Note on the etiology of Graves's disease / by D.R. Paterson.

  • Paterson, Donald Rose.
Date:
1894
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Credit: Note on the etiology of Graves's disease / by D.R. Paterson. 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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    I 1370 The Lancet,] DR D. R. PATER30N THE ETIOLOGY OF GRAVES’S DISEASE. [June 2. 1894. Remarlts.—One of the most mteresting features of this case was the absence of those symptoms^hich are usually considered to be characteristic of gastriy^lcer and of its foration. Thus, in the first place, the diagnosia..«ng^tric ulcer rested almost solely upon the^esence of a^tenc^ spojf over the stomach area, for, though^elped py tlm W^^or’ vomiting of blood many yeara^efoyel thjsvisMstabc^r was counterbalanced by the fact reliM df pa^ bv'^aking food. But this diagnosis was |mt Aojoe so^re/that the symptoms which subseque^itly arp^ were at/<mM(Teferred to their right source. These/Synoptorps, again,^er^by no means (ok^as indications fs and expression Sould be gathered Serature. Pain was means so acute or such as are usually law down ih text- of perforation of a gastric ulcer. The: were not obviously altered, and no^ from the character bf the pulse an^be almost solely thoracic and wai attended with such shock as irf^othe»'cases that have come under my notice. Thus in one instanfce, when perforation took place, the patient fell down in they^reetand was quite unable to walk, even with assistance^hough her house was only a few yards off In anothejrcase, which came under the observation of Dr. W. J. Maoiice of Reading, a servant girl was found dead on the stairs of her master’s house, and it was not until a post-mortem examination had been made that the cause of death was discovered, for she had com- plained of no suggestive symptoms during life. I believe that the above is the first reported case in which the edges of the ulcer have been excised. It seems to me to be of great importance that the edges should be freshened in this way if possible, not only in order to obtain speedier union, but for purposes of cleanliness, as the edges must of necessity be so septic as to be diflBcult to disinfect by ordinary methods. Much, however, must depend upon the vascularity of the parts. To the same end it also appeals of importanpe that the wound should, if the condition of the patient permit, be ascertained to be secure against leakage of gas or liquid by the use of the stomach tube. Since the pub- lication of my last, case of this kind' sixteen other instances have been lecorded. In Mr. Warrington Haward’s case- death took place from secondary abdominal abscess in six weeks. Dr. Stirling “ Mr. Haslam, ‘ Mr. Godlee,® and Mr. Peppei” did not succeed in saving their patients. Of three cases in the practice of Dr. Maclaren^ one was a success. In Dr. Anson’s® case, which was unsuccessful, a live-inch incision was first made in the median line and was sub- sequently extended at right angles through the rectus. This method, which I have tried, permits of the freest possible exposure cf the whole of the surface of the stomach. The greater part of the organ can, indeed, be dragged, without difficulty, out of the wound, so that a perforation in any part of its surface may be dealt with with comparative ease, It was the method employed by Kriege'* * for a perforation 3cm. from the cardiac end, which terminated successfully. He also gives details of another case, in which an incision was made from the xiphoid cartilage to within a hand's-breadth of the pubes, and a transverse one cut to the Ipft, and in which the patient died. More recently Mr. Morsehas reported a case which recovered, and Mr. Herbert Page two others which were unsuccessful. Dr. Maurice, at a meeting of the Reading Pathological Society, has also lately given details of a case which was nearly successful, the patient succumbing on the eighth day. A post-mortem examination revealed no sufficient cause for death. Of the twenty-seven instances of operation for the treatment of perforated gastric ulcer that I have been able to find recorded, and have mentioned in this and in a previous paper, six have recovered—viz , Mr. Taylor's. Mr. Barling’.s, Kriege’s, Mr. Morse’s, Dr. Maclaren’s, and the above. When one considers that the extravasation of the contents of the stomach into the general peritoneal cavity has, until lately, been regarded as almost of necessity resulting in death, these results of operative treatment cannot be regarded as otherwise than encouraging. Reading. r Brit. Med. Jour., 1893, p. 1)14. 2 Ibid., 1893, p. 952. 3 Austral. Med. Jour , 1893, p. 281. * Brit. Med. Jour., Nov. 11th, 1893. 