Notes and Queries.
The Surgery of the Thyroid from a Neurologic Standpoint.—In a suggestively written paper in the January number of the American Journal of the Medical Sciences, Dr. J. J. Putnam uses the following words: “We are rather in the habit of assuming that the removal of large portions of the thyroid does no harm, provided it does not cause myxedema. But the probability is that we shall learn to recognize affections which lie between myxedema and health, as well as peculiarities of development and disorders of nutrition for which the thyroid is more or less responsible.” ... That this is a statement of fact will hardly be disputed by any neurologist, but that it expresses a truth that has as yet been insufficiently impressed on the profession generally is another fact the importance of which is not likely to be overestimated. It is only within a comparatively brief period that we have learned that the thyroid had any definite function and our knowledge of its physiology is still very far from being exhaustive. The dangers also of interference with it are as yet also only partially known, but it is certain that they are not confined to the operation itself. The cases of sudden fatal dyspnea occurring hours after an apparently prosperous operation in Graves’ disease, recently reported by Debove and others, are in evidence of this, and Dr. Putnam adduces other important facts and arguments against any too venturesome surgery of the thyroid gland. Among these are the experiments of Halsted, showing that excision of the gland in dogs had a serious and very evident disturbing effect upon their offspring, and that even very slight operative interference produced hypertrophic changes and apparent increase of secretion in the gland itself; and the observations of Kocher of goiter and cretinism inherited from parents with no disease other than impaired thyroid function are also cases in point. Still another fact brought forward by Putnam is the one that removal or atrophy of the thyroid in infancy checks the growth and function of the reproductive organs, and gives rise to the various disturbances of development that follow the suppression of this very important function. The close relations of the various internally secreting glands, the thyroid, the testicles and ovaries, the suprarenal glands, and the pituitary body, for this it seems probable must be included in this category, are revealed in many pathologic conditions, and the thyroid as the largest, and presumably the most important, has apparently a larger part in the disturbances than any of the others. It seems to be involved to some extent in many cases of acromegaly; its relations with the genital development have already been mentioned, and its implication in many pathologic conditions of organs is probable and is strongly suggested bythe clinical history in certain cases of Graves’ disease. Seeligmann has indeed recently reported a case of this affection apparently closely associated with genital disorder in which he obtained decided benefit from the administration of ovarian extract, thus adding another suggestion to the therapeutics of the disorder.
When any organ is removed, as Putnam says, two factors are set in operation which may have more or less important effects upon the system generally. One of these is the action of toxins, the other is the effort of the organism to adapt itself to the new and changed conditions. The first of these is important enough in the case of removal of the thyroid gland, but the other, from what we are beginning to know of its physiology, must be even more important. Because the function of the organ is already deranged, it does not necessarily follow that matters will be remedied by its removal. The operation may only make a bad matter worse. The mortality of thyroidectomy, according to Poncet, is from fifteen to thirty per cent, which is alone enough to induce caution. When the facts brought forward by Dr. Putnam are also considered, the known and the possible and hinted though yet unknown effects of thyroid ablation, there is still more reason for prudence and hesitancy in this operation.
Of course when a goiter has become a dangerous mechanical embarrassment to important functions, or when a tumor exists in the thyroid that by its growth and situation has become a threatening danger, the case is clear, and operation may not only be justifiable but necessary. It is in such affections as Graves’ disease, in which thyroid operations are still somewhat popular, that we are likely to have not only useless but dangerous surgery, and the time seems to have come to emphasize the cautions implied in Dr. Putnam’s paper. The theory of hyperthyroidization in this disease, though it has apparently much in its favor, is not yet sufficiently demonstrated, and even were it so, would not form a justification for any indiscriminate or frequent practice of operative interference. Graves’ disease is not by any means a hopeless disorder under medical treatment, even in its advanced stages; it is therefore impossible to say when surgery is indicated as a last resort. When the facts of its absolute inefficiency in perhaps the larger proportion of instances in which it has been tried, the immediate dangers of the operation which are not slight, and the remote ones pointed out by Dr. Putnam, are all taken into consideration, it would seem that it ought to be relegated to innocuous desuetude.—Journal of the American Medical Association.
