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lished the results of his observations. The disease was very accurately described at that time by these men, and their observations and published reports have been of great importance, and since that time it has been known as Grave's disease, Basedow's disease, and exophthalmic goiter. Dr. Charles H. Mayo prefers to employ the term hyperthyroidism, because it is a term indicative of a condition which manifests such varied symptoms. "And it is probable then, that earlier relief will be given to many who are now treated for heart disease, nervous disease, gastric crisis, and intestinal toxaemia, until a projecting eyeball or goiter becomes sufficiently prominent to put the label of Grave's disease, Basedow's disease, or exophthalmic goiter to the unfortunate individual who must run the gauntlet of the enormous variety of therapeutic agents, which are good for the disease when properly christened."

In 1886 Moebius permanently established the fact that exophthalmic goiter is a form of poisoning of the body through a diseased activity of the thyroid gland, and not a disease due to some primary lesion of the central nervous system, nor pathological condition of the sympathetic nervous system, but a disease due to a pathological development in the thyroid gland itself. This theory is amply proven by the number of cures after removal of the gland.

There are four types of the disease to be considered:

I. The soft, vascular, pulsating thyroid, with symptoms of hyperthyroidism.

2. The hard, dry gland of the hyperthyroidism.

3. The development of hyperthyroidism in those with preexisting goiter in whom we find the changes of solid tissue, loss of colloid and vesicles filled with columnar and cubiodal cells in scattered areas, instead of general change in the gland as in the first two types.

4. Pseudo hyperthyroidism where growth within the gland is causing pressure and absorption of same.

The symptoms exophthalmus occur in the young as well as the old. The youngest exophthalmic case we have had for operation being twelve years old, while the oldest was sixty

six. These were both females. There is a marked frequency of goiter in the two sexes occurring usually in the female. Exophthalmic goiter does not appear to be directly inherited, but there is a sufficiently large number of cases on record to show that there is a distinct tendency for some families to suffer from the disease.

One instance that illustrates this condition has come under my notice. Father and mother neither have had goiter. No history of goiter in their parents. Five children were born to them. Four of them had exophthalmic goiter, which were removed here by operation in the past three years. The fifth has goiter of the simple type.

Exophthalmic goiter is characterized by primary symptoms. Enlargement of the thyroid gland, increased frequency of the pulse, tremor, nervousness and exophthalmus. In addition to these may be considerable associated symptoms, as muscular weakness, sensation of heat throughout the body, perspiration, elevation of temperature, and the gastro-intestinal symptoms. There is also a neurotic element in many of these cases that have to be taken into consideration. With the exophthalmus may occur the Stellwag symptom, retraction of the upper lid, or Van Graefe sign, lagging behind of the upper lid in looking down, or a Moebius, which is occasionally insufficient accommodation without a diplopia. From 20 to 30 per cent. of the exophthalmic cases the exophthalmus is absent.

The enlargement of the thyroid gland is present in the majority of cases, but it may be so slight as to entirely escape observation, so in many exophthalmic goiters the gastro-intestinal symptoms, tachycardia, and general nervousness, with slight enlargement of the thyroid, may be the principal sympThese symptoms may come on slowly and progress in the same manner, or come on acutely and progress rapidly. Cases of hyperthyroidism will develop with amazing rapidity. Within two or three days they will present most of the cardinal symptoms, including eye symptoms. In these acute cases you will invariably have a vascular goiter, increasing in size with the constitutional symptoms and compelling the patient to take her bed. The blood supply in the gland is greatly increased,

as shown by a palpable thrill and bruit heard over the gland with the stethoscope. Systolic murmurs may also be heard at the base and apex of the heart.

Other cases come slowly and cardinal symptoms are slow in making their appearance. The diagnosis is not readily made, and the patient will present symptoms of general nervousness and disease of the heart. The degeneration of the heart muscle will progress and become irreparably damaged before either eye symptoms or an enlarged thyroid can be plainly made out. This condition was forcibly illustrated in a case which I had recently that died a medical death. Dr. A. G. Fell saw the case with me, and only up to two weeks of her death she develop slight eye symptoms, and an enlarged lobe could be seen at this time only by having the patient swallow with the head thrown back. She was under our observation for about three weeks, but at no time was any surgical interference warranted, owing to a serious degenerated heart muscle, with associated symptoms due to a prolonged hyperthyroidism.

