Graves' disease

“ The larval forms of Graves' disease occur particularly in young persons, though they are sometimes seen in those beyond middle life. They seem to be due to a lack of development of the thyroid in consonance with the rest of the tissues, though occasionally, especially after the menopause, they seem to be connected with some degenerative process out of harmony for the moment with other forms of degeneration. When they occur in young persons they may, of course, represent the beginning of incipient Graves' disease, but they are often only functional and the symptoms may pass away entirely. ”

“ The origin of many cases of Graves' disease is closely associated with some of the causes of the discharge of nervous energy, depressive influences especially, such as nervous shocks, worry and nervous strain, disappointment in love, business reverses, illness and death of relatives and friends. The association of thyroid activity with procreation is well known, hence the coincidence of a strain of overwork or of fear with the sexual development of maturing girls is obviously favorable to the incidence of Graves' disease. ”

“ Graves’ disease is not by any means a hopeless disorder under medical treatment, even in its advanced stages; it is therefore impossible to say when surgery is indicated as a last resort. When the facts of its absolute inefficiency in perhaps the larger proportion of instances in which it has been tried, the immediate dangers of the operation which are not slight, and the remote ones pointed out by Dr. Putnam, are all taken into consideration, it would seem that it ought to be relegated to innocuous desuetude.—Journal of the American Medical Association. ”

“ General Condition.—The treatment of patients suffering from Graves' disease consists largely in having them take up some occupation that, while reasonably absorbing, does not make too great a demand upon them. Often when they complain most of their symptoms they are below normal weight and the first indication is to have them brought back to it. ”

“ Of extreme interest is the fact that, in the acute stage, the patient may be unable to refer to the exciting cause without exhibiting an exacerbation of the symptoms of the disease. I presume no case should be regarded as cured until reference can be made to its cause without an abnormal reaction. It has been established that in Graves' disease injury to any part of the body, even under inhalation anesthesia, causes an exacerbation of the disease. Fear alone may cause an acute exacerbation. ”

“ If Graves' disease be a disease of the great primitive emotions, or rather of the whole motor mechanism, how is the constant flow of stimulation of this complicated mechanism supplied? It would seem that there must be secreted in excessive amount some substance that activates the motor mechanism. The nervous system in Graves' disease is hypersusceptible to stimuli and to thyroid extract. It might follow that even a normal amount of thyroid secretion would lead to excessive stimulation of the hypersusceptible motor mechanism. ”

“ In the state of superlative sensitization which is seen in Graves' disease we find that the stimuli that produce muscular movement, the stimuli that produce emotional phenomena, and the stimuli that produce fever are as nearly as can be ascertained equally effective. Clinical evidence regarding this point is abundant, for in patients with Graves' disease we find that the three types of conversion of energy resulting from emotional stimulation, from infection stimulation, and from nociceptor stimulation (pain) , are, as nearly as can be judged, equally exaggerated. ”

“ It has offered a plausible explanation of the cause and the treatment of Graves' disease. Will the kinetic theory stand also the clinical test of controlling that protean disease bred in the midst of the stress of our present-day life? Present-day life, in which one must ever have one hand on the sword and the other on the throttle, is a constant stimulus of the kinetic system. ”

“ In the hyperactivity of the thyroid in exophthalmic goiter one sees a marked tendency to fever, in severe cases there is daily fever. In fact, in Graves' disease we find displayed to an extraordinary degree an exaggeration of the whole action of the kinetic mechanism. ”

“ In the early stages of Graves' disease, before the destructive phenomena are felt, the kinetic speed is high, and life is on a sensuous edge. Not only is there a seasonal rhythm to the rate of flow of energy, but there is a diurnal variation—the ebb is at night, and the full tide in the daytime. This observation is verified by the experiments which show that certain organs in the kinetic chain are histologically exhausted, the depleted cells being for the most part restored by sleep. ”

“ From the beginning, and often for a long period antecedent to the appearance of cardiac symptoms, the subjects of Graves' disease present a considerable mental erethism. There is an indefinable and tormenting agitation, marked by mental and motor restlessness and an imperative and impulsive tendency to be doing. Their emotions are too readily excited, and they are unusually impressionable and irritable, reacting in an exaggerated manner to all the incidents of daily life. ”

“ The Treatment and Prognosis in Graves’ Disease.—This short article is prepared solely with the view of eliciting from medical men who have met with cases of exophthalmic goiter in their practice, the results of their observations regarding many points of interest in connection with this curious disease. ”

“ Of course when a goiter has become a dangerous mechanical embarrassment to important functions, or when a tumor exists in the thyroid that by its growth and situation has become a threatening danger, the case is clear, and operation may not only be justifiable but necessary. It is in such affections as Graves’ disease, in which thyroid operations are still somewhat popular, that we are likely to have not only useless but dangerous surgery, and the time seems to have come to emphasize the cautions implied in Dr. Putnam’s paper. ”

“ It is not quite clear how this absorption causes hypertension, but it is probably through an effect on endocrine glands, chiefly perhaps on the suprarenal and secondly on the thyroid. McGarrison has shown how often Graves’ disease is caused by faulty intestinal digestion, and by the colitis that ensues; this he thinks stimulates the thyroid to overactivity or to faulty secretion. The suprarenals are probably affected still more than the thyroid, and the hyperthyroidism may be due to the upset of the balance of power ”

