Susanne
Inscrit le: 28.11.05 Messages: 340Paris 70+ |
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Posté le: 03. Nov 2006, 11:01
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Comment le Dr. Eugene Hertoghe a decouvert l'hypothyroidie et sauvé les gens . ( text ecrit en 1914 , relatant des evenements de la fin du 19eme siecle )
Resumé en francais : Le Dr. Eugene Hertoghe avoue ne rien connaitre à la thyroide , pas plus que les autres medecins de l'epoque , au debut de sa carriere au 19eme siecle . Il est confronté à un cas ou il decouvre par hasard que la veritable cause de la maladie est une insuffisance de la fonction thyroidienne . Suite à ca il se met à la recherche des patients qu'il a vu auparavent et qui presentaient des symptomes semblables et ils les guerit . Il voit aussi les frères et soeurs de ces patients qui presentent souvent la meme pathologie et il les guerit egalement .
Quand je vois ce que le Dr. Eugene Hertoghe savait au 19eme siecle deja sur la thyroide ...... je me demande toujours comment cela se fait que les medecins du 21eme siecle ne le savent toujours pas ........ !! ???
1914 Extracts from 'Thyroid Deficiency' by Eugene Hertoghe, M.D. 1914 lecture presented to the International Surgical Congress
Let us now study some cases of advanced myxedema, and, to facilitate the task, permit me to indicate the course I myself followed at the beginning of my studies on the subject. I confess that when I first found myself in the presence of a case of myxedema, I knew nothing about it. I had neglected this part of my medical studies, believing I should never encounter what was then considered a pathological rarity.
Myxedema, which meant nothing to me in 1883 when I finished my university course, interested me as little ten years later, when circumstances forced me to concern myself with it, and to recognise it without having suspected its existence.
In 1884, while in attendance at the house of MS, he confided to me that he was much concerned about the health of his wife. He informed me that she was 64 years of age, had been married at the age of 20, and had had no children. She had been delicate all her life, but recently her condition had been so much worse that he reared a fatal issue was rapidly approaching. In spite of this she absolutely refused to consult a doctor.
She was indifferent to all that went on around her, this apathy being combined with an invincible disinclination to all physical exertion. Speech was laborious to her, being slow, faulty, and indistinct, so that usually despairing of making herself understood, she cut short all attempts at conversation. Her only desire was to be left at peace, free from all emotion or anxiety.
Soon after her marriage Mme. X had a miscarriage. Her menstruation had always been profuse and the intervals between the periods much shortened, the menstrual loss was so great that it soaked through the mattress to the floor. She also bled easily after slight injuries, a simple scratch being followed by prolonged oozing. These repeated haemorrhages had produced a state of pronounced anaemia shown by the presence of marked pallor and weakness. The haemorrhages were regarded as the original causes of her condition.
At the age of 35, while driving in an open carriage, Mme. X. was caught in a heavy shower of rain which soaked her to the skin. Following this she took cold and suffered from a well defined attack of acute articular rheumatism, from which she recovered but had never since been free from pain. From that time her condition was attributed to the rheumatic attack by herself and her friends.
Such was the information given me by the husband, and at his request Mme. X. consented to see me. My diagnosis was instantaneous - it was evident that Mme. X. was suffering from an attack of Bright's disease in its last stage. The face was swollen, the eyelids were edematous, leaving only a narrow space between them, the lips were thick, everted, and bluish in colour, the speech was slow and drawling, the voice having a strange, deep, croaking tone, while the gait was awkward with slow and indecisive movements.
I communicated my opinion to her husband and intimated my fear that a fatal termination was threatening from uremia. M. X. was not surprised and told me that all the doctors previously consulted had been of the same opinion. I then examined the urine and to my great astonishment it contained only an insignificant quantity of albumin - about 1 ½ grains to the ounce.