Recently it has been claimed by several clinicians that a diagnosis of this disease can and must be made in a case where tachycardia is present, which cannot be explained upon any other pathological theory in any given case, especially if several of the other symptoms, but neither exophthalmus nor goiter, are present When either of these two symptoms is present with tachycardia, all authorities agree on the diagnosis.

It is in the hyperactive thyroid that we seek for an explanation for these symptoms, and the recent work of Dr. Louis B. Wilson has shown that there is a definite parallel between the increased amount of functionary tissue and absorbable secretion in the thyroid and the degree of severity of the symptoms, and was able to classify the pathological findings in this condition very closely with the clinical symptoms in 80 per cent. of the cases. The extent of the changes in the gland is not always indicative of the severity of the symptoms, as some patients stand the absorption of the secretion better than others.

So we may have hyperthyroidism result from a simple goiter by increase in function of the thyroid gland; or, on the other hand, by continued activity degenerative changes may appear

in the functioning cells, and blocking of the lymphatic drainage take place, so that provided the patient live long enough a case of hyperthyroidism can return to a condition of myxoedema.

The appearance of hyperthyroidism will come on quite suddenly in a latent case of exophthalmic goiter by giving iodine in any form. It makes exophthalmic cases worse, as does the administration of thyroid extract and are sure to have a harmful effect upon them.

The thyroid gland, while usually increased in size in hyperthyroidism, is not necessarily always large, it is firm in consistence, and decidedly vascular, especially in acute cases. two of our cases which came for operation, the enlargement of the thyroid could not be demonstrated before operation. Both cases had exophthalmus, general nervousness and tremor, tachycardia, and intestinal symptoms. On removal, the right side in both cases was found to be slightly enlarged and the pathological findings show cells to be increased in the whole of the gland, and an over activity from cell changes.

The enlargement is frequently preceded, for some time, by tachycardia, general nervousness, loss of flesh, intestinal symptoms and dyspnoea, and the diagnosis is not easily made unless closely observed. The tachycardia and tremor are the most important signs, although they may appear irregularly. Pulse from 115 to 150 or over is frequently noticed.

It is important to consider the degree of the disease at the time a patient consults you for operation. This particularly concerns the degree of intoxication, and also the amount of structural change that has taken place, especially in the heart. Intoxication is evidenced by special symptoms, and to illustrate this condition, it can possibly best be done by reporting a case of this kind which came for treatment. This is not an isolated case, but represents the condition that many of the cases develop if left go long enough without operative interference.

Mrs. R.; age 38; married; housewife. Has always had very good health until February, 1907, when she had a great amount of nervous symptoms, rapid pulse, diarrhoea and fever. Was kept in bed for a month and was supposed by her physician to

have had typhoid fever. She lost in flesh twenty pounds in a short time, remained very nervous and weak, and continued so until March, when she began to improve, and was able to be up and around the house, but was required to lie down a great deal of the time on account of extreme muscular weakness and rapid heart.

She gradually gained in flesh and was much better in every way until the following June, when her symptoms all returned. She now noticed an enlargement in her neck, which had not been evident before, with her previous symptoms returning. She continued in this manner until September, 1908, a period of fifteen months, when she was brought to the Wilkes-Barre City Hospital. She came quite a distance by train on a stretcher, as she was unable to take the sitting posture on account of severe exhaustion and attacks of vomiting. She had been bedridden for weeks before coming to the hospital, having diarrhoea, vomiting, tremor, jaundice, marked exophthalmus and emaciation. The above symptoms were all very pronounced on admission. Physical examination showed systolic murmurs at apex and base of heart, oedema of the legs, and markedly jaundiced. High degree of tachycardia, pulse varying from 180 to 200 and over, and irregular. Examination of urine was negative.

The patient was given a few X-ray treatments and extract belladona and quinine. One week after admission to hospital we tied the right superior thyroid artery under cocaine. One week later the left superior thyroid was tied, and patient remained in hospital three weeks, when she was taken back to her home. She was taken on a stretcher, for the reason that she was unable to assume the erect posture. This patient steadily gained in all her symptoms and gained in flesh between forty and fifty pounds in three months, and in four months after the time of operation she was doing part of her house work and could ride several miles to church. During the following spring she noticed some of her old symptoms returning, and in June, 1909, I performed a thyroidectomy, removing the right lobe isthmus. She has made a rapid and satisfactory recovery. She has gotten back her usual weight

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