The Treatment and Prognosis in Graves’ Disease.—This short article is prepared solely with the view of eliciting from medical men who have met with cases of exophthalmic goiter in their practice, the results of their observations regarding many points of interest in connection with this curious disease. I do not intend to give a systematic description of the affection in question. This can be found in any good modern text-book.Described many years ago by Parry, Basedow, and by others more recently, it is much better understood and more widely known than formerly.
Opinions differ radically as to its real nature. The best modern authorities regard it as a pure neurosis, and functional only in character, although organic changes often develop during its course in the heart, thyroid gland, and elsewhere. Some still speak of it as due to changes in the medulla oblongata; others again look upon functional and structural changes in the thyroid gland as the real cause of the malady. My own experience inclines me to view it as a neurosis pure and simple, although marked and characteristic structural changes supervene during its course, and may become permanent. Probably in the near future we shall learn more as to its exact nature. Already it is satisfactory to note that cases are far earlier and more frequently recognized, and that their treatment is more successful.
From their first appearance its special features attract attention. These are few in number, and easily borne in mind: 1. An unusual and more or less constant rapidity of the heart’s action; 2. The early presence of more or less protrusion of the eyeballs; 3. A marked enlargement of the thyroid gland; a tendency to tremors or tremblings under very little, and sometimes no excitement, although this always increases it. It is not surprising that these indications of exophthalmic goiter which develop more or less rapidly and become often most distressingly marked, should cause much anxiety to the patients and their friends, as well as to their medical attendants.
With regard to the duration of ordinary chronic cases (for acute ones are seldom met with), what has been the experience of those who may read this article? I have never met with an acute case, but have seen months and one or two years pass before there was more than a partial improvement.
One case, a very bad one, in which the patient’s circumstances were so poor that she worked on during her illness, when she should have had care and rest, recovered completely. But so serious was this case, that the sight of both eyes was entirely lost from the excessive protrusion of the eyeballs during the disease. When I first saw her, which was years after her recovery, the story of her case was intensely interesting, but most sad.
Then as to the frequency with which relapses occur in this disease, it would be interesting to get the experience of good men. Many speak of relapses being frequent, even after apparently complete recovery has taken place. Others think them not of so common occurrence.
There are also many points of great interest in connection with the prognosis. One of these is the probability of the recovery being perfect. My own experience has been that the lighter or milder the case the greater the probability of a perfect cure.
Another matter of interest is in connection with cases in which the symptoms greatly abate, the health indeed appearing to be perfectlyrestored, but in which the exophthalmos and thyroid enlargement continue noticeable; whether in such patients very slight causes may not lead to a return of the disease. From what I have seen, the conclusion appears correct, that provided the heart’s action is normal as to frequency, and not too easily disturbed, these cases are not specially likely to have a second attack, which is tantamount to saying that, provided the heart’s action has become normal, any other relic of the illness is comparatively unimportant.
I have observed, too, more or less scleroderma present when the attack has not been by any means of a serious character, and when afterward the general health became all but perfectly restored. This is an interesting concomitant. It would be desirable to have others give their experience as to its occurrence in cases they may have attended.
Then as to the effects of pregnancy during the course of the disease; some high authorities speak very strongly as to its great danger. Others remark that the affection has improved during gestation. This is another matter on which fuller information would be most useful.
As to the percentage of fatal cases, this is hardly as yet to be determined so as to be useful to the practitioner. My own cases have led me to the conclusion that every particular case has to be regardedper se, that is, if the symptoms are light and comparatively trifling, and show signs of abating, the prognosis is favorable, while under an opposite state of things it is the reverse.
