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.

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    tof the operation. It was a case of anuria or rather of retention of urine in the kidneys from compression of both ureters by a uterine fibroid. Cases of this kind being comparatively rare, precise rules have apparently not yet been laid down as to the method of treatment to be employed in such emergencies. The patient was 48 years of age. Two years previously she had been operated on by Prof. Tillaux for a subperitoneal fibro-myoma of the uterus. She was admitted to the Beaujon Hospital complaining of re- tention of urine of three days’ duration. A catheter having been intro- duced it was found that the bladder was absolutely empty. She was in reality suffering from renal retention due to the pressure exerted on both ureters by a fibroid tumour of the uterus which filled up the true pelvis to such extent that a finger could only be introduced with difficulty into the vagina. The abdomen was distended and tympanitic, and there was absolute constipation. Lastly, she had an extremely feeble pulse with cold extremities and, in fact, she presented such grave constitutional symptoms that I hesitated to intervene. What was 1 to do? Nephrotomy and ureterostomy were out of the question, seeing that the operation would have had to be performed on both sides, and further, as there were signs of intestinal obstruction, the formation of an artificial anus was indicated. The best thing that could be done under the circumstances was to remove the cause of these urgent manifestations. I decided, therefore, in favour of abdominal hysterectomy, the operation being performed on the very morning of the patient’s admission. An elastic ligature having been passed round the pedicle, the tumour was excised and the pedicle secured externally. On the following day micturition was reestablished and by the fifth day the quantity of urine excreted in the twenty-four hours had returned to normal. As a matter of fact the patient made an uninterrupted reco- very, although a small fistula corresponding to the pedicle persisted for some time. She is now in excellent h alth and has apparently com- pletely recovered from the grave kidney lesions from whicn she was un- doubtedly suffering at the time of the operation. Tuberculosis of the Peritoneum and Mesenteric Glands; Laparotomy; Improvement. Dr. Picque.—The treatment of peritoneal tuberculosis by laparotomy has given rise to considerable discussion and although a tolerably large number of observations have been published on this subject, one has had but little opportunity of verifying the beneficial effects of the ope- ration by a post-mortem examination performed some time after the intervention. The following brief account of an autopsy performed under these conditions may not, therefore, be devoid of interest. The patient was a woman, aged 30; she had enjoyed tolerably good health, though with a tendency to frequent colds, until 1891 when she was admitted to the hospital for a painless tumour, situated in the left flank and suggesting the existence of a floating kidney. She only re- mained a short time at the hospital but soon after leaving she began to complain of pain in the abdomen. In January 1893 the pain had become worse and the tumour had increased in size. It now extended across the middle line to the right side of the abdomen. She was ad- mitted into Dr. Perier's wards at the Lariboisiere Hospital where the diagnosis of tubercular peritonitis with enlarged mesenteric glands was arrived at by exclusion. I may add that suspicious signs were found on examining the lungs, notably some dulness on percussion in the left clavicular region with harsh breathing. On my advice the patient consented to an exploratory laparotomy which was performed on April 13th. The parietal and visceral layers of the peritoneum were both studded with a large number of tuber- cular granulations, the tumour itself being composed of a mass of tubercular glands to which the coils of intestine were extensively adhe- rent. The operation was perfectly successful and the patient recovered with- out accident of any sort. She left the hospital very much the better for the intervention, but a few weeks later she returned with a gangrenous abscess of the neck accompanied by very grave symptoms of infection to which she succumbed at the end of a week. At the autopsy it was found—a fact which had been recognised before death—that tne abdominal tumour had considerably diminished in size being only about a third of what it was at the time of the operation. Moreover, the tubercular granulations had almost entirely disappeared from both the visceral and parietal peritoneum. Dr. Berger.—It is generally admitted by those surgeons who have investigated the question of the influence of an exploratory laparotomy on tubercular peritonitis, that the operation is especially indicated in cases in which the affection is associated with ascites or circumscribed serous or purulent effusion. Cases are also met with in which laparo- tomy may be necessary to relieve urgent symptoms of intestinal obstruc- tion due to constriction of the bowel by peritoneal adhesions. In a cer- tain proportion of cases, however, no benefit is to be derived from the intervention. In respect of the manner in which the improvement is brought about, two theories have been suggested: According to one, the ameliora- tion observed in the condition of some of the patients is to be referred to the evacuation of the effusion and the formation of adhesions by which the granulations are strangled, as it were. The supporters of the other theory maintain that the peritoneal effusion is not only a fa- vourable medium of culture for tubercle bacilli but that it also contains