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THE INFLUENCE OF THE THYROID GLAND ON METABOLISM.
316
replaced by fibrous tissue and that there exhumation was ordered and a necropsy performed. The of enlargement in the parotid glands. proceedings were, however, cut short by the suicide of the In another instance a midwife amputated an Dr. Osler inclines to the view that the disease was associated midwife. with inherited syphilis, which he thinks is borne out by the inverted womb in the belief that it was a tumour." These improvement which occurred under mercury and iodide of nefarious performances led to regulations being drawn up, potassium. With all the deference due to the high position and the midwives are now under proper supervision. which he holds we must dissent from him emphatically. Ulceration of the cartilaginous septum nasi, even to the THE ROYAL COMMISSION ON TUBERCULOSIS. extent of perforation, is by no means necessarily syphilitic. In this case there is not a single fact to support such a conMEETINGS of this Commission were held at 7, Whitehallclusion-no interstitial keratitis, no malformations of the place on Jan. 19th, 20th, 21st, and 22nd, the following upper central incisors, no history personal or family members being present : The Right Hon. Sir Herbert On the other hand, the Maxwell, Bart., M.P. (chairman) ; Sir Richard Thorne, in the least suggestive. termination of the case favours the view that the K.C.B., F.R.S. ; Sir George Brown ; Mr. Shirley F. ulcer, if not actually tuberculous, was of the kind which Murphy; Mr. Harcourt E. Clare ; Mr. Cooke-Trench; and sometimes occurs in this position in persons of tuberculous Mr. John Speir. tendencies. As to the improvement under specific treat’ment, in general this counts for little (for many diseases THE INFLUENCE OF THE THYROID GLAND ON METABOLISM. respond to mercury and to iodide of potassium) and here for nothing. The improvement was very much slower than that THE results of three series of researches on the influence which occurs in syphilis. Moreover, cure has been obtained of the thyroid body on nutrition have recently appeared. in one case under this very treatment where there was no These researches are calculated to modify the opinion question of syphilis. We allude to a case published in the generally entertained in regard to the value of this organ. Transactions of the Ophthalmological Society, vol. iv., by It is usually accepted that removal of the thyroid body leads Mr. Jonathan Hutchinson.1 It appears to be the first case to nervo-muscular disturbances, to tremors and twitching of of the disease on record and, strange to say, has been muscle and tetanus, and to nervous depression and stupor. In 1892, eight overlooked by all subsequent writers. It is believed, too, that a substance-iodothyrin-produced described the next case and years afterwards, Mikulicz by the thyroid body possesses an antitoxic action, so that its claimed it as a form of disease previously unrecognised. administration as a medicine is capable of supplying the loss Mr. Hutchinson’s patient was a Hindoo barrister who of the The researches of Dr. H. Munk seem to show gland. suffered from proptosis first of one and then of the other that this doctrine is untenable. It is true, indeed, that eye in association with enlargements of the lacrymal, ablation of the is often followed by serious indisgland parotid, and cervical lymphatic glands. The proptosis was position and by death but, on the other hand, more not due to enlargement of the lacrymal gland which overthan 50 per cent. of monkeys and rabbits and 25 per hung the eye and was moveable on it. Mr. Hutchinson cent. of dogs and cats remained unaffected by the operathought that it was due to some swelling of the fibrous or tion. The thyroid body cannot therefore be regarded as an fatty contents of the orbit and that the case should be organ of extreme importance in the maintenance of life. placed in the same group as the diffuse lipomata of the neck. Dr. Munk has satisfied himself that in the animals operated Though he had never seen any of these cases complicated on no fragment of the organ was left, that there were no with proptosis or enlargement of the lacrymal glands, in one bodies, and that no growth of other the parotids were enlarged exactly as in the case described. accessory thyroid as the hypophysis cerebri was noticed. such That the growth is of the interstitial connective tissue of analogous organs Moreover there were no poisonous effects observed from the glands, but lymphomatous and not lipomatous, subsethe products of normal metabolism acting on the nervous quent observations have confirmed. Kumel found a complete The differences noted in different instances were substitution of the gland tissue by leucocytes. But why system. too numerous and too great to permit them to be referred to this peculiar distribution of the disease ?? An instructive individual peculiarities in the formation, accumulation, and and parallel fact is that mumps is sometimes, though very action of any special poison. Dr. Munk does not find rarely, complicated by acute dacryo-adenitis. The general that exposure of the animal after ablation to a low temlaw that disease of one part tends to spread to similar perature favours the occurrence of tetanus or that exposure structures gives some explanation of these cases. to a high temperature favours chronic cachexia without .glands was
no
were
trace
"
-
THE MIDWIVES OF CHICAGO.
