On some rarer factors in Graves's disease.

  • Maude, Arthur.
Date:
[1893]
Catalogue details

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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    After the administration of iodo-theobromine, the pressure rises in the radial artery from 150 or 170 to 200 grammetres and from 250 to 306 grammetres. Should the pulse be so weak and soft that the blood pressure in the artery cannot be accurately deter- mined, a dose of iodo-theobromine steadies the heart and the blood pressure rises sufficiently to permit of its being expressed in grammetres. In a case of mitral stenosis and incompetence with some cor- responding incompetence of the tricuspid valve, and venous pul- sation over the liver and in the jugular veins, the force of the cardiac contractions considerably increased under the daily admi- nistration of two and a half grammes (thirty-eight grains) of iodo-theobromine in the twenty-four hours, while the venous pul- sations disappeared and the pulmonary second sound which was verv weak when the treatment was commenced became distinctly audible. There can be no doubt about the diuretic action of iodo-theo- bromine and iodo-caffeine. It is manifested even in the absence of oedema or dropsy of any kind and in spite of the existence of polyuria as in the resolution stage of subacute nephritis. In a case of pleurisy with a large accumulation of fluid in the leura, the total quantity of urine excreted in the twenty-four ours rose from 20 oz. to 67 oz. under the influence of theo- bromine. Iodo-theobromine was also tried in a case of hypertrophic venous cirrhosis of the liver complicated by ascites and anasarca, in which repeated doses of calomel and diuretine (salicylate of sodium and theobromine) had failed to give relief; under the administration of iodo-theobromine the quantity of urine excreted in the twenty-four hours increased from 10 or 15 to 42 or 50 oz., and the diuretic action of the remedy persisted for a few days after the cessation of the treatment. In a case of diffuse subacute nephritis with anasarca, the total quantity of urine excreted in the twenty-four hours increased to 67 and even 80 oz., while the oedema disappeared. The dose varied from fifty centigrammes to three grammes (eight to forty-five grains) in the twenty-four hours for an adult. In no case did we find it necessary to have recourse to larger doses. The remedy is best administered in the form of powders or in cachets. From a comparative study of the therapeutical effects of iodo- caffeine and iodo-theobromine we have arrived at the conclusion that the latter is more active in increasing diuresis, the force of the cardiac systole and the blood pressure. So far as we are able to judge from clinical experience, iodo- caffeine seems to be especially indicated when—as in cases of mitral stenosis—it is necessary to increase the amplitude of the diastole in order to facilitate the passage of the blood through the stenosed auriculo-ventricular orifice into the ventricle. Iodo- theobromine should be preferred to iodo-caffeine (which is not so stimulating to the inhibitory cardiac mechanism) in cases in which it is desired to increase diuresis and the strength of the ventricular contractions, and when — as in aortic incompetence — the action of caffeine on the diastole might prove injurious by favouring the regurgitation of blood into the left ventricle through the incompetent aortic valves. Iodo-caffeine and iodo-theobromine exert no special action on the respiration or temperature. They are well borne by the sto- mach, and are rapidly eliminated by the kidneys, provided these organs are not too extensively diseased. There is only one drawback to the use of these substances : when administered in large doses they are apt to excite a spasmodic cough due to the free elimination of iodine by the respiratory mucous membrane. From the foregoing facts we believe we are justified in conclu- ding that the introduction into medical therapeutics of certain xanthine derivatives, combining the physiological properties of the iodides with those of caffeine and theobromine, is not devoid of interest from a practical point of view. (Clinical lecture ON GALACTOPHORIT1S. Delivered, at the Charitc Hospital. By Dr. BOiSSARD, Accoucheur to the Paris Hospitals. The discovery of the existence of infective germs has thrown quite a new light on the pathogeny of numerous affections which until a few years ago were erroneously attributed to a host of different causes. These affections comprised the various inflammatory changes, whether accompanied by suppuration or not, observed in the mammae post-partum. How far is our pre- sent conception of the pathogenesis of these phenomena from the old theories according to which the mammary inflammations of the puerperium were to be referred to metastatic influences, con- gestion or obstruction to the flow of milk ! The humoural theory, the old favourite, has now been super- seded by the