There was no renal epithelium present, but squamous cells from the bladder were abundant. I was much embarrassed at finding a case of Bright's disease which had reached the stage of threatened uremia practically without change in the urine. Next day I explained to M. X. that the case was somewhat unusual, and asked his permission to keep the patient under observation for ten days in order to make a further examination, to which he willingly agreed.
I could then examine the patient at leisure. The heart presented no appreciable change, though the pulse was slow. The kidney region was painless on palpation so far as it was possible to examine it, for Mme. X., while not obese, was short and stout, weighing 204lb. Her lower limbs did not appear notably swollen and though large were not out of proportion to her body.
Her temperature was rather low and she complained of cold although it was the end of May and a large fire made the room uncomfortably warm. The patient told me that she always felt the cold most intensely about 4 o'clock in the afternoon, at which time she felt as if cold water had been poured on her back, causing her actually to shiver. She soon became tired during my examination and even fell asleep while I talked to her, complaining of extreme lassitude and rheumatic pains throughout the whole of her body.
Having discovered all this I had advanced no further than before. That a woman 64 years of age should be sleepy, chilly, 'easily tired' and suffer from rheumatism was neither very extraordinary nor was it pathognomonic. Five days had passed, when chance, - the Providence of doctors, - came to my assistance. M. X. informed me that he was expecting an early visit from his wife's cousin who suffered from a very troublesome goiter which at times threatened to suffocate her.
He also told me that I might be consulted by her an, should alarming symptoms occur, I might even be asked to remove the tumor. Now goiter is a rarity in Antwerp and for my part I had never seen a single case and was rather worried at the prospect.
My situation was truly awkward, the old lady apparently had Bright's disease but without albuminuria and seemed to be at the point of death without presenting a single positive symptoms which I could lay hold of:- and then this cousin must needs come from the other end of Austria possessed by the desire to be operated upon for a tumor which she would a hundred times better have had removed in her own county, where they are accustomed to similar exploits.
I returned home in a state of great anxiety and felt a real relief on finding on my table a large parcel containing the treatise on surgery in 8 volumes by Duplay and Reclus which had jut been published. I turned toe the article on goiter by Broca. Oh, yes! goiter could certainly be removed: it was not easy, but with determination and a score of artery forceps it could be done. Then there were complications - one must not divide the recurrent laryngeal - must guard against hemorrhage and sepsis.
And this was not all, - one must beware of removing the whole of the thyroid gland - for this was followed after a short interval by a special cachexia which Kocher had named "Cachexia strumipriva" and Reverdin had called "Post-operative myxedema". This was becoming more and more interesting.
Thus when the patient had escaped from the dangers of the operation, hemorrhage, and sepsis, just when we might expect him to enter upon convalescence, a very strange condition gradually disclosed itself, characterised by the following symptoms:- lassitude, feebleness, clumsiness, heaviness of the limbs, pain in the arms, legs, neck, and shoulders, swelling of the face and puffiness of the eyelids. The eyes become sunken, the activity of the brain diminished and mental effort dulled.
Then there came an extraordinary phase: "The urine is almost always normal, to the astonishment of the early observers who expected from the appearance of the face to discover albumin. And again another phrase:- one of the most remarkable phenomena is a sensation of cold, which is almost constant.
Truly M. X. presented a complete picture of these symptoms. She had the false suggestion of albuminuria without the presence of albumin, and the general swelling of the body. Like the patients operated upon by Kocher, Feverdin, and Bruns, she had the drawling voice, the sluggish attitude of body, the thinned hair and eyebrows, the swollen mucous membranes, and the difficulty in swallowing. Her tongue appeared too large for her mouth, the floor of which was swollen and raised till it suggested a double ranula.
Even her ocular conjunctiva was edematous and prolapsed while her complexion was amber-yellow with patches of red on the cheeks. She had also the low temperature with subjective sensations of cold - but indeed Mme. X. presented all the symptoms described in post-operative myxedema and if so she must suffer form spontaneous myxedema.
At last my diagnosis was made. M. X. was too polite to say that he did not believe me, though his face plainly showed his incredulity, but he followed my instructions to the letter.