city of Chicago are upwards of a thousand who practise the art of midwifery, and we read with some astonishment in a report on the subject by Dr. F. W. Reilly that until last year these women plied their occupation without let or hindrance from the State. It required, it seems, "certain peculiarly atrocious developments"in the spring of 1896 to awaken public opinion and to stimulate legislation. There was apparently a growing practice among the midwives of Chicago to prescribe medicine for those under their care and, if they deemed it necessary, to apply instruments. These tendencies led, as was to be expected, to dire results; indeed, in the report to which reference has been made we are furnished with an account of a certain midwife who, in her zeal to extract a child with the forceps, lacerated the cervix of the uterus and also the intestine. The woman died and was buried, but the facts coming to light an WITHIN the
women
1
THE LANCET, July 12th, 1884.
spasms. The cachexia observed occurs in consequence of disturbance of the digestive organs, insufficient exercise, and other bad effects of imprisonment ; a myxoedematous cachexia with or without antecedent tetanus does not occur in animals as a consequence of the extirpation of the gland. The disturbances of the economy occasioned by the operation were neither prevented nor removed by the artificial ingestion of the thyroid body and he is unable to support the statements of Eiselberg in regard to the effects of the transplantation of the organ. He admits that removal of the thyroid body endangers life, but denies that it is essential or highly important for the preservation of life. M. Sch6ndor:ff’s experiments were directed to the determination of the metabolism of albumin in the dog on a diet containing thyroid gland substance as compared with a diet free from thyroid. The nitrogen, fat, and in part the amount of glycogen in the thyroid-free diet were accurately determined. The diet consisted of meat and rice or lard. Twelve experiments were made on the same dog, each lasting for days. When the income and expenditure had
several
317 equilibrium, five and then ten thyroid given for twenty-four days. The excretion of nitrogen first rose for a few days, then sank to the normal amount. The body weight steadily decreased throughout the whole period. This coupled with the known increase in the absorption of oxygen during the consumption of thyroid body points to the loss of fat. The increase in nitrogen loss at nri?t, he believes, in opposition to all other exbeen
brought
tablets
into
were
perimenters, to be due to the elimination of urea and similar substances from the body. In the course of the following three weeks during which twenty tablets were given daily the dog, becoming thin, eliminated more nitrogen than it ingested. In order to prove that this excess of nitrogen
need a Sunday’s rest as well as other people; and they con tribute unmistakably to the sobriety of the people. Those who have indulged in excessive drinking on Saturday-and they are 11 a numerous host "-have the chance of pulling themselves together before the Monday comes. There is a general, feeling that the hours might be still further restricted with advantage. So long as no hardship is inflicted on those who. depend on the public-house for their ordinary dinner and supper beer daily, Sundays included, no serious opposition would be offered even in the metropolis to more Sunday closing with discretion left to local authorities to extend the time in localities peculiarly situated. In many country towns. it is probable that it would be quite feasible to close the. houses altogether. As the Archbishop of Canterbury pointed out on Monday in his address to the Church ofEngland Temperance Society at St. Andrew’s Hall, Bethnalgreen, investigation in many localities has shown that even the classes who use the public-house are favourable to its being closed on the Sunday, but any attempt at entire closure on Sundays in the metropolis would do great harm and would play into the publicans’ hands. The time has come for intemperance to be seriously dealt with, and one of the first. things to be done is to begin with really practicable reforms such as that advocated by the Archbishop.