As to treatment, what has succeeded best in my hands has been enjoining upon patients the necessity of a great deal of physical rest, at least ten or twelve hours a day if possible, and the avoidance of all mental worry. On this, great stress should be laid. These patients require abundant nourishment. Galvanism in my hands has been found most useful; employed twice a day and so applying the poles that the current may go from the back of the neck through the thyroid gland, and the heart, and even (the current being made very weak) through the eyeballs. This current has been continued for months, and in some cases for a year and a half, with good effects. Sometimes tincture of digitalis has been useful in moderate doses, ten or twelve minims three times in twenty-four hours, in some cases, and useless in others. Iron has been found of great value and persisted in for a long time. As a nerve-tonic, strychnine in small doses has been exceedingly beneficial. Quinine, if used, should, unless malaria complicates the case, be used in small doses only, such as 1½ grains three times a day, with the iron and strychnine.
I know that many of the matters I have mooted in this paper have been quite recently discussed by Drs. Ord and McKenzie, of London, in an excellent article on exophthalmic goiter in the fourth volume of the new System of Medicine edited by Allbutt, but a still wider discussion on the matters alluded to, and on many others, by practitioners who have met with and treated such cases, will do much good, and tend to make the care of such cases more pleasant and the results of treatment more satisfactory.Walter B. Geikie, M. D., C. M., D. C. L., in Philadelphia Medical Journal.
Dangers of the Nasal Douche.—Lichtwitz (Sem. Med., November 26, 1897,) deprecates the routine prescription of the nasal douche in all cases of hypersecretion of the nasal mucous membrane. Irrigation is called for only when the nasal fossæ require clearing of pus and crusts, for instance in idiopathic ozena. This affection is mainly limited to the nasal fossæ properly so called, and irrigation is in such a case the most fitting form of procedure. An ordinary syringe or enema syringe with suitable nozzle should be used. In all other nasal affections irrigation is inadequate or useless; it is even dangerous. Repeated flooding of the mucous membrane may give rise to olfactory lesions. Antiseptics are highly injurious and pure water is badly borne; the physiological solutions of sodium chloride, sod. bicarb. or sod. sulph. are the only harmless liquids. In numerous cases irrigation has caused the sense of smell to be temporarily or permanently diminished or lost. Distressing frontal or occipital headache may result owing to the liquid passing into the sinuses. The injection of irritating liquids may even set up inflammation of these cavities. The most skilful and careful irrigation is insufficient in many cases to prevent the resulting headache. A very grave complication is the penetration of the liquid into the middle ear, suppurating otitis media occasionally supervening. In acute coryza, especially in children, douching should never be practiced. In one such case known to the author mastoiditis followed irrigation of the nasal cavities. The predisposition to otitis is increased after retro-nasal operations, in particular after ablation of adenoid vegetations. For eight years the author has given up all irrigation after pharyngo-tonsillotomy, and during that period has met with no case of post-operative complication.—British Medical Journal.
Antipyrin.—In July of this year the antipyrin patent, held by the Hochst color-works, will expire by limitation, it having run its course of fifteen years—the span of life allowed to a German patent. During these fifteen years the monopolists have sold the drug at about $12.50 a pound, but it will, of course, fall considerably in price the moment the manufacture and sale are permitted competitors. It is anticipated that it will shortly fall to at least half its present price, when the usual convention of the principal competitors will be called and the inevitable trust formed, leading to a consequent rise in price. It is rumored that a number of chemical works are busy with the manufacture of antipyrin, so as to be prepared with it immediately upon the expiration of the patent.—Philadelphia Medical Journal.
Professor Robert Kochhas been invited by the Indian Government to make another stay in India for the purpose of studying the epidemic and endemic diseases of man and beast so prevalent there. Koch is now engaged on work that will keep him in German East Africa for some time, probably about a year, and does not think of leaving until he has concluded it.