A contribution to the clinical history of Graves' disease (exophthalmic goitre) / by J. Russell Reynolds.

  • Reynolds, John Russell, 1828-1896.
Date:
1890
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Credit: A contribution to the clinical history of Graves' disease (exophthalmic goitre) / by J. Russell Reynolds. 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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    amount of lung tissue deprived of air. The plug is some- times suddenly removed by a fit of coughing. The methods of inspection and palpation aid us little in bronchitis, and we have, as regards physical signs, to rely upon the negative sign of the absence of dulness, and the auscultatory rhonchus, sibilus, and mucous rales. The only symptom of bronchitis, in addition to the cough and sputum, which need be mentioned is one which has been already incidentally alluded to — viz., dyspnoea. A certain amount of dyspnoea is always present, but id may be very slight—in fact, it varies from a slight wheezing to the pronounced excessive dyspnoea such as is observed during an attack of asthma. When the dyspnoea is great, there is either inflammation of the small tubes with fever, with marked sibilant sounds on auscultation; or the exudation is inclined to be croupous rather than catarrhal, or a plug is lodged in a bronchial tube, producing the con- dition before described; or finally, there is some complication such as broncho-pneumonia. One of the most important rognostic criteria under these circumstances is the con- ition of the circulation. If there be much blueness of the lips and tongue, with coldness of the extremities, cold sweats and small, feeble, perhaps irregular pulse, the con- dition is serious. It is also a sign of the gravity of the attack if there is high fever, coupled with loud and intense rales all over the chest; and again, according to Stokes, if with the fever during ordinary respiration we hear little or no rale, because in the latter case the finer ramifications of the bronchial tubes are so turgid that during ordinary respiration the air cannot enter them with sufficient force to produce a tone. A forced inspiration, however, will bring the sounds forth with considerable distinctness. I do not propose to devote more time to the subject of primary bronchitis, but will next turn for a few minutes to the second class, into which I have divided bronchial catarrhs, and that only for the purpose of drawing attention to the fact that the presence of marked and persistent bronchial catarrh may be such as to make a case of typhoid fever be mistaken for general acute tuberculosis of the lung. I have seen such a mistake made, and it is neither very uncommon nor yet deserving of much blame. Now, in typhoid fever and in measles bronchitis is suffi- ciently common, and is, in all probability, a manifestation of the specific poison in both cases ; in rheumatism and (according to various weighty authorities) in gout, again, the catarrh is but a manifestation of the working of the specific poison. Dr. Greenhow has laid stress upon the frequent con- currence of gout and psoriasis or eczema with bronchitis among the out-patients of our hospitals. He found that in about one-quarter of the cases of bronchitis among his out-patients gout showed itself in a regular form, either coincidentally or alternately with the bronchitis ; in others bronchitis was joined with the so-called rheumatic gout. He also called attention to the form of dyspnoea generally known under the name of gouty asthma, or the “ asthmatic dyspnoea ” of Dr. Graves. This form of dyspnoea, in which spasm of the bronchial muscles is .said to enter, is always associated with bronchial inflammation in which the exuda- tion is particularly sticky and difficult of expectoration. The third class of cases, which includes those I have called local bronchial catarrhs, is I think even more im- portant to us as connected with a chest hospital than the preceding two classes, as under this head is included the bronchial catarrhs connected with pulmonary tuberculosis. Before we can discuss the connexion between bronchitis and phthisis, it will be necessary to allude to a condition of the lung which is connected with bronchitis—that is to say, bronchiectasis. Of the chief causes which produce chronic bronchitis, oneof thecommonestmay be said to betheconstant inhalation of irritating particles, which is bound to happen in occupations such as that pursued by coal-miners, masons, knife grinders, and the like. In this form of chronic bron- chitis the course of the carbonaceous particles has been carefully traced by Professor Hamilton by means