Note on the etiology of Graves's disease / by D.R. Paterson.

  • Paterson, Donald Rose.
Date:
1894
Catalogue details

Licence: Public Domain Mark

Credit: Note on the etiology of Graves's disease / by D.R. Paterson. 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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    ninth. The average time in the hospital was six weeks, after which the children were sent to the convalescent home for three weeks. In conclusion, in cases in which resection was performed, the mortality in the above series of cases was 11 per cent., for children under three years of age 12 percent., and for ■double empyemata 28 5 per cent. If these figures be com- pared with those given in a recent number of The Lancet ^— ■viz., 20 per cent, in all cases, 50 per cent, in cases under ■three, and 84 per cent, for double empyemata—I think they show that a definite advantage is gained by resection of one ■or more ribs. Airlie-gardeus, Campden-hill, W. A CASE OF PERFORATED GASTRIC ULCER; GASTRORRPIAPHY; RECOVERY. By HASTINGS GILFORD, F.R.C.S. Eno. The patient in this case was a married woman twenty- mine years of age, who first showed symptoms indicative of the presence of a gastric ulcer eight years ago, when she vomited blood twice ; but, though she has been subject to occasional dyspepsia of an indefinite nature for more than ■eleven years, she has until recently had no marked pain or return of vomiting. I have known her for five years, during which period I have treated her at times for ansemia and ■mild flatulent dyspepsia,' but I did not suspect the presence •of a gastric ulcer until December, 1892, when she suffered from vomiting and epigastric pain. The vomiting appeared >to bear no relation to the ingestion of food, and the vomit was free from blood; but, while pressure over the greater part of the abdomen gave rise to no pain, at one spot, which •could be covered with a shilling, the pressure of the finger •caused acute pain. I diagnosed gastric ulcer, advised her regarding her diet, and prescribed pills containing bismuth and creasote, but did not see her again until the ulcer perforated. I subsequently heard that she had improved so much that she did not consider it necessary to continue the ’treatment, and that she remained well until April 10th, ,11893, when she had a return of the pain and vomited ■once. She was better on the following day, but the pain still troubled her occasionally. It was not induced by ■eating, but, on the contrary, was relieved by taking food. ■On June 22nd, at 10 a.m., after a breakfast at 8.30 a.m. of cold mutton and bread and butter, she was bending over, washing her baby, when she felt a sudden agonising pain a 'little above and to the left of the umbilicus. She and the baby were alone in the house at the time, but she succeeded with difliculty in walking downstairs to get a neighbour to come for me. When I saw her at 10.30 a m. she was lying in bed moaning with pain, which she referred to the middle and lower end of the sternum, and especially to the shoulder cf each side. Respiration was mainly thoracic and was so increased by deep breathing that she dreaded to take a ■sufficient breath and suffered from dyspnoea in consequence. As she answered questions her hands involuntarily went to her shoulders, the arms being crossed over the chest, and she cried out with pain. Pain in the abdomen had been slight ■since the beginning and was referred to the epigastric and left hypochondriac regions, and, while the abdominal muscles were rigid and were sensitive to pressure, the rigidity and tenderness were most pronounced in the same areas. Pain cn pressure, moreover, was referred less to the abdomen than to the sternum and shoulders. The features were not shrunken, and there was no coldness of the extremities. 6he felt sick, but did not retch or vomit until half an hour after I had left her. The temperature was 96 ■8'’F. and the pulse 68, regular, and of normal size and tension. I diagnosed perforation of a gastric ulcer and injected twenty minims of a solution of opium beneath the skin, greatly to the relief of her pain and breathing. The injection had to be repeated twice in the course of the day. The pulse-rate gradually rose, until at 6 p.m. it was 104, while the temperature was 101°. Dr. Moody-Ward saw her with me late in the afternoon and concurred with my ■opinion that laparotomy was advisable. The operation, therefore, took place at 6.30 p.m.. Dr. Abram kindly giving chloroform. An incision three inches and a half in length 1 The Lancet, May 5th, 1894. was made in the middle line, starting half an inch from the ensiform cartilage. After the linea alba had been cut