The administration of thymus in exophthalmic goitre / by R.H. Cunningham.

  • Cunningham, R.H.
Date:
1895
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Licence: Public Domain Mark

Credit: The administration of thymus in exophthalmic goitre / by R.H. Cunningham. 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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    bouillon from the meat, the cachexia rapidly develops. The writer has, on the other hand, fed thyroidecto- mized dogs on thymus without apparently hastening or delaying the appearance of the cachexia otherwise than if the animals had been fed on so much ordinary cooked meat. Nor have I ever seen any diminution in the symptoms of exophthalmic goitre follow a diet of underdone meat, provided no other therapeutic means were employed at the same time. That a functional relationship, at present unknown, does exist between the ductless glands is manifest from the results both of experimental investigation and of clinical observation. Thus the compensatory (?) hy- pertrophy of the thyroid that occurs after extirpating the spleen is well known. According to Cadeac 38 en- largement of the thymus follows thyroidectomy in lambs. Likewise, Rogowitsch 16 has found that after the thyroid has been removed in rabbits, the pituitary body becomes enlarged. Clinically, Boyce and Beadles 11 emphasize the frequency of the same occurrence in myxoedema, sporadic cretinism, and cachexia thyreo- priva in man. In acromegaly 23 hypertrophy not only of the hypophysis, and either hypertrophy or atrophy of the thyroid occur, but an hypertrophy or a “ re- vival ” (Marie18) of the thymus has often been re- ported. In myxoedema, and especially in exophthal- mic goitre,18 a similar hypertrophy or revival of the thymus is frequently found, as is evident from the cases of the latter disease reported by Johnston, Hale White, Mosler, Spencer, Marie, Moebius, Lasvenes, Reymond,31 and several other observers. The possibility of the participation of the quantita- tively or the qualitatively altered internal secretion (?) of such glands, whether hypertrophied concomitantly with the thyroid or secondarily to the thyroid, as a cau- sal factor of some of the symptoms in certain cases of exophthalmic goitre is therefore worthy of considera- tion. That the increased secretion of the thyroid is not the sole producing cause of the whole complex of symptoms of exophthalmic goitre many eminent ob- servers concede. A mere glance at the final results of surgical interference with the enlarged thyroid that oc- cur in certain cases of this disease will show that such is correct. Briefly summarized, these surgical results may be stated to be as follows : After partial extirpation of the supposed hyperse- creting thyroid a complete (?) cessation of the symp- toms occurs in one set of cases. In the second set merely a temporary moderation 20 of the symptoms has followed, and this moderation has been succeeded in a short time by an increase even in some of the former symptoms. In other cases no immediate or remote diminution in the symptoms has resulted from the operation. Lastly, the operation has been followed in a number of instances by fatal results which were accompanied by the symptoms of acute thyreopriva in some cases, while in others the cause of death was attributed to the “ inundation ” 19 of the system by the large amount of thyroid juice that was unavoidably introduced into the circulation by the necessary manipulations of the operation. Equally suggestive are the results of the observations both of clinicians and of recent experimenters. Among the clinical reports of sundry diseases treated by the administration of the thyroid extract the most striking in this connection is by Beclere.23 According to this observer, after a myxoedematous patient had taken 92 gm. of thyroid extract in eleven hours, the symptoms of the myxoedema disappeared and were replaced by the symptoms of “ intoxication,” which consisted of tachycardia, instability of the action of the heart, fever, insomnia, agitation, incomplete paraplegia, increased respiration, exophthalmos, and fixedness of look. A practically similar though less marked effect has been noted by a number of writers to follow the ad- ministration of large and repeated doses of the thyroid extract, but nothing definite as regards the artificial production thereby of a goitre is mentioned except by Ballet and Enriques.24 These investigators state that after injecting the thyroid extract into dogs they suc- ceeded in producing fever, tachycardia, tremor, and in addition a goitre ; all of which disappeared when the thyroid was discontinued, but reappeared when it was readministered. It is true such injection experiments are complicated, as Horsley23 pointed out some years ago, by the presence of toxic tissue fibrinogens, and due allowance must be made therefor. The writer has, however, fed dogs with enormous quantities (50 gm. per day) of commercial thyroid extract, also with 100 to 200 gm. of fresh thyroid daily for fifteen days, but so far with a negative result. On the other hand, cases of exophthalmic goitre that have been treated with the thyroid extract have improved 26 instead of becoming worse. Such improve- ment results, according to Kocher,19 from the “ thyreo- idin ” causing a retrograde metamorphosis of the hyper- trophied thyroid, and as the thyroid disease is not always primary, it is in this way beneficial. The most natural way, and the one more in accord with the evi- dence above, is that a sufficient quantity of a proper quality of the so-called “ thyreoidin ” is added to the altered blood, and by this addition some of the symp- toms of exophthalmic goitre are caused to disappear, while others are moderated only, or even unaffected, and in some instances slightly, or even greatly, in- creased. In this connection those cases30 which pre- sent at the outset the symptoms of exophthalmic goitre, later the symptoms of a combination of exophthalmic goitre and of myxoedema, and finally of myxoedema alone, are very interesting ; likewise the case of Jean- selme27 in which exophthalmic goitre and scleroderma coexisted. Similarly acromegaly and myxoedema, or cretinism and acromegaly, are well known to occur in combination. Lastly, we are confronted with the fact that cases of exophthalmic goitre exist in which the administra- tion of thymus is followed by a disappearance of the symptoms and by a recurrence of them, as in Dr. Owens’s case, if the thymus is discontinued. This lat- ter factor, as I stated above, certainly negatives the idea of the mere coincidence of spontaneous improve- ment. Likewise no variation of the ordinary diet ex- cept the addition of the thymus was resorted to in the cases under my observation, and though a moderate improvement, which disappeared when a meat-diet was resumed, has been observed to follow the employment of a milk-diet,36 either with or without special atten- tion to the correction by drugs of the disturbed diges- tion, the effects possibly resulting from this source are reduced to a minimum. It will be noticed from the description of the cases reported by myself that they, as well as Owens’s case, are evidently not of the type that is secondary to an ordinary hypertrophied thyroid and what the ultimate effects of the thymus administration will be on the symptoms exhibited by this latter class of cases, the writer is unable at present to state definitely; but judging from the apparent absence so far of any effect in several such cases that have lately come under his observation, probably no very great improvement will ultimately result. A consideration of the above evidence and a careful comparative study4,10 of the similar and of the opposite objective and subjective symptoms that are met with in exophthalmic goitre, acromegaly, and myxoedema, or in the combinations of these diseases, will lead one reasonably to conclude that the alteration that fre- quently occurs in one or more of the ductless glands besides the thyroid possibly plays a more or less promi- nent part in the causation of some of the symptoms of the disease (or possibly diseases(?) ) to which the terms exophthalmic goitre, Graves’s disease, and Basedow’s