Exophthalmic Goitre.

Synonyms.—Graves' Disease; Basedow's Disease.

Definition.—A disease characterized by enlargement of the thyroid gland, tachycardia, protrusion of the eyeballs, tremors, and generally derangement of the nervous system.

Age, sex, and heredity may be mentioned as the predisposing causes of the disease.

Age.—Although Deval records a case following scarlet fever in a child two and a half years old, and Charcot mentions a case at sixty-eight years of age, the disease is very rare at the extremes of life. Bramwell states that in women the disease occurs most frequently between the ages of fifteen and thirty, and in men between the ages of thirty and forty-five.

Sex.—Women are very much more prone to exophthalmic goitre than men. Out of four hundred cases recorded, forty-three were males and three hundred and fifty-seven females, a ratio in favor of women of 83 to 1.

Heredity.—The frequency with which several members of a family have been recorded as suffering from the disease, leaves but little doubt as to the influence of heredity.

Of the exciting causes no specific factor has been found, though nearly all writers agree that wrongs either of the cerebro-spinal or sympathetic system of nerves lie at the foundation of the disease. Thus great and prolonged worry, excessive grief, anger, or fright, excessive mental or physical exertion, and severe shock precede the disease. There are other exciting causes such as nasal affections, pregnancy, sexual excesses, severe acute diseases, goitre, and others; the variety and number of causes assigned to the disease being the best proof that the true etiological factor is still unknown.

Pathology.—The chief feature in the hypertrophied thyroid gland is the increase in the secreting structure together with increased vascularity. It is uniformly enlarged. The protrusion of the eyeballs is due to dilatation of the blood-vessels of the orbit and an excess of the retro-orbital fat. There are no constant changes in the heart. In some there is dilatation and hypertrophy, though many cases show no changes whatever. The same may be said of the nervous system; no constant lesion can be found peculiar to exophthalmic goitre. The thymus gland is often found enlarged.

Symptoms.—The disease may be divided into acute and chronic.

Acute Form.—This is a rare form, and may speedily terminate in death. It is characterized by exceedingly rapid heart-action, great irritability of the stomach and bowels, resulting in persistent vomiting and purging, protrusion of the eyeballs, tremor, and sometimes marked cerebral disturbance.

Chronic Form.—In most cases the invasion is gradual, the tachycardia being the earliest and most constant symptom. It varies from 80 to 90 or 100 beats per minute to 120 to 150 or even 300 per minute, depending upon excitement and physical exertion. Gradually the thyroid increases in size, though in rare cases it remains almost unnoticeable. The bulging of the eyeball is also progressive, and when developed is most characteristic.

Von Graefe's Sign.—This consists in the failure of the upper eyelid to descend upon the eyeball when it is directed downward. Normally, as the eyes follow a descending object from a level above the eyes to one below them, the lids descend with the downward movement of the eyeball, and in none is the white sclerotic coat brought into view, but in exophthalmus the white sclerotic is markedly visible, constituting Von Graefe's sign.

Tremor.—This is also a constant symptom, and is best observed by having the patient extend the hand, palm upward.

General nervousness is also found in most cases, the patient being exceedingly nervous and restless, is easily disturbed, and magnifies small incidents and happenings out of the ordinary; is inclined to be pessimistic and melancholy. Insomnia is very common, the patient having great difficulty in getting to sleep.

Gastro-intestinal disturbances are the rule, diarrhea occurring at intervals and lasting from one to three days. Gastric distention of the stomach, attended by irritation, is a frequent complaint. Respiration may be increased in frequency, due either to cardiac disturbance, anemia, or to pressure from the enlarged thyroid. At times it is normal.

Cutaneous Symptoms.—Pigmentation, while not a constant symptom, is often present, being especially prominent at those parts where the pigment is naturally abundant, such as the areolar tissue around the nipple, and in the genital region. The face is sometimes of a darker hue than in health. Profuse sweating is not an uncommon symptom.

The general health is always more or less impaired. Wrongs of digestion, impaired innervation, and impaired circulation, soon give rise to muscular weakness, anemia, and more or less emaciation.

Diagnosis.—The diagnosis of Graves' disease is readily made by the presence of tachycardia and muscular tremors, even though other characteristics are absent, and when we add to the above symptoms, enlargement of the thyroid and the bulging of the eyeballs, the white sclerotic coat showing, there is no room for doubt.

Prognosis.—The prognosis is unfavorable as to cure, though the patient may live for years. A few cases will entirely recover.

Treatment.—The treatment will be hygienic, medicinal, and surgical. When possible, the patient should be sent to a climate of equable temperature, where there is a maximum of sunshine and of moderate elevation, from 2,500 to 3,500 feet.

Medicinal.—Aconite, veratrum, belladonna, cactus, strophanthus, ergot, digitalis, sodium salicylate, and many others, have been advocated, and when specially indicated may be of some benefit, though too much should not be expected from medicines. Galvanism has been highly extolled, and may prove beneficial in some cases.

Surgical.—Although of the one hundred and ninety cases reported by Starr where operative measures were taken, twenty-three resulted fatally, yet it promises more in the way of permanent relief than does medication, and with improved surgical measures the death rate of 12 per cent will be materially lessened.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.