Goitre examined in 10 cases of Graves's disease. Of these S were dif fuse and 2 nodular. The diffuse were divisible into three groups. In the first the alveoli were large and filled with colloid material, and were distinguished from those of normal thyroids only by the presence of colloid in the lymph- and blood- vessels and between the fibres of the stroma. In the second group the follicles were smaller, and usually only partly filled with colloid, which was not so shining as in the first group. The septa contained less colloid in the con nective tissue and lymphatics, but just as much in the veins. The epithelium showed a tendency to form papilla:. The thyroids of the third group con tained many solid cell-masses, of which some were follicles filled with des quamated epithelium, others lobules and groups of lobules made up of narrow cell-strands. In the nodular goitre some lobules attained a diameter of to 3 centimetres; others were com pressed to a diameter of 'I,, millimetre. Many nodules were made up of solid cell-strands containing in numerous places balls of colloid matter. Other nodules consisted of small, solid cell masses; still others resembled the ordi nary colloid goitre. The first group of diffuse hyperplastic goitres showed hy persecretion; the second, an increase of function associated with an alteration in the secreted matter, allowing more ready absorption; while in the third group the increased activity of the gland manifested itself partly in hypersecre tion. partly in the formation of solid cell-masses. Ferner (Virch. Arch., Mar., '96).
Examination of muscular system hi 4 eases; a wide-spread degeneration cans ing a replacement of the fibres by fatty tissue found in all. This accounts for the tremor, the exophthalmos (from weakness of the orbital muscles), inco ordination of the eyeball, and general muscular weakness. The heart-muscle does not appear to be included in the process, although excess of connective tissue due to a proliferation subsequent to degenerative process was found. The nervous system affected showed no or ganic change. In the thyroid there was proliferation of the epithelium of the follicles, absence of the colloid material, and failure of differentiation of the cell masses. Askanazy (Deutsches Archiv f. klin. Med., B. 61, p. 11S, '98).
The lymph-glands throughout the body may be enlarged and the thymus persistent. A great number of special lesions have been found in one or an other segment of the nervous system, especially the medulla oblongata, but they are, in all probability, secondary and indicative of the excitation going on there.
The heart may be found dilated and its muscles degenerated; and so, also, de generations in the arteries and in the internal organs have been found; and in the spinal cord.
The time has gone by when any con siderable number of supporters can be found for the theory that this disease is due to the localized lesions occasionally found in the medulla oblongata or the sympathetic system.
Emphasis laid upon the presence of a permanent stimulation of that portion of the cervical sympathetic which pre sides over the dilatation of vessels in the orbit, in the thyroid body, and over the heart. The thyroid enlargement con sidered to be secondary effect of this distension; to be a symptom of the dis ease, and not the cause. That super abundance of thyroid secretion thus induced may be injurious is, however, admitted.
The lesion is nuclear, the nuclei of nerves influencing the heart and blood vessels, as indicated, being discrete in the bulb and upper portion of the cord (while those influencing the limb and trunk-vessels are lower down and there fore escape), and are there affected singly or in groups. Abadie (Arch. d'Opht., Nov., '96).
The pathological lesions thought by some to be due to the introduction into the system of a poison from without; this may possibly be a protozcain. This is supported by wide circle of diffusion which suggest its being a general disease, such as urticaria; mania; epistaxis; oedema of the conjunctiva; fleeting oedemas; general anasarca; pulmonary, intestinal, meningeal, and cerebral orrhages; vomiting, with intense tration; and intermittent albuminuria. It is possible for a simple endemic goitre to drift into the exophthalmic form. Carter (Edinburgh Med. Jour., Oct., '99). The key to the real mystery of the disease must be sought elsewhere, and it is generally agreed that the only sible explanations of the great array of symptoms which are liable to present themselves are, on the one hand, that suggested by the name "neurosis," and, on the other hand, that which assumes a toxic action due to altered secretion of the thyroid gland. The "neurotic ory" is certainly a reasonable one. It is true that the term is vague, but the ment brought forward by Mobius, that one could not properly attribute the largement of the thyroid to a nervous disorder is certainly untenable. It has been proved experimentally that the most trifling mechanical injuries of the gland are enough to change the character of the secretion and induce matous hypertrophy, and it is far from unreasonable to suppose that the same result might follow an alteration of the secretion due to nervous influence. In favor of the "neurotic" theory is, of course, the strongly-marked clinical re lationship of the disease and its mode of origin. On the other hand, there is also a great deal to say in favor of the view that the altered and increased secretions of the thyroid gland are important fac tors. The therapeutic and experimental study of thyroidization is in support of this view, and the striking contrast be tween myxcedema, and Graves's disease, as regards the condition of the skin, the nervous system, and the like, even though it does not fully bear critical analysis, is, in general, in favor of this conception.