The result exceeded my hopes. After three weeks treatment the bodily and mental transformation was so complete that she would no longer have been recognised as the same woman. The edama of the tongue, of the lips, and of the eyelids disappeared as if by enchantment and the face assumed and intelligent expression.
The patient then went to the county where the treatment was continued by the local doctor, who gave me valuable assistance. I did not see her again from over two months by which time she had complexly recovered, that is to say the absorption had been complete.
If you ask me what we have to learn from this observation as regards mild myxedema, and on what point it helps our knowledge of this condition, I would first direct your attention to the metrorrhagia which is presented by the history of the patient. As a rule thyroid weakness shows itself by the presence of metrorrhagia which is sometimes appalling in its amount.
The administration of thyroidin moderates these losses, and if large doses are given one may even completely suppress menstruation, as in the same way complete anemorrhea is not infrequently present in cases of exophthalmic goiter. Women with feeble thyroids conceive readily, but abort as readily in consequence of the onset of profuse bleeding which carries away the fertilised ovum.
I do not mean to say that a woman suffering from thyroid weakness cannot go to full term, as from the beginning of pregnancy the thyroid gland undergoes hypo trophy with increase in size and in the amount of its secretion. In fortunate cases this increased activity is maintained throughout pregnancy and forms an effectual protection to the embryo against the menstrual return. Such women tell you that their health is better when pregnant. The increased activity of the gland continues during lactation, and such patients instinctively prolong suckling beyond the physiological period.
After weaning, the symptoms of thyroid weakness reappear and certain authors have even discovered in prolonged lactation a cause of myxedema. Thus when you encounter cases of profuse menstruation in which you can exclude such ordinary causes as fibroids, cancer, or placental remains, think of possible thyroid defect and search for other symptoms of this condition.
Think of it also in those disheartening cases of repeated abortion, in which the administration of thyroxin will often permit a pregnancy to go to term when all other rational means of treatment have failed.
I would in the second place direct your attention to the rheumatic pains from which this patient suffered. In almost all cases of severe myxedema one finds that the patient at some period of life has passed through an attack of acute articulator rheumatism.
This affection can itself cause grave disturbances of the thyroid gland, the congestion of which in the course of acute articulator rheumatism is a classic symptom. I believe, however, that its influence is usually limited to producing an aggravation of a pre-existing thyroid weakness, thus bringing to light symptoms hitherto unnoticed. The metrorrhagia from which Mme. X. had suffered before the occurrence of her acute rheumatic attack supports this view.
The chronic rheumatic of rheumatoid condition is almost always associated with mild myxedema, and its occurrence should be carefully inquired into, especially when metrorrhagia is also present. These pains, which are often complicated by neuralgia, tend to assume a characteristic form and course, to which I will now refer.
The most frequent rheumatoid pain experienced in mild myxedema is that affecting the back between the shoulder blades, and is most severe in the morning on rising, after the chilling and inanition of the night. Driven from bed by the pain, these patients rise absolutely worn out, as if they had slept on a hard uneven mattress. The pains subside gradually during the day, owing to the warmth produced by food and exercise, and disappear completely in the evening after a good meal with plenty of wine. Such patients are strongly attracted to the use of alcoholic stimulation.
I have already stated my opinion as to the lowered temperature and the subjective feeling of cold, so I need not insist further on this point. The hard, cold hand of a patient suffering from severe myxedema is very characteristic, and in the milder forms coldness of the extremities is usually present, though to a less degree, as I have already stated.
Among the symptoms presented by Mme. X., one of the more interesting was the special character of the voice and speech. The voice was deep, rough, and croaking, with n indescribably quality which when once heard could not be forgotten. This symptom is caused by the infiltration of the vocal chords and the pharyngeal mucous membrane, and is present in a less marked degree in milder forms of hypothyroidism.