when the fat of the animal is fed more freely with fat till equilibrium was reached and then supplied with thyroid substance. Transient increase of nitrogen elimination was again observed followed by diminution, indicating a retention of nitrogen in the system occurred. Still the total body weight diminished, so that there must have been consumption of fat. On the withdrawal of thyroid substance from the food the body weight immediately underwent an increase, with retention of nitrogen in the body to no inconsiderable amount, whilst it diminished again when the thyroid was given coincidently with increased metabolism of albumin. It would appear, then, that the THE ACHIEVEMENTS OF ABDOMINAL SURGERY. body albumin is first attacked when the greater part of the WE print in another column a brief account from Mr. fat has been used up. In the next experiment the dog was Treves’s pen of a surgical operation that forms in a manner made to fast for thirty-eight days and during this period a fitting pendant to the interesting case under Professor the elimination of nitrogen was the same as in a moderately fat dog, the excretion of nitrogen falling at first and then Schlatter’s care which we published in our columns on Jan. 15th. Professor it will be remembered, reremaining stationary for twenty-six days, finally rising moved the whole of theSchlatter, carcinomatous stomach of an elderly slowly. A consideration of the loss of weight of the animal woman and relieved her symptoms by his drastic act. Mr. led to the interesting conclusion that this was so small that whole of the bowel of a child below in the final period of fasting not only was no fat con- Treves has removed the the transverse colon together with the anus, and the patient sumed but the loss DE body substance calculated from the made an easy recovery, while the symptoms incident to the elimination of nitrogen was greater than the observed condition known as 11 idiopathic dilatation of the diminution in body weight, and this could only be perilous " colon disappeared as the result of the operation. explained on the supposition that the animal retained Mr. Treves’s case, like Professor Schlatter’s, may be This view was supported by an water in its body. as one where a tremendous operation was regarded examination of the body of the dog when dead, for whilst the the last resource left to the surgeon, for the issue normal water of the body amounts to 75 per cent. it was of cases of so-called idiopathic dilatation of the colon now found to be 80 per cent. The increase in the quantity of water was most remarkable in the bones, the normal being e is as certainly fatal as the issue of cases of carcinoma. of the intestines. That the little patient on’ whom 22-24 per cent. whilst it was here 54’07 per cent.-that is, it I Treves Mr. would have died without prompt operated had increased about 120 per cent. The proportion of fat interference no one can doubt who reads the surgical the dead animal was 1-78 per cent. It was determined separnotes of the deplorable condition into which she had drifted. ately in each organ, the brain containing the largest quan- The attacks of obstruction of the bowel were growing more tity 8’812 per cent., the blood the smallest, containing only and prolonged, the abdominal distension was frequent 0’261 per cent., from which Dr. Munk concludes that at the no aperients could be used, and enemata had lost extreme, close of the period of feeding with thyroid body the animal contained abundant fat, so that there was no reason for the their effect. What was actually done and how it was done can be read in Mr. Treves’s own words, the whole story body albumin to be consumed. The third series of researches a perfect illustration of the remarkable possibilities were undertaken by Dr. A. Schiff, who has found as a result forming and resources of abdominal surgery. of feeding animals with thyroid and hypophysis cerebri substances that there is greatly increased excretion of phosphates with comparatively small increase of excretion CEREBRAL ABSCESS AND TUMOUR. of nitrogen, which points to increased metabolism of bone IN the series of Cerebral Cases of Unusual Interest and substance. Importance which Dr. Byrom Bramwell is contributing to the Scottish Medical and Surgical Journal that which is THE ARCHBISHOP OF CANTERBURY ON .described in the November number of the journal is so SUNDAY CLOSING. remarkable as to call for special attention. The patient was AN enormous amount of good is to be effected by a curtail- a man, aged forty-two years, whose previous health and ment of the hours of drinking short of that millennium for family history offered no unusual features. He was in his the teetotalers when the whole trade in alcoholic liquors shall usual health when he noticed some slight pain on the left have been destroyed. One obvious curtailment is that of side of his head. The next day he experienced numbness in the hours of the Sunday during which drink may be obtained. his right hand and had somej difficulty in writing. In the Practically the whole population acquiesces in the present following night he had three severe epileptic fits, one at short hours of Sunday work in public-houses. They are midnight, the next at 4 A.M., and the next at 7 A.M. The were not confined to one side and when seen about thought only fair to ttose who are employed in the trade, who z
elimination first
occurs
