged that increased attention should be given to the employment of hydrotherapy. Dr. A. L. Loomis said that the paper was a very sensible one be- cause it inculcated common sense in the practice of medicine. In a study that had been made of the treatment of pneumonia at the Massa- chusetts General Hospital for seventy-five years, the time was divided into decennial periods, and after eliminating everything that might vitiate the figures, after taking into consideration the age and surround- ings of the patients, the results of treatment during that period were for- mulated into a graphic curve. This period, it will be remembered, includes the venesection treatment, the antimony treatment, the calomel treatment, the stimulating treatment, the do-nothing treatment, the an- tipyretic treatment, and lastly the antiseptic treatment. This graphic curve instead of being a zig-zag line was straight, a strong proof that a certain number of cases die and a certain number recover, despite any method of treatment. The older we become the less we are attached to drugs. The essentials in treatment are air, water, food, relief from dis- turbing influence, and little medication. The speaker was often sur- prised at the small number of medicines he used in his private and hospital work. Dr. A. Jacobi said no sane person would say that medical practice consisted in prescription writing, any more than medical science con- sisted in making a diagnosis. Yet both are necessary. A large number of the diseases we meet have a tendency to get well: let the disease alone, keep the patient in bed, give fresh air, regulate the diet, and refrain from the tempt- ation of disturbing recovery bv drugging the patient. No hard and fast rule of practice should be made; necessities may arise in any case that will take away the odium from all proscribed drugs. Venesection has been condemned, yet engorgement may occur in some cases that demands immediate venesection, and it alone will save life. While fully agreeing that antipyretics should not be generally employed, yet in some cases the temperature should be reduced and an antipyretic ought to be employed; it would not do to forbid it or to say that water will exercise the same action. The number of remedies in the pharmacopoeia are gradually dwindling down, and so do we drop them in practice. He would not undertake to treat diphtheria, endocarditis, and numerous other diseases without the assistance of many drugs besides quinine, mercury and the iodides, or water, rest and diet. In a self limited dis- ease such as whooping-cough he would give chloral, or atropine, or bromoform, even if he only succeeded in reducing the duration of the disease by two weeks. NEUROLOGICAL SOCIETY. Tuesday, October jrd, 1891. A case of generalised Paresis ending in complete Recovery. Dr. E. C. Seguin related the case of a boy aged 13, who was brought to him in October, i885, for an opinion as to the nature and prognosis of a singular condition of increasing muscular weakness, which had come on during the preceding 17 months. Tne boy's family history was fairly good. His mother was of a nervous temperament and for a few months had been addicted to the chloral habit. Out of six children only one, a sister, had had a nervous disease, namely, a mild chorea ’extending over several years. There was no trace of muscular disease, atrophic or dystrophic, in the family. The patient's history, previous to the onset of this aisease, was negative. At the age of six years he had a severe attack of albuminuria, which left no traces. In April, 1886, he had what seemed to be a mild attack of articular rheumatism. He was a very active and daring boy, and had numerous falls, none of which, however, were followed by serious symptoms. There was a history of masturbation, carried on for several years. There was no history or evidence of metallic intoxication, nor at any time was there any indication of hysteria. The only positive causative element in the case was the self-abuse. This practice, the boy stated, he had given up in the Spring of 1885, when he himself noticed that he had slight difficulty in articulating his words. Five months subsequent to this, the boy's symptoms were first brought to his father's attention by the fact that he twice fell out of the saddle and by his suddenly dropping the oars in a boat and acting as if paralyzed for’ a few minutes. Even before that, it was recalled, he had become rather awkward in but- toning his clothes and in using his knife and fork, and that after reading aloud for a few minutes his articulation became thick. Very gradually he lost his energetic ways and became awkward in every- thing ; his attitude had changed so that he stooped, the head hanging down and the abdomen protruding. His facial muscles lost much of their expression and his laugh was constrained and unnatural. All these symptoms developed and progressed very slowl}r during the years 188, and 1886. The boy was subject to “ sudden collapses ”, as his father called them, characterized by the sudden loss of control over certain muscles, resulting in falls or in dropping objects from the hand. These last-named symptoms suggested petit mat, but this affection was excluded after careful observation. The symptoms were entirely of a motor order ; no numbness, no anaesthesia, no neuralgia, no psychical or trophic symptoms. All his organic functions were normally performed; nutrition was good and the eyes were normal. The legs were appar- ently strong, and the boy could rise from the dorsal recumbent posture on a flat couch and also from a squatting posture, but these acts were performed feebly, slowly and with great effort. The spine was not tender and presented ho deviation, excepting an antero-posterior one. Local paresis of the muscles was demonstrable only in the extensor group of