In women with feeble thyroids the voice is slightly hollow or muffled. Sometimes this is only occasionally present, as during menstruation, when a considerable part of the thyroid resources is employed in the inhibition of the menstrual function. We will not consider further the case of Mme. X., though interesting from the standpoint of our subject, but will bear in mind as leading symptoms the metrorrhagia, the recurring abortions, the rheumatoid pains, the feeling of chilliness, and the alteration of the voice.
After my attendance on Mme. X., I reproached myself for having so long neglected to inform myself as to the diseased conditions of the thyroid gland. During my ten years of practice I must have already met with these cases of apparent Bright's disease; I had treated them, and they had disappeared and been forgotten. Surely I had heard somewhere a voice similar to that of Mme. X., but when? and where?
On racking my brains, I remembered that one day I had been summoned as an expert before the Chief Pensions Commission, the administrative body to which the servants o the State apply when on account of infirmity the they wish to claim their pension before the retiring age or when it is necessary to retire them. It decides in accordance with the advice of the medical experts.
A professor of solfeggio in the Antwerp Conservatoire had appeared before us. His condition was so lamentable, so profoundly cachectic, that my colleague and I requested the President to send some one home with him lest he should fall in the street. The strange, hoarse, croaking voice of this man whose occupation was the teaching of singing to children, was so irresistibly comic that commissioners and doctors alike had great difficulty in keeping their gravity. The medical examination did not take long and the verdict was explicit - Bright's disease in its last stages with uraemia, and he was at once retired on pension.
I searched for and found the singing master who was still alive, and whom I now recognised to be suffering from myxedema. I informed the Minister of the error, who sharply rebuked the Commission for a mistake made through no fault of theirs. The board then had the patient examined afresh by other doctors, who discovered nothing wrong with him as he no longer presented the least sign of myxedema.
The proposal to retire him was withdrawn, and his voice having now recovered, he was able to resume his class with a brilliancy to which he had been long a stranger. He was at this time 55 years of age. Before treatment was begun his whole face was swollen, especially the eyelids, the space between which was reduced to a mere slit. He also suffered from rheumatic pains, a constant feeling of cold, and continual dispense. The skin was dry, thin, and scaly, the epidermis covered with fine lozenge-shaped wrinkles. The whole body was heavy, clumsy, and infiltrated with a firm resistant edema. He complained of invincible somnolence, depression, and weariness of life. The infiltration was rapidly absorbed under treatment, his weight falling from 160lb. to 136lb.
Here for the first time dyspnea appears as a leading symptom of myxedema. The patient had suffered from it for a long time, and in my former notes of his condition I found it occupied an important place. His walk was slow and difficult, and he required to support himself by the furniture, making signs that he could not speak for want of breath. In mild myxedema this breathlessness is constantly present, though to a less degree, only showing itself on walking rapidly or uphill, and is usually accompanied by palpitation.
Sometimes the breathlessness is intermittent, like the insufficiency of the thyroid secretion of which it depends, and is then liable to be mistaken for an attack of asthma.
The gratitude of this singing master was all the greater that he had been restored to his duties and escaped the misery of a premature pension. He told me that one of his friends, a police agent, who had been put upon the retired list ten years before, suffered from the same condition as himself. This was rather too much - to have myxedema diagnosed by a patient who had only just recovered from the disease.
I called on the police agent. He was suffering from very advanced myxedema and though only 42 he appeared much older. His whole face was infiltrated, the eyelids being so swollen that the eyes could be opened only with the greatest difficulty, while the thickened lips resembled those of a Negro. The complexion was amber yellow with bright red patches on the cheeks. The trophic changes in the hair were striking, the forehead presented a band of brown pigmentation and there were similar marks on each side of the neck.
The head was too heavy for the infiltrated muscles and ligaments of the neck so that it fell forward and the patient could raise it only by throwing the trunk backwards. He complained of rheumatism and a perpetual feeling of cold, huddling himself night and day under thick bedclothes. The breath was offensive, the teeth bad, the gums red and inflamed. Speech was much impaired.