microbial theory or theory of infection, which enables us to appreciate the real significance of many facts that would otherwise remain obscure or would be only very imper- fectly understood; moreover, we are now in a position to under- stand the hidden relationship between certain manifestations which are apparently perfectly distinct from one another. That the nature of the “ soil” plays an important part in the development of the affections already alluded to, there can be no doubt, although the influence of this factor has yet to be accura- tely determined ; but it is now universally recognised that the mammary inflammations of the puerperium are due to infection by an infective or septic agent of some sort. Although such cases are becoming rarer and rarer at the present time owing to the strict application of the rules of antisepsis, they are still occasionally met with. This is not surprising, seeing that for several days after labour, the patient is in imminent danger of infection especially as it is extremely difficult to keep the wounded parts (uterus, vagina, vulva) perfectly aseptic on account of their anatomical arrangements. Even such a physiological sequence of labour as suckling may be a cause of infection by favouring the introduction of septic germs into the ulcerations, excoriations, etc., which are of such frequent occurrence on, or around, the nipple. It is even maintained by certain observers that the pre-existence of a crack or fissure is not essential for infection, that the infective agent, having been deposited on the surface of the nipple, is ca- pable of passing along the milk ducts, in the opposite direction to the flow of milk, setting up galactophoritis, just as the go- nococcus is capable of setting up urethritis or cystitis by passing up the urethra in the opposite direction to the flow of urine. The mammary manifestations observed during the suckling period, and especially at the commencement of that period, are of two kinds, both of which are due to the same cause ; they appear in the form of lymphangitis or galactophoritis, culminat- ing sometimes in the formation of an abscess. In cases of lym- phangitis, however, we are dealing with a periglandular inflam- mation invading the cellular tissue of the breast through the lym- phatics; while in cases of galactophoritis, we are confronted with a glandular, parenchymatous suppuration invading the acini of one or more of the mammary lobules through the lactiferous ducts. It is the latter condition, and galactophoritis in particular, that I propose to discuss in the present lecture. Mammary abscesses have been recognised and described by the most ancient writers and they have been very appropriately di- vided by J.-L. Petit and Velpeau into parenchymatous glandular abscesses and abscesses of the cellular tissue. It seems to me, however, that the part played in the aetiology of these cases by the milky way has not received due consideration ; and those of you who have attended mv ward visits have had ample oppor- tunities of satisfying themselves of the importance of this chan- nel of infection. This I shall endeavour to demonstrate, for I believe a knowledge of this fact may prove useful to you in the future. I feel quite at home in discussing the subjet of galactophoritis in this hospital, for I am backed upby the authority of Dr. Budin, the accoucheur in charge of these wards, who in a clinical lec- ture delivered here in 1888, and in a communication to the Academy of Medicine in the following year, withdrew this old morbid entity from the oblivion into which it had fallen, devis- ing at the same time a successful method of treatment based on the principle then enunciated. Galactophoritis consists in an inflammation of the lactiferous ducts, due to the invasion of these ducts by septic micro-or- ganisms (streptococcus, staphylococcus). It may be localised or pure, to use a more precise term, that is to say, it may occur as a primary infection, neither accompanied nor followed by any lymphangitis. On the other hand, lymphangitis and galactophoritis are often found associated in the same patient and naturally the sypmtoms are different according as these affections exist simultaneously or separately. I may addthat simple primary galactophoritis may, and often does, escape detection seeing that it is very insidious in its onset and does not give rise to a very pronounced reaction. This is the reason why this affection has remained for a long time unrecognised in spite of the description that was given of it by Chassaignac under the name of canalicular intero-mammary abscess. The terminal manifestation of the process, viz., the, formation of a parenchymatous glandular abscess was alone taken into account while the initial change, viz., the presence of pus in the lactiferous ducts was ignored, as the pus escaped mixed with the milk. Although galactophoritis may arise primarily without any antecedent lymphangitis, I am hot quite sure that infection can