Another point needing investigation is how far the analogy holds good between Graves's disease and the complex of symptoms met with in fright and kindred states. These states may be spoken of as quasiphysiological, but are, in fact, pathological.
Peculiarities of the disease as affecting children; from an analysis of forty-four cases: The symptoms reach their maxi mum more rapidly in children than in adults; palpitation does not come on so quickly as with adults; thyroid enlarge ment is always present in children; the exophthalmos is less marked and the eye-muscle symptoms are much less common or severe; choreiform move ments are often present, probably as a complication; hysterical symptoms are well marked in some cases. On the whole, the disease is less severe in chil dren. Myxcedema may supervene even with children. Steiner (Wiener med. BI., p. 91, '97).
Symptoms.—Enlargement of the thy roid usually begins at about the same period with the appearance of the other symptoms, but sometimes much earlier or later. The right lobe is commonly more prominent than the left. Vascular (arterial) murmurs of "swirring" char acter, obtained by auscultation directly over the gland, are probably pathogno monic when present, but are not always heard; or they may be heard over limited areas. It is doubtful whether enlarge ments attended with this special vascular murmur—i.e., enlargements of the spe cific Graves's-disease character — are ever present for long without other symptoms. This murmur is to be distin o b mished from the "hum" due to com pression of the cervical veins. When one lobe of the thyroid is more enlarged than the other and one eye is also more promi nent, there is usually a concurrence as regards right or left side; but marked exceptions to this rule occur, and should be noted. In spite of the presence of these murmurs, and in spite of the fact that the gland is capable of swelling with great rapidity, arterial dilatation is not a marked feature of the post-mortem changes. The characteristic disease con sists in changes in form and arrange ment of the secreting cells and alteration of the secretion, the exact nature of which latter is not known. This is usu
ally, but perhaps not invariably, attended by enlargement.
From whatever point of view we re gard Graves's disease,—i.e., whether as a toxic affection or as a neurosis,—it is clear that the main part of the signs and symptoms, even many of those which are ostensibly limited to other tissues and organs, are referable to disorders of func tion or, eventually, of nutrition, of the nervous system.
A mild grade of multiple neuritis is an almost constant accompaniment of Graves's disease, and many of the well known symptoms are due to this com plication. Maude (Brain, Summer ed., p. 229, '94).
The symptom of exophthalmic goitre indicates a mode of dissolution of the nervous system, and is a degenerative neurosis making a line of cleavage at some point at which the nervous func tions are exposed to the strain. Putnam (Boston Med. and Surg. Jour., Aug., '95).
The mental symptoms are excitability; restlessness, often of an agitated charac ter; capriciousness; depression, or, on the contrary, an unnatural gaiety, with an apparent incapacity to appreciate the gravity of the situation; delirium, either in terminal stages of the disease or curring in paroxysms during its course; typical insanity, and degenerative affec tions of the brain.
To account for these phenomena we can invoke the influences associated with the disease itself, the neuropathic tend encies of the patients, the exhaustion from the sickness, and concurrent influ ences. In other words, the mental changes may be of parallel significance with the other signs of the disease, or may be only its accompaniments and secondary results; and, the more "spe cific" their character, the more likely it is that they are essential phenomena of the affection. However the mental symptoms arise, their presence is un favorable, as increasing the patient's emotional instability.
Since a certain proportion of cases finally become insane, the indication is to place around such patients the same prophylactic precautions which are necessary in cases having an hereditary predisposition to insanity. C. M. Hay (Med. Age, June 10, '91).