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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    been taken from a male. Had Mr. Hudson dissected the broad liga- ments, he would have been able to assert definitely whether the ovary was provided with a parovarium showing whether or not the ducts of Gartner were in question. CLINICAL SOCIETY. Friday, October 13th, 1893. Dilatation of the Stomach and severe Pain dependent on Pyloric Adhesions, treated by Abdominal Section and Separation of Ab- normal Attachments; with general remarks on Visceral Adhe- sions as a cause of Obscure Abdominal Pain. Mr. Mayo Robson (Leeds).—I am enabled to relate the history of two cases which were sent to me for operative treatment on account of extreme emaciation dependent on dilatation of the stomach and severe pain in the epigastrium and right hypochondrium. Medical treatment had been previously tried without relief. In both, I had recourse with success to the same treatment, separation of adhesions of the stomach and pylorus; the original cause of the adhesions being, in the one case, gallstones, and in the other, ulceration of the stomach. I have brought forward these cases because, although it is known that simple adhe- sions may produce serious symptoms, it is not generally recognised that dilatation of the stomach may be cured by their separation. Many instances of severe abdominal pain, often spoken of as neuroses are due to. or associated with, the vermiform appendix being distorted and tied in an abnormal position; the ovaries or Fallopian tubes, or both, displaced and fixed; and last, but not least, omental adhesions of great variety produc- ing visceral distortion; all these conditions are curable or relievable by a carefully planned and skilfully performed laparotomy, and that with- out any mutilation of viscera. 1 may further remark that although it is difficult to lay down any hard and fast rules, yet, personally, I should feel it wise in cases of obscure abdominal pain producing invalidism or disability, after medical treatment has been fully tried ancl failed, to open the abdomen in order to clear up the diagnosis, and then to adopt that line of treatment which seemed to be indicated. I am of opinion that these cases are interesting, not only from a diagnostic and an etiological point of view, but also from that of the treatment, for if some of those cases of dilated stomach, depending on pyloric distortion can be cured by simply separating adhesions it will be manifestly a safer and more sa- tisfactory method than that of dilating the pylorus or performing pylo- roplasty or gastro-enterostomy, in alf of which the stomach has to be opened. I am afraid it woulcl appear as though I have included two distinct subjects in one paper, viz. : dilatation of the stomach and ob- scure abdominal pain dependent on adhesion; but a more careful study of the paper will show that what 1 wish is to lay special stress on adhe- sions producing visceral disability, and their capability of cure by ope- ration, and if 1 have succeeded in demonstrating that adhesions are not as harmless as some observers would lead one'to suppose, my purpose has been served. Mr. Hulke.—There must be considerable risk in attempting to separate adhesions of the stomach when these are the sequel of ulcera- tion because in such cases they may prove to be the only barrier to per- foration and in separating them we may do mischief which may prove irreparable. The author is certainly to be congratulated upon the success of his intervention but it is not quite easy to see, after the adhesions have been broken down, how they can be prevented from reuniting. That may be possible when the adhesions are small in extent and thready but when two large raw surfaces are left in apposition there is no obvious reason why they should not unite afresh. Dr. Frederick Roberts.—For many years past I have been drawing attention to, and have endeavoured to impress upon my students, the importance of these internal adhesions. They are, I believe, at the bottom of a great many of the sufferings of which our patients complain. The author will find some useful information on the subject in a paper which I contributed many years ago to a Liverpool medical journal. I quite agree with the remarks that have fallen from him in respect of the importance of these adhesions, both in the chest and in the abdomen, as the possible source of disturbance of function and pain as to the real nature of which little can be made out. I myself have met with cases of dilated stomach associated with adhesions in the neighbourhood though I have never seen a case in which relief was afforded by surgical measures. It is a curious fact that in some cases though nothing is found to account for the symptoms on opening the abdomen, yet the symptoms have been relieved as the result of the intervention. Only to-day a surgeon related to me the history of a case in which I had diag- nosed the presence of a gallstone. He had operated without alighting upon anything of the kind yet the patient has since completely reco- vered and is now in perfect health. Dr. Hale White.—Eight years ago I made a post-mortem examina- tion of the body of a patient with a dilated stomach. During life some- thing was vaguely made out in the region of the pylorus and the case was diought to be one of malignant tumour. At the post-mortem examination 1 found an extreme degree of the condition so well described by the author. The gall-bladder was adherent to the pylorus which was considerably thickened by chronic inflammatory growth. Though jaundice had never been complained of the source of the whole trouble was a gallstone which had presumably ulcerated through the pylorus. This seems to me just the sort of case which, if treated early in the way recommended by the author, would probably have yielded a complete and triumphant success. In another case, one of typhlitis, the patient, a woman, recovered under the ordinary treatment but some months later her menstrual periods became very painful and it was supposed that the vermiform appendix had become adherent to the ovary. This proved to be the case on performing an exploratory operation and on the appendix being removed together with the ovary to which it had contracted adhesions, all the symptoms disappeared. Mr. Pearce Gould.