of micro- scopic examination of the lungs of patients who have died of the disease, as follows: “They first penetrate through the infundibula, air vesicles, and smallest bronchi, and from these they are poured into certain of the peri-bronchial lymphatics, but mostly into the large peri-vascular branches. Those which enter the peri-bronchial lymphatics appa- rently very soon pass into the larger lymphatics round the arteries. From the peri-vascular lymphatics they run into the lobular septa, from this to the deep layer of the pleura, and finally into the bronchial glands.” The peri-bronchitis and peri-arteritis which follow in some cases appear to implicate not only the fibrous tissue around the bronchi and arteries, but also the lobular septa and pleura, so that a very large amount of new fibrous tissue results. It is by the cicatrisation of this tissue that irregular dilatations of the bronchi result, so Dr. Hamilton says. They may occur anywhere in the lung, but particularly in the apex and base. In the latter case it is very likely that it is the chief posterior basic bronchus in either lung which is affected. This has been shown by the researches of Aeby and Ewart to be the main continuation of the bronchial stem. It is only fair to say that some pathologists and physicians take a different view of the formation of irregular bronchiectases in the lower lobe of the lung than the one here given. Many believe that they are due to antecedent pleurisy and consequent fibrous thickening. Whether this view is correct or not, there is no doubt that chronic bronchial catarrh is always associated with the condition described. I have no time to touch here upon the other forms of bronchiectasis—viz,., the fusiform and sacculated. The term “Graves’ disease” is employed in this paper in preference to that of “ exophthalmic goitre,” inasmuch as it has a wider range of meaning and connotes three sets of symptoms which are not hinted at in this latter term, but which are quite as important as those two which it does convey. Moreover, it involves no theory as to the nature o the connexion between those symptoms, nor any suggestion as to their relative value or order of sequence. Prominence of eyeball and enlargement of the thyroid body have been in many cases delayed until long after cardiac or nervous symptoms have been developed, and become urgent; so that the real nature of the malady has been con- cealed, and its treatment rendered ineffective. It is this fact which has led me to make the following communica- tion, in the hope that its perusal may lead to an earlier recognition of the true nature of the malady, and so further to its treatment at the time when such treatment is by far the most efficacious. During the past four years, from 1886 to 1890, I have made notes of forty-nine cases of Graves’ disease which have come under my oare in private practice. Of these, by far the most severe, characteristic, and acute in develop- ment presented themselves in the year 1888, in which year also a larger number occurred than in any two of the other years. To this matter I shall recur presently when speakiDg of external conditions in relation to the possible etiology or this curious disease. But, I. With regard to the internal conditions of the indi- viduals affected. Sex.—Forty-eight were females, and one only was a male, but in this latter the symptoms were highly charac- teristic and severe. I have not included in this category a curious case of a gentleman over sixty, whose pulse while lying was 120, who was partly crazy, and had notably prominent eyeballs, without any enlargement of the thyroid. The exophthalmos was rather a simple peculiar! ry of shape of unknown duration ; and the rapidity of pulse was probably due to past, but considerable, intemperance with alcohol. Age.—Of 48 cases there were 12 from ten to twenty years of age ; from twenty to thirty, 15 ; from thirty to forty, 10 ; from forty to fifty, 7 ; from fifty to sixty, 4. So far as this small number of cases can show anything on such a large subject as the influence of age in the pro- duction of disease, it is to the effect that although more than one half of the cases were under thirty, yet the influence of age is reduced to next to nil if regard be paid to the number of people living in the succeeding decades. The cases which occurred in 1888 exhibited nothing special in relationship to the age at which the malady occurred. Social position.—All the patients whom I have seen A CONTRIBUTION TO THE CLINICAL HISTORY OF GRAVES’ DISEASE (EXOPHTHALMIC GOITRE). By J. RUSSELL REYNOLDS, M.D., F.R.S., F.K.C.P. PHYSICIAN IN ORDINARY TO IIER MAJESTY’S HOUSEHOLD. f )