greatly reduced, it
was
in
spasms
replaced by fibrous tissue and that there exhumation was ordered and a necropsy performed. The of enlargement in the parotid glands. proceedings were, however, cut short by the suicide of the In another instance a midwife amputated an Dr. Osler inclines to the view that the disease was associated midwife. with inherited syphilis, which he thinks is borne out by the inverted womb in the belief that it was a tumour." These improvement which occurred under mercury and iodide of nefarious performances led to regulations being drawn up, potassium. With all the deference due to the high position and the midwives are now under proper supervision. which he holds we must dissent from him emphatically. Ulceration of the cartilaginous septum nasi, even to the THE ROYAL COMMISSION ON TUBERCULOSIS. extent of perforation, is by no means necessarily syphilitic. In this case there is not a single fact to support such a conMEETINGS of this Commission were held at 7, Whitehallclusion-no interstitial keratitis, no malformations of the place on Jan. 19th, 20th, 21st, and 22nd, the following upper central incisors, no history personal or family members being present : The Right Hon. Sir Herbert On the other hand, the Maxwell, Bart., M.P. (chairman) ; Sir Richard Thorne, in the least suggestive. termination of the case favours the view that the K.C.B., F.R.S. ; Sir George Brown ; Mr. Shirley F. ulcer, if not actually tuberculous, was of the kind which Murphy; Mr. Harcourt E. Clare ; Mr. Cooke-Trench; and sometimes occurs in this position in persons of tuberculous Mr. John Speir. tendencies. As to the improvement under specific treat’ment, in general this counts for little (for many diseases THE INFLUENCE OF THE THYROID GLAND ON METABOLISM. respond to mercury and to iodide of potassium) and here for nothing. The improvement was very much slower than that THE results of three series of researches on the influence which occurs in syphilis. Moreover, cure has been obtained of the thyroid body on nutrition have recently appeared. in one case under this very treatment where there was no These researches are calculated to modify the opinion question of syphilis. We allude to a case published in the generally entertained in regard to the value of this organ. Transactions of the Ophthalmological Society, vol. iv., by It is usually accepted that removal of the thyroid body leads Mr. Jonathan Hutchinson.1 It appears to be the first case to nervo-muscular disturbances, to tremors and twitching of of the disease on record and, strange to say, has been muscle and tetanus, and to nervous depression and stupor. In 1892, eight overlooked by all subsequent writers. It is believed, too, that a substance-iodothyrin-produced described the next case and years afterwards, Mikulicz by the thyroid body possesses an antitoxic action, so that its claimed it as a form of disease previously unrecognised. administration as a medicine is capable of supplying the loss Mr. Hutchinson’s patient was a Hindoo barrister who of the The researches of Dr. H. Munk seem to show gland. suffered from proptosis first of one and then of the other that this doctrine is untenable. It is true, indeed, that eye in association with enlargements of the lacrymal, ablation of the is often followed by serious indisgland parotid, and cervical lymphatic glands. The proptosis was position and by death but, on the other hand, more not due to enlargement of the lacrymal gland which overthan 50 per cent. of monkeys and rabbits and 25 per hung the eye and was moveable on it. Mr. Hutchinson cent. of dogs and cats remained unaffected by the operathought that it was due to some swelling of the fibrous or tion. The thyroid body cannot therefore be regarded as an fatty contents of the orbit and that the case should be organ of extreme importance in the maintenance of life. placed in the same group as the diffuse lipomata of the neck. Dr. Munk has satisfied himself that in the animals operated Though he had never seen any of these cases complicated on no fragment of the organ was left, that there were no with proptosis or enlargement of the lacrymal glands, in one bodies, and that no growth of other the parotids were enlarged exactly as in the case described. accessory thyroid as the hypophysis cerebri was noticed. such That the growth is of the interstitial connective tissue of analogous organs Moreover there were no poisonous effects observed from the glands, but lymphomatous and not lipomatous, subsethe products of normal metabolism acting on the nervous quent observations have confirmed. Kumel found a complete The differences noted in different instances were substitution of the gland tissue by leucocytes. But why system. too numerous and too great to permit them to be referred to this peculiar distribution of the disease ?? An instructive individual peculiarities in the formation, accumulation, and and parallel fact is that mumps is sometimes, though very action of any special poison. Dr. Munk does not find rarely, complicated by acute dacryo-adenitis. The general that exposure of the animal after ablation to a low temlaw that disease of one part tends to spread to similar perature favours the occurrence of tetanus or that exposure structures gives some explanation of these cases. to a high temperature favours chronic cachexia without .glands was
no
were
trace
"
-
THE MIDWIVES OF CHICAGO.