2 Ibid., March 17th, 1894. 6 Ibid. 7 Ibid. * The Lancet, March 4th, 1893. 2 Berliner Klinische Woch’nschrift, December, 1892. )“ The Lancet, March 17th, 1891. NOTE ON THE ETIOLOGY OF GRAVES’S DISEASE. By D. R. PATERSON, M.D.Edin., M.R C.P. Lond., physician to the HOSPITAt, FOR SEAMEN ; PATHOLOGIST \ TO the CARDIFF INFIRMARY. The influence of depressing emotions and prolonged bodily effort on the genesis of Graves’s disease has received ampl& recognition. Patients not infrequently attribute the onset of their illness to grief or fright, or overstrain from some arduous- exertion, and the same factor may come into play in bringing on recurrence of the malady after apparent cure. Whether these causes suffice to start the affection in the first instance^ is not quite clear, but there is no doubt of their power to- hasten the appearance of the more prominent symptoms. This is well shown by a case at present under my care, which- I may be allowed to quote, as it illustrates another point to which I shall refer later. A girl seventeen years of age came under treatment in June of last year for enlarged tonsils. She exhibited some tremor and agitation, which increased- readily on excitement. The tonsils having been removed' under chloroform, two weeks later the patient presented a slight fulness of the middle lobe of the thyroid, which had just- come on ; prominence of the eyeballs was barely noticeable, and, according to the patient’s statement, the trembling now extended to the legs. Ten days later the heart had increased in frequency, and at present all the symptoms of Graves’s- disease are in evidence. Inquiry elicited that for eighteen- months the patient had been subject to attacks of tremor, which occasionally interfered with the power of writing and had latterly been more frequent. The importance of tremo? in the diagnosis of Graves’s disease is now established, and it is obvious that that aHection was developing slowly when the mental impression produced by the operation pre- cipitated its course. Exacerbations are not uncommon from the same cause, the thyroid enlarging and tremor and palpitation increasing under the influence of fear or sustained grief. I have notes of the case of a woman seeii five years ago, in whom the affection was lighted up afresh by arduous nursing. It is noteworthy that, while tremor was- very marked in the original attack, it did not recur on th& later occasion, though enlargement of the thyroid gland was prominent. Anything that conduces to nervous depression- may originate or light up an attack. Unhealthy surroundings and insufficient food are not without result. Rendu records- a case brought on by large doses of iodide of potassium, and Russell Reynolds believes that atmospheric conditions, such as low temperature, diminished rainfall, and diminished sun- shine, may have some significance. These facts are suggestiva- in relation to the view revived of late years by Mobius that Graves’s disease results from diseased activity of the thyroid* gland. It seems to be generally accepted that this gland is a- secreting organ which pours its j uice through the lymphatica into the general circulation. Now, physiological teaching tends to show that secretion in general is diminished or arrested by emotional states and anything that lowers nerve force. Fear paralyses the action of the salivary glands, and the mental depression and slowing of the circulation induced* by prolonged grief are more likely to dry up secretion than promote it. It is true, vaso-motor dilatation is determined by emotional states, but stimulation of the secretory nerves doe» not necessarily follow, and there may be obvious enlargement of the thyroid gland from vascular engorgement without increased secretion of thyroid juice. Prominence of the- gland suggested its primary affection as the essence^ of Graves’s disease, though there is the fact that goitre may come on with exophthalmos some months after other syrriptoms have set in, as the case quoted above shows ; and, on- the other hand, there may be enlargement of the thyroid gland* long antecedent to any other departure from health. Certain facts give support to the idea that some of the symptoms at least may depend upon excessive secretion of the gland, and these are admirably set forth by Murray. In this relatioD- the tremor first noted by Charcot, and the “ rapid heart, ” are- perhaps the most significant. Along with other nervous dis- turbances they have been noticed after large doses of thyroid* extract. But, on the other hand, it is known that similar symptom.s follow or are produced by loss of the thyroid gland. Horsley established the occurrence of muscular tremor
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