On the whole, it seems to me perfectly clear, on grounds that cannot be elabo rated here at length, that we are still far from grasping the problem in its whole complexity. There is one aspect which has never been sufficiently dwelt upon, and that is the relation of the symptoms of Graves's disease and of myxcedema as well to quasiphysiological states. If in those two conditions we have indications of an excess, on the one hand, and a de ficiency, on the other, of the thyroid se cretion, then there must be a middle point corresponding to health, and, if alterations of the thyroid secretion in one direction causes abnormal mobility of the nervous system and in the other direction an abnormal sluggishness (leaving out of consideration, for brev ity's sake, the question as to the develop ment of uncompensated tissue-poisons), then it is fair to assume that the ordinary mobility of the nervous system is, in a way, dependent on a normal amount and quantity of the thyroid secretion. However this may be, it seems more than probable that we have in Graves's dis ease a collection of symptoms which are united together not only as manifesting the action of the thyroid poison, but as having a certain quasiphysiological re lationship to each other.
Personal case in which death occurred from exoplithalmie goitre along with myxcedema. Eleven cases, already re ported in medical literature, in which myxcedema and exophthahnic goitre were diagnosed as co-existent. These 11 cases can be placed under four categories: (1) four in which the exophthalmic goitrous symptoms were episodes only during the course of myxcedema; (2) two cases of exactly the converse; (3) two instances of the diseases appearing and persisting simultaneously; (4) three others in which, during the course of either of these conditions, symptoms of the disease hitherto absent appeared, but not so fully as to present a complete clinical picture of it. Faure (Presse Med., Sept. 23, '99).
Series of twenty cases studied with the Riva-Rocci and von Recklinghausen instruments, the measurements being compared wills the rapidity of the pulse. The cases were divided into five groups, in direct accordance with the measurements of the blood-pres sure. The lowest group and the high est included most of the severe cases. The blood-pressure, however, was not in direct accord, either when very low or very high, with the severity of the disease. The cases of the remain ing three groups show moderate blood pressure (115 to 135, von Recklinghau sen); but, as a rule, those with low pressure were severer cases and those with direct pressure were milder. The pulse-rate showed no direct and con stant relation to the severity of the dis ea:e. The conclusions reached are: That the blood-pressure does not show any constant changes in exophthahnic goitre. It may he reduced or increased; but, in the milder cases, is about normal. The changes which occur in the pressure are due both to alterations in the heart-action and to vasomotor changes. D. Spiethoff (Centralb. f. innere Sled., Aug. 23, 1902).
Prognosis.—Some cases of Graves's disease run a rapid course, ending in re covery, and this is especially true of breaks occurring in childhood. In a case under the observation of a colleague of the writer, a girl, S years old, had an acute attack due to fright from harsh treatment by her father, but was well at the end of a few weeks. Recovery is also possible in acute cases occurring in adult life and in mild chronic cases, though it is far more common to see some few symptoms persist in spite of substantial recovery from the rest. The
exophthalmos often overlasts the signs.
Some cases have a malignant aspect almost from the outset, and die very rapidly after a few weeks or even days, or from exhaustion and cachexia at the end of a few years. Even cases of great severity may, however, take a favorable turn and substantially recover under favorable conditions; so that no case ' ought really to be despaired of.
Case of rapidly-fatal exophthalinic goitre observed, the patient dying hi three days after pronounced symptoms had appeared. Lloyd (Polyclinic, Apr., 'SS).
Prognosis is comparatively favorable, as far as life is concerned. Nothnagel (Med. Press and Circular, Nov. 27, 'S9).
Prognosis is more unfavorable in men than in women. Kahler (Inter. klin. Rund., Mar. 10, '90).
Gradual subsidence of the cardinal symptoms in Graves's disease noted for long periods. In such cases complete recovery may be claimed. Pribram (Wiener klin. Rund., No. 44, '95).
In 24 cases there was fatal termina tion in 6; recovery complete or almost complete in 7; improvement in 7; con dition much the same in 3. R. T. Will iamson (Brit. Med. Jour., Nov. 7, '96).
Treatment.—A great number of meth ods have been used for Graves's disease and have had their enthusiastic support ers, but it is the conviction of the writer,. after a careful trial of them all, that the principal factor in bringing about the favorable result has been not so that any one of them has struck at the real root of the disease, but that they have either induced an improvement in some one particular, or have inspired the patient with confidence and encourage ment, and through one or both of these ways have given a new "set" to the dis ordered nerve-functions, which form the chief feature of the malady. In no other way can we explain why it is that one observer has insisted upon the impor tance of the treatment of the intestinal tract; another on the treatment of the sympathetic system, or the heart; another on that of the nervous system; another on that of thyroid; one on weak, another on strong, electrical currents, etc. If this generalization is correct, it follows that the conscientious physician should have two aims in view: first, to treat his patients with persistence and deter mined confidence, in order that they may catch his tone of encouragement; next, that each case should be energetically treated at the most assailable point, or points. The treatments proposed may be roughly divided into the "empirical," or "symptomatic," and the "rational," or those based on some theory of the dis ease. Of the former class the most im portant are the treatment of the heart, the nervous excitability, the digestive disorders, and the like. To the second class belong the electrical treatment of the sympathetic nerves, the surgical treatment of the thyroid gland, the use of specific remedies like thyroid and thymus extracts (see ANIMAL EXTRACTS: THYROID, THYMUS, and SPLENIC Ex TRACTS), the adoption of special diets, used without regard to particular forms of indigestion. Any or all of these treat ments may have their value, as above in dicated, by encouraging the patient, but those which are really most effective in combating some one feature of the dis ease and thus helping to give an impulse toward recovery are, in the writer's opin ion, the following: Absolute rest, pro vided this can be accomplished under favorable and effectual hygienic condi tions agreeable to the patient; surgical treatment of the thyroid or sympathetic nerves.