through, the subperitoneal fat and fascia projected like a bladder between the lips of the wound, and on puncturing it gas escaped, together with peritoneal fluid and stomach contents. On introducing the finger into the wound it almost immediately ran into the open ulcer, which was situated on the anterior surface, apparently near the middle. It was too small to admit of the introduction of the finger, but its edges were so brittle that the finger could be forcibly pushed in without difficulty by splitting the callous adjacent surface of the stomach. The edge of the ulcer appeared to be quite half an inch thick. The interior of the stomach was first explored for other ulcers, but with a negative result, and the margins of the perforation were then excised. Ten silkworm gut sutures were next introduced through the whole thickness of the stomach, including the mucous membrane. This material was used because it was evident that catgut would not be sufficiently durable, and silk appeared inadmissible from its greater liability to conduct septic matter along its threads. The number of sutures was necessitated by the length of the wound, which was about two inches, by the extreme brittleness of its tissue, and by the difficulty experienced in bringing the indurated edges together. Two sutures cut through while the others were being put in, and required to be replaced. Finally, when the wound had been firmly closed, a tube was passed into the stomach, and water was poured into it through a funnel, in order to test the efficiency of the sutures. As no water escaped, the abdominal cavity was well irrigated with boiled water and the wound closed, a bulbous glass drainage- tube being first passed through, so that its bulbous extremity rested on the closed ulcer. On the second day after the operation, when the wound was dressed, there was very little watery discharge, but the tube had slipped along the lesser curvature until it was parallel with the external wound. As it could not be readily replaced it was taken out. The bowels acted loosely seven times in the night, and at 11.30 A.M. she passed urine for the first time for twenty-four hours and a half. She was fed during the next seven days with peptonised milk enemata, varied occasionally with beef-tea or raw meat, six ounces of which were given every four to six hours. On the ninth day after the operation the temperature, which had been normal for nearly forty-eight hours, began to rise, and varied between the extremes of 99 4° and 100-5° for the next five days. The wound suppurated, and she looked haggard and was very depressed. These symptoms indicated to me the presence of pus within the abdominal cavity and the necessity for a return to stomach feeding. Peppermint-water was first given in small and repeated doses, and on the tenth day after the operation two tablespoonfuls or peptonised milk and one of beef jelly were given every hour. Three days later she had advanced to oysters and farinaceous diet. On the four- teenth day after the operation she passed a motion which was said to be capped with pus, but through inadvertence it was thrown away before I saw it. I thought it probable that undigested milk had been mistaken for pus, for the patient felt no indication of an abscess having burst ; the temperature was not affected, and no pus was found in the next motion passed. When, therefore, on the seventeenth day after the operation the temperature rose to 103° and the pulse to 132, and her features became anxious, sunken, and haggard, I thought it would be advisable to give chloroform and explore the abdomen in the neighbourhood of the in- cision with a needle ; but fortunately, before carrying out this intention, I got Dr. Moody-Ward to see her, and he advised waiting until the temperature again rose to 103°. The next night at 1 30 A M. she was suddenly roused from sleep by a sudden sharp pain a little above and to the left of the umbilicus, and almost immediately afterwards called out for the bed-pan. A pale, loose, highly offensive motion was then passed, evidently composed principally of pus, and three other motions of a similar character were subsequently passed during the day. The temperature rapidly fell and two days afterwards was below normal, where it remained. She speedily improved in general condition and three weeks after the operation was sitting up in a chair. During the year which has since elapsed she has increased in flesh and has remained free from dyspeptic trouble. During the first three months of that time the thickened area of the healed ulcer and the ends of the sutures could be plainly felt through the abdominal walls, but no sign of them can now be detected.