certain toxic products, which cause the fever and intoxication, these symptoms subsiding as soon as the products in question are evacuated especially if the fluid is not allowed to reaccumulate. My own personal observations fully confirm what I have just said as to ihe indications for laparotomy in cases of tubercular peritonitis. I remember four cases of this kind in two of which the patients were lads about 14 or 15 years of age, both of whom were suffering from peritonitis with effusion. The improvement which followed the opera- tion was so marked and sustained as to amount practically to a radical cure. In a third case, the patient was a young woman, the subject of very chronic peritonitis associated with symptoms of intestinal obstruction. Exploratory laparotomy was performed but, although the operation seemed to give temporary relief the patient died on the tenth day. Lastly, 1 once performed laparotomy on an adult male for tubercular peritonitis with a considerable amount of effusion, the peritoneum being touched in this as in the previous cases, with camphorated naphthol. The patient seemed to improve a little after the operation but the ame- lioration was not maintained and he died at the end of a month. Dr. Picque.—The indications for laparotomy are not limited to cases in which the tubercular process is accompanied by effusion into the peritoneal cavity. In the case I have related there was a small amount of effusion but it was in reality a case of dry tubercular peritonitis. I may mention that there was nothing in the post-mortem appearances found in the case in question which could be construed in favour of the theory that the curative effect of laparotomy is due to the formation of adhesions, MEDICAL SOCIETY OF THE HOSPITALS. Friday, October r$th, 1893. On Mumps. Dr. Catrin.—I wish briefly to relate my experience of 139 cases of mumps under my observation during an epidemic of this affection whicn broke out among the Paris garrison last winter. Mumps begin with equal frequency on the right and on the left side, the swelling of the parotids reaching its maximum in from a few hours to five days. The prodromal symptoms of this affection are rigor, pains all over the body, headache, sleeplessness, night sweats, epistaxis, noises in the ears, rheumatoid pains, etc. In about two-thirds of the cases, these prodromata were associated with inflammation of the pharynx and tonsils, extending sometimes to the buccal orifice of Stenon’s duct. It would appear, therefore, that the in- fection is propagated through the buccal secretions. In four out of every five cases fever is present, but it is usually slight and of short duration, though the temperature sometimes rises as high as 104° F. The gravity of the attack bears no relationship to the degree of enlar- gement of the parotids ; the enlargement is due to swelling in some cases of the glandular tissue proper, in others of the periglandular con- nective tissue. The submaxillary glands are involved in half of the cases. The treatment should be continued for at least a fortnight or twenty days, in order to avoid secondary involvement of the testicle or a relapse and to prevent the patient from communicating the disease to those around him. Of the contagiousness of mumps there can be no doubt, but the disease is only communicated by direct and prolonged contact, so that infection is easily prevented. The incubation period of mumps is tolerably long, the average -being from a fortnight to twenty days. Relapses are more frequent than is generally supposed. They occur in about 6 % of the cases. In respect of the testicular manifestations, the true orchitis of mumps must be distinguished from simple congestion of the testicle which is apparently never followed by permanent changes in the gland. Out of 139 patients 41 had orchitis and 13 others had congestion of the testicle. Of the 41 cases of orchitis in 13 both testicles were involved. In diagnosing primary orchitis of mumps the possibility of a previous attack ot slight parotitis or inflammation of the submaxillary gland must always be taken into account. Other complications of mumps are rheumatism, otitis, localised oedema, endocarditis, albuminuria, suppurative arthritis, etc. In none of my cases were there any meningeal complications, distur- bances of sight or mental trouble. Dr. Antony.—I agree with Dr. Catrin that attacks of mumps are fre- quently heralded by swelling of the tonsils and submaxillary glands. I do not think there is a single well-authenticated case on record o meningitis as a sequel of mumps. The only case of meningitis under my observation in which the affection was apparently to be traced to such a cause was shown at the autopsy to be simply a case of tuber- cular meningitis. On the other hand, I cannot agree with Dr. Catrin as to the mode of propagation of the disease. I believe that it is not always communicated by direct contact with the patient but that simple contact with the patient’s clothes may be sufficient for that purpose. It seems to me therefore, that the necessary prophylactic measures should be taken to prevent infection by this means. THERAPEUTICAL SOCIETY. Wednesday, October nth, 1893. On “ Moyrapuama ” from a Pharmacological Point of View. Dr. Rebourgeon.—The forests of the Amazon contain a large variety of plants which are employed for medicinal purposes by the aborigenes. Among these plants is a shrub belonging to the natural order acan- thaceae, and known under the name of moyrapuama, the root of which is said to possess tonic and aphrodisiac properties. I propose to commu- nicate to the Society the results of the chemical analysis of this root and of the experiments performed therewith, in Prof. Fournier’s laboratory. 1 have succeeded in isolating, by the ordinary methods, a number of