On replying to a question he opened his mouth widely, so that the motions of his tongue could be plainly seen although he uttered no sound, and it was only after a lengthy effort that the words were slowly formed. His weight was 152lb. of which he lost 22lb. under treatment with the simultaneous improvement of all his symptoms. The loss of weight in this case amounted to 18, 28 and even 36 ounces a day. His hair grew again rapidly, muscular contractility was regained so that he could again raise his had, and he was delighted to find his self-confidence return, complete recovery being attained in about two months.
This case directs our attention to the trophic changes of the hair, teeth, and gums. In the milder type of myxedema the hair may also be shed early, though more frequently it becomes prematurely grey. The destruction of the teeth and the chronic alteration of the gums is also observed, though to a less extent.
Whatever the type of myxedema, the baldness very constantly presents a special distribution, the hair being first shed in the frontal region, then on the nape of the neck. The loss of the hair in the eyebrows is early and constant, even in mild myxedema, and has been called the eyebrow sign. It is not so easily concealed as the baldness of the scalp, and it gives to the patient's face an air of perpetual astonishment.
A young woman aged 23 had suffered from uterine haemorrhage since her confinement, four months previously, for which she had been packed and curetted several times. The absence of the eyebrows is striking, and though the frontal baldness had been skilfully concealed, she at once suggested to me a case of insufficient thyroid secretion. She suffered much from migraine and also from occipital headaches; she was always cold, while her menses were always very profuse. Under thyroid treatment the hemorrhage ceased in a fortnight.
A very interesting case of myxedema had a marked loss of hair which in addition to the usual situations had affected the sagittal line, but he baldness was concealed by the presence of back crusts which covered the whole scalp, the eyebrows were also markedly affected. This patient might be classed as an advanced case of myxedema and the result of treatment was very striking. She always been tired, constipated, and somnolent, breathless on the slightest exertion. Her face was infiltrated, the eyelids and lips being specially swollen, and after four months treatment, was completely changed both morally and physically, having regained courage, strength, and cheerfulness. She even became coquettish and would not believe that her appearance had been as in the first photograph.
Another patient was only 39 years of age. He was a cigar maker, who had been unable to work for six years, owing to his fingers having become stiff and clumsy. He had taken to drink and he and his family had fallen into extreme poverty. He was positively ugly, and the boys of the district, who knew him under the name of Favachol, followed him on the street. I literally picked him out of the gutter and kept him under observation for a week before commencing treatment.
He complained of pain in the spine, a constant feeling of cold and insuperable fatigue, and was melancholic, depressed, and extremely miserable. His hair was unaffected, except in the occipital region, which was bald. During the week before treatment was commenced he excreted on an average 323.4 grains of urea per day, which increased under thyroidin to an average of 477.4 grains pr day, during the first week, with a further increase during the second week to 677.6 grains per day. In consequence of the absorption of the infiltration his weight feel from 167 lb. to 138 lb.
His urine contained an extraordinary number of spermatozoa, this symptom persisting for a whole month, when it suddenly ceased. He rapidly recovered, and he not only regained his health but also his self-confidence, so that he resumed his work, at which he was expert, and after some months sailed for America in quest of a better situation. He obtained work at once, and is now himself and employer, and has made money. Every two or three years he returns to Europe to express his gratitude to me.
Soon after the cure of the singing master and the police agent I remembered that at the beginning of my career I had treated a woman of whose peculiar voice I was reminded by that of these two patients. She had left town, but at last I discovered her. In those days she had suffered form rheumatism involving all the body, the muscles being stiff, hard, and painful. The joints were also swollen, the gait stiff and awkward, while the pains in the back were very severe. I had formerly treated her by every means I could think of, without benefit.
On her reappearance I found that she was really suffering from myxedema. The puffiness of the face, the swelling of the lips, especially the lower one, the loss of the hair of the scalp and eyebrows, the redness of the cheeks on a yellow skin, the drawling, croaking voice, the dry wrinkled skin, and the desquamation of the scalp left no doubt as to the diagnosis.