city of Chicago are upwards of a thousand who practise the art of midwifery, and we read with some astonishment in a report on the subject by Dr. F. W. Reilly that until last year these women plied their occupation without let or hindrance from the State. It required, it seems, "certain peculiarly atrocious developments"in the spring of 1896 to awaken public opinion and to stimulate legislation. There was apparently a growing practice among the midwives of Chicago to prescribe medicine for those under their care and, if they deemed it necessary, to apply instruments. These tendencies led, as was to be expected, to dire results; indeed, in the report to which reference has been made we are furnished with an account of a certain midwife who, in her zeal to extract a child with the forceps, lacerated the cervix of the uterus and also the intestine. The woman died and was buried, but the facts coming to light an WITHIN the
women
1
THE LANCET, July 12th, 1884.
spasms. The cachexia observed occurs in consequence of disturbance of the digestive organs, insufficient exercise, and other bad effects of imprisonment ; a myxoedematous cachexia with or without antecedent tetanus does not occur in animals as a consequence of the extirpation of the gland. The disturbances of the economy occasioned by the operation were neither prevented nor removed by the artificial ingestion of the thyroid body and he is unable to support the statements of Eiselberg in regard to the effects of the transplantation of the organ. He admits that removal of the thyroid body endangers life, but denies that it is essential or highly important for the preservation of life. M. Sch6ndor:ff’s experiments were directed to the determination of the metabolism of albumin in the dog on a diet containing thyroid gland substance as compared with a diet free from thyroid. The nitrogen, fat, and in part the amount of glycogen in the thyroid-free diet were accurately determined. The diet consisted of meat and rice or lard. Twelve experiments were made on the same dog, each lasting for days. When the income and expenditure had
several
317 equilibrium, five and then ten thyroid given for twenty-four days. The excretion of nitrogen first rose for a few days, then sank to the normal amount. The body weight steadily decreased throughout the whole period. This coupled with the known increase in the absorption of oxygen during the consumption of thyroid body points to the loss of fat. The increase in nitrogen loss at nri?t, he believes, in opposition to all other exbeen
brought
tablets
into
were
perimenters, to be due to the elimination of urea and similar substances from the body. In the course of the following three weeks during which twenty tablets were given daily the dog, becoming thin, eliminated more nitrogen than it ingested. In order to prove that this excess of nitrogen
need a Sunday’s rest as well as other people; and they con tribute unmistakably to the sobriety of the people. Those who have indulged in excessive drinking on Saturday-and they are 11 a numerous host "-have the chance of pulling themselves together before the Monday comes. There is a general, feeling that the hours might be still further restricted with advantage. So long as no hardship is inflicted on those who. depend on the public-house for their ordinary dinner and supper beer daily, Sundays included, no serious opposition would be offered even in the metropolis to more Sunday closing with discretion left to local authorities to extend the time in localities peculiarly situated. In many country towns. it is probable that it would be quite feasible to close the. houses altogether. As the Archbishop of Canterbury pointed out on Monday in his address to the Church ofEngland Temperance Society at St. Andrew’s Hall, Bethnalgreen, investigation in many localities has shown that even the classes who use the public-house are favourable to its being closed on the Sunday, but any attempt at entire closure on Sundays in the metropolis would do great harm and would play into the publicans’ hands. The time has come for intemperance to be seriously dealt with, and one of the first. things to be done is to begin with really practicable reforms such as that advocated by the Archbishop.
