Exophtalmic Goitre.
Synonyms:—Graves' disease; Basedow's disease; Parry's disease.
Definition:—A serious disorder, characterized by protrusion of the eyeballs, serious heart symptoms, among which the most conspicuous is tachycardia, and some enlargement of the thyroid gland. There is also serious involvement of the nervous system, a conspicuous feature of which are tremors. It must not in any way be confounded with goitre, as commonly understood, as it is in every way a distinct and separate disease.
Etiology:—This disorder occurs much more frequently in women than in men, the proportion being six or seven to one, and between the ages of sixteen and thirty-five, although children may be attacked. In men it occurs later in life; it is seldom found in advanced age. It is by no means a rare disease, but occurs quite commonly, being especially observed in the hospitals of the larger cities. The exact cause is not determined. Most writers believe it to be due to abnormal action of the thyroid gland. It is more apt to be a disorder of the sympathetic nervous system. It occurs in young women who are very sensitive and inclined to be slightly neurotic, who have much responsibility, anxiety and worry, and at the same time whose labor requires severe mental action or mental concentration. It may also follow serious menstrual irregularities, early pregnancies or sexual excesses, and it may occur during the early convalescence of severe and protracted disease. It may also follow a case of simple goitre. There is some argument for the statement that the condition is hereditary. It seems to be the antithesis of that which occurs in myxedema and cretinism. There seems to be an excessive secretion from the thyroid gland diffused throughout the system, and an undue activity of the functional action of the thyroid.
Symptomatology:—The early symptoms differ materially in the different cases. There are a very few cases recorded in which the evidences assumed an acute form. There were pronounced nervous symptoms, apparent agitation of the nerves, tremors and excitability with rapid heart action, palpitation, sighing or difficult respiration and vomiting and purging, and the protrusion of the eyeballs increases rapidly. Most commonly, however, the onset of the disease is slow or gradual, the early symptoms are the irregularity or the rapidity of the heart's action, the nervous excitability or tremors, and a very gradual increase in the protrusion of the eyeballs.
In still other cases the exophthalmos is the first symptom. This may increase rapidly until it becomes extreme and constantly attracts attention. It may be impossible to close the lids over the balls. Von Graefe designated this inability when the eyes were directed downward as a characteristic sign; Stelwag pointed to the widening of the palpebral fissure, with retraction of the lids, showing the sclerotic coats above and below the iris. In this case winking is materially interfered with.
The vision is seldom impaired. The condition of the nervous system is a conspicuous factor. The patient is depressed and inclined to despondency; there is general nervous weakness and functional disorder. Insomnia is a common complication. The patient may have an irritating cough, and occasionally difficult breathing becomes a serious complication. This is not apt to be present unless there is considerable enlargement of the thyroid. There is a tremor in the muscular system which is more perceptible in the fingers. Usually it is fine, but in rare cases it becomes coarse and conspicuous. It may be observed when the patient is holding the hand out with the palm turned upward. Diarrhea occasionally occurs, and loss of appetite with indigestion is a common symptom. In serious cases obstinate vomiting occurs from sympathetic causes, and this must be looked upon with apprehension. The nervous irritation may finally become very great, so that the patient starts or trembles with every noise, and magnifies every cause of irritation to an extreme point. There is a gradual general failure with loss of flesh and increasing debility.
While the name of this disease suggests the enlargement of the thyroid as a conspicuous factor, this may be entirely absent at first, and only slowly develop, at no time becoming very great. There is an increase in the vascularity of the organ and undue activity of its secreting function, which has been mentioned. It is usually soft, and fluctuates somewhat, and varies quite perceptibly in size at different times. This is due to the circulatory derangement in the gland. It does not become hard, as in some cases of goitre.
If the fingers be pressed gently against the gland, a distinct thrill will be felt, and occasionally a regular pulsation will be observed. These patients may sweat profusely, and are sometimes subject to a discoloration of the skin, a pronounced pigmentation which is usually plainly apparent in the face. There is pruritus, urticaria, and occasionally edema.
Diagnosis:—The exophthalmos and nervous tremors accompanied with tachycardia are pathognomonic of this disease. The diagnosis is confirmed by enlarged thyroid and constitutional symptoms named. An early mistaken diagnosis can be made by the fact that the exophthalmos and thyroid enlargement may be delayed for quite a little time after the nervous and heart symptoms are apparent.
Prognosis:—Occasionally one of these patients will make a complete recovery; more often the conspicuous symptoms will abate and the condition become more or less permanent for perhaps months or even a year or more, until a marked relapse will appear. In other cases the treatment will materially reduce the symptoms and result in a gradual abatement of all the phenomena, until the patient is restored to a condition of health, which, while not satisfactory, will be more or less permanent, the patient continuing in this condition for years, with perhaps no return of the conspicuous symptoms. The sudden occurrence of tachycardia with vomiting, diarrhea and prostration, is evidence of serious advancement of the condition.
Treatment:—These patients should be subjected to enforced rest for a prolonged period. The nervous irritation should be controlled, and everything should be done to promote mental quietude—a lack of anxiety and excitability. The climate undoubtedly exercises a conspicuous influence. A moderate elevation, a dry atmosphere and a uniform temperature are very desirable requisites. The food should be palatable, nutritious, and its ready appropriation should be encouraged. For the acute symptoms those remedies which act as special heart sedatives may be given in small doses, frequently repeated at times. At other times gelsemium will be available. Lycopus has exercised a beneficial influence in a few cases. Strophanthus and cactus have been advised by different writers, and I am confident that these remedies may be correctly adjusted to certain conditions. Veratrum should be given also, when the feebleness of the heart's action is not pronounced. Mistletoe has been suggested as exercising a favorable influence upon the action of the heart, and apocynum will be serviceable if edema be present. A number of writers have expressed themselves as enthusiastically in favor of fucus vesiculosus. Tt seems to exercise a direct influence upon several of the existing conditions. When there is pronounced disturbance of metabolism, or when the thyroid gland is conspicuously enlareed, echinacea and phytolacca may be administered. The regular school place much confidence in ergot and salicylate of sodium.
Thyroid feeding is advised to increase the size of the thyroid gland and its functional activity, and to promote the conditions that depend upon the functional action of this gland. This course for most cases would seem irrational, as exophthalmic goitre is due to an overactivity of the gland; therefore, instead of increasing the glandular activity, this should be diminished. If the increased activity depends upon circulatory disturbances—among which seem to be some capillary engorgement—ergot, belladonna and the bromids, or the iodids, would be indicated, because in their physiological activities they would reduce the local hyperemia. Gelsemium should also exercise a special beneficial influence on the condition.
Thyreoidectin, a substance recently brought before the profession, has produced good results in four cases which have been brought to my notice.
Surgical measures are adopted by many, but great care should be exercised in selecting the cases which would be benefited by operation. The entire gland should never be removed, and satisfactory results occur only in a few cases where surgical measures are adopted. Electricity has been applied with some benefit, but its stimulating influence must be guarded against.
