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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Licence: Public Domain Mark

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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    The left membrane showed a large perforation filled with granulations, and the canal was occupied by a little pus. There was no tenderness or swelling over the mastoid. Temperature 104° ; pulse 64. Bowels loose : motions liquid and yellowish. No optic neuritis. So far, if it had not been for the prominence of the pyremic symptoms, rigors, vomiting, and the great variations of temperature (08° to 104'4° on' the day of and the day following admission), enteric fever must have been the diagnosis.— May 27th : Patient’s condition has in no way improved, notwithstanding frequent irrigation of the canal with sublimate solution. I therefore scraped out the tympanum with a curette, offensive granulations and thick pus being removed.—28th : Patient much worse than on admission. Severe headache, high fever with one or two large daily oscilla- tions, profuse sweating, hands and lips tremulous, voice feeble, no optic neuritis. At 4 P. M. slight swelling and tenderness were noticed over the upper part of the jugular vein, and over the mastoid process on the left side. Shortly after- wards a consultation was held, in which Mr. Croft, Mr. Glutton, and others took part.- It was felt that operative interference was the only chance which the patient had of life, and that relief from the perilous state in which he was should be at once attempted by trephining the mastoid. I was assisted at the operation by Mr. Robinson and Dr. Turney. A f-in. trephine was used and a small gouge. No mastoid antrum was opened. The bone was very hard. On getting into the deeper layers of bone, I found they were greenish in colour, softened, and possessed of a foul odour. More bone was then removed, and on opening the groove for thelateralsinusbubbles of indescribably offensivepus and foul air welled up. The bone was then cut away so as to expose about one inch of the sinus, which was collapsed, and when subsequently opened was discovered to contain offensive clot. The extra-dural pus cavity was cleansed as much as possible with perchloride of mercury solution (1 in 2000). A probe so passed as to explore the posterior surface of the petrous bone allowed of a further escape of pus and foul air. The sinus was opened for the whole extent of the hole in the skull, and the clot in it was syringed out, or removed with a curette, as much as possible. The internal jugular vein was ligated in two places just above the omohyoid and divided between the ligatures. For a short time the patient’s face and lips became blue, but this rapidly dis- appeared. The immediate change after the operation speaks for itself : for thirty-six hours he was bright and cheerful, with a normal temperature and restored appetite. The subsequent history shows the hold pyaemia already had npon tiim. Although never approaching in gravity the condition before operation, he became extremely ill. On June 3rd he produced blood-stained sputum and a patch of consolidation at the back of the right apex, and on the 5 th a rigor, with pain and swelling of the right shoulder-joint and the right metatarso-phalangeal joint of the great toe. On the 7th, by pressure on the neck pus could be forced out of the opening in the sinus; so an incision was made down to the vein at the lower border of the parotid gland. It was opened, and pus came out; the sinus and vein were then irrigated with perchloride, a free stream of fluid passing in either direction, and bringing away small fragments of offen- sive clot. On the 17 th a large abscess in the right buttock was incised, and on syringing the mastoid opening, that part of the lateral sinus which extended from the opening in the skull to the torcular, one inch and three-quarters in length, came away as a slough. The local treatment consisted in frequent syringing with perchloride solution, and internally quinine, alcohol, and invalid nourishment of all kinds were given. The two joints, whichbecame duringthe illness swollen and painful, did not suppurate ; they remained painful and stiff for a couple of months. During this period they were wrapped up, and treated by the application of belladonna. Whilst the sinus and vein were being irrigated the patient persistently declared that “ he could always feel the water trickling down the inside of his neck.” He completely recovered, and left the hospital on Aug. 29th. Two months later he returned to his occupation as carman.3 Case 2.