“ We cannot recall any alteration of the thyroid gland that is not accompanied by nervous symptoms. In Graves’s disease (exaggerated activity of the thyroid) we observe a condition of great nervousness, so much so that, according to some authorities, Graves’s disease may be termed a neurasthenia with tachycardia. There are many women treated for simple hysteria who are, in fact, suffering from a partial form of Graves’s disease with its cardinal symptom: tachycardia. ”

“ Even more interesting in these modern times, however, than Graves' attitude toward the treatment of fever is the position he took with regard to the habits of life that were best for the consumptive. At that time tuberculosis of the lungs was considered to be an inflammatory disease requiring the patient to be in the house most of the time, carefully protected from cold, and during any rise of temperature to be kept in warm rooms, without any special encouragement to take food. ”

“ In women who have borne a child the thyroid is usually somewhat enlarged. Good authorities in obstetrics have insisted that they could pick out of a group of women in evening dress, those who had borne children, from the appearance of their necks. Probably this is an exaggeration, but there is no doubt that the thyroid is intimately related to the genital functions in women. It has been said that a direct connection could be traced between disappointments in love or in sexual matters and the development of Graves' disease. ”

“ The methods in vogue in Edinburgh had not impressed Graves favourably. Students were not then regularly called upon to investigate cases for themselves, nor trained in so doing: they might obtain their degree without having ever practised diagnosis or co-operated in curing disease even to the extent of writing a prescription. “Often have I regretted,” said Graves in his introductory lecture at the Meath Hospital in 1821, “that, under the present system, experience is only to be acquired at a considerable expense of human life. ”

“ Thus, with thyroid degenerations, as in myxœdema, the skin is pale with a yellowish tinge. In Graves’s disease pigmentation of the skin can often be observed, and not rarely cutaneous eruptions.
In affections of the sexual organs in woman similar conditions of the skin can occur. Such persons often present wrinkles at a very early age, and certainly look older than their years. Infants suffering from congenital degeneration of the thyroid gland often look withered and present a face as wrinkled as a sexagenarian. ”

“ Basedow, a physician of Merseburg, published, in 1840, a description so complete that the Germans regard it as the classical one. The three symptoms which he signalized—swelling of the thyroid gland, protrusion of the eyeball and palpitation of the heart—the Germans sometimes call the "Merseburg triad," [8] which they also designate by the simple telegraphic epithet "Basedow." Among English-speaking people, exophthalmic goiter is usually known as Graves's disease, after the well-known Irish clinician who printed an accurate account of it in 1835. ”

“ There is at least one other class of disease usually considered to be much more modern, the type of affection known as Raynaud's disease, or a tendency to spontaneous stoppage of the circulation in the extremities, and also the other type now known as Weir Mitchell's disease, or erythromelalgia, in which there is suffused redness and pain in the extremities, examples of which Graves picked out from his hospital service and described in such a way that it is easy to recognize them even at this distance of time. ”

“ Mr Proctor:—Yes, but the Brunonian doctrines were then in full fling, and practitioners had not learned the full use of the lancet.
Graves states very fairly the reasons that induced them to take blood in the influenza of 1833, as well as the results of the practice [721] :
“The sudden manner in which the disease came on, the great heat of skin, acceleration of pulse, and the intolerable violence of the headache,—together with the oppression of the chest, cough, and wheezing—all encouraged us to the employment of the most active modes of depletion ”

“ In 1843 and 1844 Graves was President of the Irish College of Physicians, and was elected a Fellow of the Royal Society in 1849. He was led by his experience to hold strongly the belief that typhus and typhoid were not distinct fevers. His great service to the treatment of fevers is however independent of this. He recognised the ill effects of a lowering system upon fever patients, and steadily set himself to maintain the patient’s strength by food and stimulants. ”

“ The changes found in autopsies, such as a dark color of the blood, deficient coagulability, extravasations into and friability and granular degenerations of the tissues, accumulations of degenerated cells, and granules between the fibres, degeneration mainly of the heart-muscle, the presence of heart-clots, thrombi in remote veins,—they all show to what extent the disease can destroy life in the shortest time possible. ”

“ For my own part, I am of opinion that the small-pox is a disease of the lymphatic system only, and my opinion seems to be confirmed by the impossibility of communicating [Pg 76] the infection by inoculating with the blood. Be this as it may, it is indisputably true, that the crude lymph is sufficient to give the infection, and that there is no necessity to draw blood at the time of incision. Add to this, the frequent tumour of the lymphatic glands in the axilla soon after the operation. ”

“ Then several cases of typhoid fever broke out, owing to the insanitary conditions; but strangely enough the disease did not spread, and the mortality from it was small. Imagine the miseries of an unhappy man, who, while suffering from a smashed thigh which prevented him from even moving to resist the maggots that assailed him, was then smitten with small-pox or typhoid fever!
Little by little the septic troubles increased, and at last the crown of misery was reached when hospital gangrene made its appearance. Few civilian medical men now practising have ever seen hospital gangrene ”

“ When the belly, or glandular part of these lymphatics, becomes torpid, the fluid absorbed by its mouth stagnates, and forms a tumour in the gland. This disease is called the scrophula. If these glands suppurate externally, they gradually heal, as those of the neck; if they suppurate without an opening on the external habit, as the mesenteric glands, a hectic fever ensues, which destroys the patient ”

“ The lymphatic glands are frequently the seat of tubercular infection, especially in the neck, and are enlarged in scarlet fever, tonsillitis, and diphtheria. In syphilis there is general glandular enlargement, and the glands in the groin become enlarged in all diseases of the genital organs. In malignant growths, such as cancer, the extension of the disease is often along the lines of the lymphatics. ”