Sixty-Sixth Annual Meeting of the British Medical Association
BMJ (Clinical Research Edition)
THE great amount of obscurity that still surrounds the etiology and pathology of Graves's disease and the unsettled state of opinion that exists in reference to its therapeutics are topics that still so largely exercise those who have an opportunity of dealing with such cases that any contribution that may directly or indirectly throw light on these questions is deserving of consideration. I deem the following case of importance, as the evidence it supplies is certainly in the direction of
... e direction of verifying one at all events of the many theories that have been held as to the causation of that strange, complicated, and, up to this, unexplained condition, and to which has been appropriately attached the name of Robert Graves, who gave the first clinical description of the malady. For the notes of the following case (both before and after operative treatment) I am indebted to Mr. F. C. Heffernan, late Clinical Clerk in the Meath Hospital. G. D., aged 32, by occupation a farmer, was admitted into the Meath Hospital, under the care of ml y colleague, Dr. Craig, for the first time in October, 2894, and again on May 29th, I896. He stated that about seven ,years previously he got a frightiroiii seeing a friend of his killed by a threshing machine. About three weeks subsequently he noticed a slight swelling in his neck, but at the time did not pay much attention to it. The enlargement, however, continued to increase in size, and he felt weak and suffered frorn attacks of palpitation. A short time after this he remarked tllathis eyes were becoming very prominent and "bloodshot," and the palpitation increased in a marked degree. This was greatly intensified on attempting to do any work requiring physical effort. Any slight exertion was also followed by other characteristic symptoms, such as flushes of heat, particularly about the head and face, profuse sweating, whiclh also took place irrespective of any exertion. especially if the patient ;got excited. He soon became very languid and weak, and constantly complained of great weariness. He suffered from a more or less constant headache, andbecame very irritable anid depressed. The appetite was vely irregular, as he sometimes lhad an extreme longing for food a very short time after meals. while at other timiies he suffered from anorexia and thirst. The bowels were also vely irregular, but more frequently constipated than otherwise. Occa-:sionally, too, he suffered from fits of trembling, and as a rule slept badly. -Several local plhysicians were consulted, but little benefit was derived from any liine of medical treatment that was recommended. He was advised to come up to Dublin, which he did, and was admnitted into the Meath Hospital. lie was then given ergotin and belladonna, and subsequently thyroid extract. White in hospital his general health became much improved, the tumour in the neck decreased in size, the eyes became less prominent, and the tremors subsided. This improvement, however, was only temporary. After about a year the symptoms recurred, and were more marked than before. He accordingly returned to hospital in May, x896, On adlmission the patient was anoemic, the thyroid was enlarged, particularly the central lobe, which was about the size of a large Tangerine orange; the lateral lobes were also somewhat enlarged. The circumference of the neck at tlle most prominent part of the enlargement I8 inches. There was a systolic murmur heard over one gland, and a oruit in the vessels of the neck. The heart's action was very irregular, but not very fast, and there was a slight trace of a systolic murmur in the mitral area. This was probably lhiemaic in character, as it was not stant, and disappeared on excitement. The eyes were prominent, the palpebral orifice enlarged, and there was well-marked nystagmus. Von Gr aefe's sign was notwell marked, or Stellwag's. Therewere tremors, butno skin pigmentations; the urine was acid in reaction, free from albumen sugar, aind specific gravity m02o. There was no evidence of any local general cedenma. On his admission he was given thyroid extract, and mixture containing ext. cascara sagrada, nux vomica, and glycerine. The case was then tr-ansferred to me, and after consultation with Dr. Craig, deeming that it was a suitable one for sTurgical interference, I operated and removed the large central tumour. During the operation the patient got three attacks of very alarming dyspncea. Otlherwise the operation was in no respects eventful, tlhe removal of the elnlargement being unaccompanied by alny special difficulty. A smaller growth, about the size of a pigeon's egg, was found lyilng to the right, but on posterior plane to the larger growth. This was also removed, and with it a polrtion of the right lobe of the thyroid. The larger tumour was heavy, elastic, and somewhat larger than a tennis ball. Owing to some haemorrhagic oozing from the cut surface of the gland the wound was packed with.boracic gauze, and sutures inserted, but not drawn togethdr except at each end of the wound. During the afternoon the patient had several attacks of syncope, one of which was somewhat alarming, as he completely lost consciousness, and the face became deadly white. These attacks were followed by profuse sweating. These symptoms were treated by the exhibition of diffusible stimulants in small quantiti,es every hour. During the patient's convalescence nothing very special was to be noted except, perhaps, the occurrence on the fourth and fifth days of alternate attacks of extreme heat and cold. On the fourth day the temperature rose to1030,°but after that it fell and remainedfrom that time on practically normal. Three weeks after the operation the patient was sent to the Convaleseent Home in Bray. Many of his symptom* have already sliqwT sign4 of abatement. The result in this case naturally suggests consideration of some of the views held and promulgated in reference to the symptomatology, etiology, and therapeusis of Graves's disease. In many respects the first of these is well illustrated in the case I have detailed, although several well known ones were wanting. For example, von Graefe's and Stellwag's signs were not well marked, namely, a want of synergic action in the lid and brow when the globe was turned downnwards, and incomplete closure of the palpebral fissures; also the condition of osteomalacia noted by Revilliod,1 consisting of exaggerated flexibility of the finger and wrist joints, brittleness of the bones, and loss of weight; again, the occurrence of tetanic spasms of the upper extremities, and dyspncea from mechanical pressure, a condition not often found in the ordinary forms of bronchocele, as noticed by Steinlechner.2 It was this latter condition that chiefly induced Lord Lister to operate on the case he published in I877, when life was threatened by suffocation. The result obtained in this case was very encouraging, for in a few weeks after the operation there was a marked alleviation of all the symptoms, and the patient ultimately recovered-lastly, the symptoms noted by Gerhardt,3 namely, splenic pulsation, a condition previously noted by him in connection with aortic incompetence. The principal theories that have been held in regard to the etiology of this disease appear to be three in number. First, that the heart affection (Trotisseau) is primary, and is caused through disturbance of the sympathetic nervous system; secondly, that the primary lesion is a central one; and thirdly, that it is caused by the secretion of the thyroid gland of a toxic substance. Grube4 strongly supports the view that the disease is distinctly infectious. This is based on the observation that it may supervene in cases of endemic or hereditary goitre, and be accompanied by enlargement of the lymphatic glands. He holds that the infective agent may act in three ways; first, on the thyroid gland, causing a perversion of its functions, the nervous system being affected secondarily; secondly, on the thyroid gland and nervous system, and, thirdly, on the nervous system directly. The hereditary character of Graves's disease has also been recognised. The causes which are usually assigned as factors in inducing the malady, such as shock, excitement, over-exertion, etc., can hardly be considered as of first moment, except as possibly renderina the system less liable to resist infection.