—E. P , aged eighteen, was admitted under my care into the West London Hospital on Aug. 29th, 1889. He had had a discharge from the right ear ever since he was 2 This patient chiefly owes his life to the strenuous advocacy of operative treatment by my friend and colleague, Dr. Hawkins, resident assistant physician to St. Thomas’s Hospital. This patient, in robust health, was present at the meeting of the [Society. a child. It partly ceased fourteen days ago, when he became feverish, and suffered from pain in the head and neck, vomit- ing, shivering, and delirium at night. On admission, the notes say: “The boy is ill nourished and thin, with an anxious, dull expression of face. There are oedema and tenderness over the mastoid and over the upper part of the right internal jugular vein. There is marked tenderness on deep pressure at the posterior edge of the mastoid and just below the external occipital protuberance. Pulse 120 ; temperature 104°; tongue dry; boy drowsy; pupils small, equal; reactions normal; slight optic neuritis of both discs. Some fetid pus in right external auditory meatus. No abdominal signs, but some rhonchus in lungs, with muco- purulent expectoration, occasionally tinged pink.” An operation seemed a desperate undertaking; but I decided at once to explore the sinus, which without doubt was plugged, and give the patient a last chance. Mr. Lloyd and Dr. Arkwright aided me at the operation. A §-in. trephine was applied over the position shown in Fig. 1, and as soon as the groove was open in which the sinus lies,’ about half a teaspoonful of foul pus and a few bubbles of fetid air escaped. The trephine opening was then enlarged in the course of the sinus in both directions with angular cutting bone forceps. In cutting forwards, the mastoid, antrum, and tympanum were opened, so that the tympanum, antrum, and meatus could be flushed with perchloride solution. A probe was introduced, as shown in Fig. 2, in order to explore the posterior surface of the petrous bone, and along it a fresh quantity of foul pus and air escaped. The sinus itself where it had been in contact with pus was covered with whitish patches of lymph. A grooved needle was inserted into it to decide as to whether it was or was not plugged. As no blood came along the needle, the sinus was freely slit up with scissors. The clot it contained was not very offensive, and as far as possible it was removed by the syringe and curette. The internal jugular vein was then tied at the upper border of the thyroid cartilage in two places and divided between. When the jugular was ligatured the face became blue, but this soon passed away as some dark blood oozed out of the opening in the sinus. This haemorrhage was encouraged, and distinctly gave relief to the venous engorgement. It probably depended upon the fact that clot contracts, and that therefore it did not quite obstruct the sinus and vein beyond the mastoid opening. Thus, if my ligature was placed on the jugular vein beyond the great tributaries, such as the common facial and lingual veins, a recurrent stream would at first make its way up the jugular, and escape out at the trephine hole. Sublimate solution was used at the operation and for the after-dressing. By the end of the operation the pulse was running, very feeble, and could not be counted. It was with much diffi- culty that the patient was rallied. The next morning the temperature had fallen to 101°. He was taking milk and brandy well; he had not vomited, the pain in the head was gone, and the enemata were retained. There was some rhonchus in the chest, the breathing was quick, and the pulse about 140. The following day he seemed still better, the pulse was stronger, the temperature below 100°; he was taking food well, and his only discomfort proceeded from the chest. The same evening (9 P.M.), however, he became violently delirious, the temperature rose to 106% and he died. Post-mortem : No visible meningitis; no abnormal state of brain detected, except that the anterior part of the right lateral lobe of the cerebellum, where it touched the dura mater near the trephine opening (the dura mater, in fact, which had confined a collection of pus), was stained superficially, over an area about the size of a sixpence, of a greenish-yellow colour. The sinus was plugged from the internal occipital protuberance, and the clot extended into the vein for about two inches. The ligature on the vein was well below the termination of the clot. The abdominal viscera were healthy ; there were no infarcts. The lungs showed many small infarcts and small abscesses. The operation was performed too late; the septic material had already travelled down the jugular, before a ligature was applied, in too large a quantity to be successfully dealt with by the “ amoebae”4 of this patient. Case 3.—L. T , aged fifteen, was admitted into St. 4 See Lauder Brunton’s Pharmacology, Therapeutics, and Materia Medica, pp. 69 and 47. “The struggle for existence is between the amcebm and the pathogenic bacteria.” See also a discussion on Obsolete Pus, St. Thomas’s Hospital Reports, vol. xvi , p. 186, and Carl Hess, Untersuchungen zur Phagocytenlehre, Virchow s Archiv, Band cix., Heft iii