Under thyroid treatment the infiltration rapidly disappeared. The general pain and stiffness also disappeared steadily, though slowly, along with marked breathlessness, to which she had always been subject, and which I had formerly attributed partly to obesity and partly to pulmonary emphysema. Finally all these symptoms were completely abolished, but on the patient ceasing treatment the pains gradually returned, to cease again on the administration of thyroidin. This woman had suffered form these rheumatic symptoms for so many years that she had become resigned to them, and sought advice only when the pain the back or ht swelling in the wrists or knees became unusually severe. The pain was then, as later, simply a manifestation of defective thyroid secretion.
Let us now take an example of mild myxedema occurring in a descendant of a patient presenting a more severe type of myxedema.
The patient was the daughter of the singing master whose case I have already described. The woman was 40 years of age. At all times her menstruation had been profuse and exhausting and she suffered much from migraine and dullness in the head, while her hair had come out freely.
When closely examined her face presented a slight degree of swelling, she was tired, worn out, somnolent, with an urgent desire to sleep. At the time she complained of sciatic pains in the left leg. Her hands were large, cold, bluish red in colour and were covered with chilblains in winter. Under very small doses of thyroidin the swelling of the face disappeared, and the other symptoms ceased, including the shooting pains in the left sciatic. This case forms a good example of mild myxedema.
Finally, let me give an example where the study of the collateral relations of the patient has been of great value.
The venerable ecclesiastic suffered form well marked myxedema. He was the priest of a parish in the neighbourhood of Antwerp, and having visited his church, which was of archaeological interest, I heard him preach. He stood by the steps of the altar painfully supporting himself with both hands on the communion rail.
His speech was so defective that I could not understand a word of his discourse. Then he mounted the steps of the altar, very slowly, and with great difficulty, leaning on the shoulder of the server. There was no doubt as to the diagnosis, he was suffering from well marked myxedema. I had the satisfaction of quickly restoring him to health. This patient, as you may imagine, had been previously treated in various ways in the course of a disease which had lasted ten years. He was much troubled by great thickening of the nasal mucous membrane, for which he consulted a specialist, who nimbly removed a portion of his hurbinals, at the price of an alarming haemorrhage. Myxedematous patients are very haemophilic. The operation had no beneficial result for the patient.
I inquired into the state of health of his brothers and sisters. One of the latter lived with him, she was very thin and had a pronounced nasal voice with marked hypertrophy of the mucous membrane of the nose. This was in her the only symptom of thyroid defect. Another sister was married. She was as myxedematous as her brother the abbé. Under treatment she quickly and completely recovered her health, but this was not all.
The abbé had a brother aged 54, who for ten years had suffered from an obscure condition characterised by weakness, anaemia, and progressive exhaustion. Along with the loss of strength his vision had gradually failed which had been attributed by well-known specialists to white atrophy of the optic nerves. Three years before, on his return from an exhausting journey, he suffered severely from headache, then suddenly collapsed and became unconscious with complete loss of motion and sensation. This state of coma lasted three days and on recovery he remembered nothing that had taken place, but presented no loss of functional power.
He continued to suffer from weakness and exhaustion and his eyesight became steadily worse, so that when I saw him two years later he was almost blind. I confess, if I had not previously seen the abbé and his sister, I would not have suspected thyroid weakness in this case, but once my attention was 0directed to this possibility it was easy to confirm the diagnosis. The low temperature, the yellowish pallor and slight swelling of the face, the fine and scanty beard, the breathlessness, and extreme weakness all pointed to this conclusion. Even the attack of coma, hitherto so difficult to explain, fitted in with this opinion in a very simple manner.
As the result of an harassing journey there was produced an abnormal exhaustion of the resources of the thyroid gland in a patient in whom they were already very restricted. This had caused a severe and sudden attack of coma.
Susanne
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comment le Dr. Eugene Hertoghe a decouvert l'hypothyroidie