when the fat of the animal is fed more freely with fat till equilibrium was reached and then supplied with thyroid substance. Transient increase of nitrogen elimination was again observed followed by diminution, indicating a retention of nitrogen in the system occurred. Still the total body weight diminished, so that there must have been consumption of fat. On the withdrawal of thyroid substance from the food the body weight immediately underwent an increase, with retention of nitrogen in the body to no inconsiderable amount, whilst it diminished again when the thyroid was given coincidently with increased metabolism of albumin. It would appear, then, that the THE ACHIEVEMENTS OF ABDOMINAL SURGERY. body albumin is first attacked when the greater part of the WE print in another column a brief account from Mr. fat has been used up. In the next experiment the dog was Treves’s pen of a surgical operation that forms in a manner made to fast for thirty-eight days and during this period a fitting pendant to the interesting case under Professor the elimination of nitrogen was the same as in a moderately fat dog, the excretion of nitrogen falling at first and then Schlatter’s care which we published in our columns on Jan. 15th. Professor it will be remembered, reremaining stationary for twenty-six days, finally rising moved the whole of theSchlatter, carcinomatous stomach of an elderly slowly. A consideration of the loss of weight of the animal woman and relieved her symptoms by his drastic act. Mr. led to the interesting conclusion that this was so small that whole of the bowel of a child below in the final period of fasting not only was no fat con- Treves has removed the the transverse colon together with the anus, and the patient sumed but the loss DE body substance calculated from the made an easy recovery, while the symptoms incident to the elimination of nitrogen was greater than the observed condition known as 11 idiopathic dilatation of the diminution in body weight, and this could only be perilous " colon disappeared as the result of the operation. explained on the supposition that the animal retained Mr. Treves’s case, like Professor Schlatter’s, may be This view was supported by an water in its body. as one where a tremendous operation was regarded examination of the body of the dog when dead, for whilst the the last resource left to the surgeon, for the issue normal water of the body amounts to 75 per cent. it was of cases of so-called idiopathic dilatation of the colon now found to be 80 per cent. The increase in the quantity of water was most remarkable in the bones, the normal being e is as certainly fatal as the issue of cases of carcinoma. of the intestines. That the little patient on’ whom 22-24 per cent. whilst it was here 54’07 per cent.-that is, it I Treves Mr. would have died without prompt operated had increased about 120 per cent. The proportion of fat interference no one can doubt who reads the surgical the dead animal was 1-78 per cent. It was determined separnotes of the deplorable condition into which she had drifted. ately in each organ, the brain containing the largest quan- The attacks of obstruction of the bowel were growing more tity 8’812 per cent., the blood the smallest, containing only and prolonged, the abdominal distension was frequent 0’261 per cent., from which Dr. Munk concludes that at the no aperients could be used, and enemata had lost extreme, close of the period of feeding with thyroid body the animal contained abundant fat, so that there was no reason for the their effect. What was actually done and how it was done can be read in Mr. Treves’s own words, the whole story body albumin to be consumed. The third series of researches a perfect illustration of the remarkable possibilities were undertaken by Dr. A. Schiff, who has found as a result forming and resources of abdominal surgery. of feeding animals with thyroid and hypophysis cerebri substances that there is greatly increased excretion of phosphates with comparatively small increase of excretion CEREBRAL ABSCESS AND TUMOUR. of nitrogen, which points to increased metabolism of bone IN the series of Cerebral Cases of Unusual Interest and substance. Importance which Dr. Byrom Bramwell is contributing to the Scottish Medical and Surgical Journal that which is THE ARCHBISHOP OF CANTERBURY ON .described in the November number of the journal is so SUNDAY CLOSING. remarkable as to call for special attention. The patient was AN enormous amount of good is to be effected by a curtail- a man, aged forty-two years, whose previous health and ment of the hours of drinking short of that millennium for family history offered no unusual features. He was in his the teetotalers when the whole trade in alcoholic liquors shall usual health when he noticed some slight pain on the left have been destroyed. One obvious curtailment is that of side of his head. The next day he experienced numbness in the hours of the Sunday during which drink may be obtained. his right hand and had somej difficulty in writing. In the Practically the whole population acquiesces in the present following night he had three severe epileptic fits, one at short hours of Sunday work in public-houses. They are midnight, the next at 4 A.M., and the next at 7 A.M. The were not confined to one side and when seen about thought only fair to ttose who are employed in the trade, who z
elimination first
occurs
greatly reduced, it
was
in
spasms