—1 should like to know how the author makes out the fact of there being no actual narrowing of the passage of the py- lorus. In the case described by Dr. Hale White I do not think that mere breaking down of the adhesions would have been sufficient to prevent their reforming. 1 do not see how the patency of the pylorus can be made out even when it has been exposed. Inasmuch as relief of the painful symptoms sometimes ensues when no adhesions have been found to break down it is not safe to conclude that the relief obtained is always and entirely due to this severance of adhesions. In some cases of this kind, as in movable kidney for example, it is rather the creation than the demolition of adhesions that is indicated. Mr. Mayo Robson.—Peritonitis occurred in both of my cases, in one with great severity. When I expose the pylorus I grasp it between my fingers in order to ascertain whether it is of normal size. Then 1 roll it between my fingers when I can feel the internal surfaces slide over each other. This gives a very fair idea of the integrity of the passage. In some cases the pylorus has been thickened and hard, rendering it diffi- cult to distinguish from a malignant growth. It is not difficult to pre- vent the reformation of adhesions when, for instance, the adhesions are between organs normally as far apart as the appendix and the ovary, but in this particular case I believe that mere separation of the adhesions would have produced as good a result as removal did. When we have to separate the pylorus from the liver we must be careful to place them at some distance from each other, carefully stopping all bleeding and wiping them dry after the application of antiseptics. The risk of fresh adhesions is thus reduced to a minimum. In many of my opera- tions for gallstones it has appeared to me that the breaking down of the adhesions had more to do with the ultimate success of the operation than even the removal of the stone. The impaction of a gallstone in one of the ducts almost always gives rise to some peritonitis and indeed unless I find traces of this peritonitis I hardly expect to find a stone but to this rule there are of course exceptions. I remember one case in which on exposing the pylorus there was a solid mass into which the omentum had grown just as in a malignant tumour. I therefore de- sisted from further interference and gave an unfavourable prognosis. Yet the patient subsequently made a good recovery and was not again troubled. I have seen the same thing when all I did was to let out a quantity of ascitic fluid. 1 cannot offer any explanation of these curious cases but they are worth putting on record in order to facilitate the ex- planation which will doubtless sooner or later be forthcoming. Two Cases of Excision of Malignant Tumour from Large Intestine. Dr. W. Edmunds related two cases of malignant disease of the large intestine. In the first case the patient, a man, aet. 50, was admitted suf- fering from a lump in the right hypogastric region. There was a history of haemorrhage in considerable quantity from the bowel, but of no ob- struction. Laparotomy was performed, a tumour involving the caecum was found and brought out, and the portion of bowel involved was excised, and the two ends of bowel brought externally. The patient recovered, and is now, four years after the operation, in good health. No attempt to re-establish the continuity of the bowel has been made. The second patient was a man, aet. 54, suffering from incomplete obs- truction. By a median incision a malignant tumour of the sigmoid flexure was found and brought out, a glass tube being passed beneath it. On the fourth day the portion of bowel involved in the tumour was excised and the divided ends of the bowel sutured together. The bowels acted normally, but a faecal fistula formed through which in time the greater portion of the faeces escaped. An anastomosis was formed by Halsted’s method between the two portions of bowel. This operation is a lateral anastomosis, but it differs from Senn’s operation in the fact that no plates are used and the sutures are not carried through the whole thickness of the bowels, but only through the peritoneal and muscular coats and into the submucous coat, which is very dense and can be recognised by the resistance it offers to the needle. Subsequently the communication thus made is laid open and the surface opening closed, the continuity of the intestine is thus re-established, the bowels acting normally. Now, fifteen months after the first operation, the pa- tient is well, there only remaining a minute fistula leading to the bowel. I may remark that in similar cases, whenever possible, it is desirable to excise the growth and not to be content with a palliative operation. The reason why the growth was not at once excised and the bowel re- sutured in the second case was to avoid peritonitis from leakage, a dan- ger which it was hoped would be avoided by having the line of sutures shut off from the peritoneum. Mr. Hulke.— Thanks to the success which attends abdominal opera- tions with an improved technique it is probable that this operation will soon become a recognised mode of treatment. What was the condition of the motions in tne author’s first case ? In right colotomy there is often a great trouble in consequence of the liquid character of the motions giving rise to excoriations, etc. Mr. Gould.—Did the author experience any practical inconvenience from the liquid character of the motions in these cases? This cons- titutes a standing objection against right colotomy. In one patient on whom I performed this operation the motions are liquid but they are re- gular every morning, after which the patient is in peace and there has not been any excoriation. Cases have been recorded by Messrs. Ailing- ham, Treves, Bryant and others. Mr. Mayo Robson.—We have had several cases of malignant tumour of the bowel in the Infirmary at Leeds and our rule is that when there have been symptoms of acute obstruction with distension to make an artificial anus, but in cases where there are no indications of actual obstruction or distension then we perform either immediate suture of the ends by lateral apposition, Senn’s plates, or the bone bobbin, or else immediate suture of the open bowel end to end. It seems to me that in such cases it is much better at once to remove the tumour and to join the bowel ends than to make an artificial anus even though this be only intended as a temporary measure. I remember a case in