Clinical lectures on Graves' disease : delivered at the Hospital for Consumption and Diseases of the Chest, Brompton / by Hector W.G. Mackenzie.

  • Mackenzie, Hector W.G.
Date:
1890
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Credit: Clinical lectures on Graves' disease : delivered at the Hospital for Consumption and Diseases of the Chest, Brompton / by Hector W.G. Mackenzie. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    THE LANCET, September 13, 1890. (fliiiical fcctiircs (p ON GRAVES’ DISEASE. SDelivcrcd at the Hospital for Consumption and Diseases of the Chest, Brompton, HECTOR W. G. MACKENZIE, M.A., M.D., ASSISTANT PHl-SICIAN TO THE HOSPITAL, MEDICAL REGISTRAR TO ST. THOMAS’S HOSPfTAL, AND ASSISTANT PHYSICIAN AND PATHOLOGIST TO THE ROYAL FREE HOSPITAL. LECTURE I. Gentlemen,—Several reasons determined the subject of ■these lectures. In the first place, I happen to have under iny care at the present time a large number of cases of Graves’ disease; secondly, I believe that a good many of .its symptoms, recognised only of late years, are by no means so •widely known as from their importance and freouency ■they merit; and thirdly, I feel sure that througli a ■want of ■knoAA’ledge of these symptoms many cases of what is known <as the incomplete type of the disease faU to be recognised. I propose in this first lecture to discuss in particular these Hess well known symptoms and to show you a series of cases mostly of the kind I have referred to; ■while in the second lecture I shall say something about the course and termina- tions, the pathology and treatment, illustrating my remarks •by bringing forward cases of recovery and of long duration. Nearly all writers Yvho have reported cases of this disease have mentioned fright or other severe mental shock and over-fatigue as exciting causes of the malady. Gowers,for instance, mentions that a number of cases occurred in Alsace and Lorraine after the Franco-German war. In my own cases I have noted the following among others as the ■events from which the patients dated their illnesses: a severe burn; being thrown out of a trap; an unusually long and difficult confinement; unexpectedly finding her father dead; having her house broken into by burglars; a drunken man falling in at the door unexpectedly; terror in a solitary -house. I shall refer again to this matter of fright Avhen touching on the pathology. _ Quinsy and rheumatism are antecedent or coincident in a significant number of cases. Out of some forty cases I have noted quinsy in nine and acute rheumatism in five. This agrees with the experience of other observers. Thus, West has recorded rheumatism in eight cases out of thirty-eight, and the occurrence of quinsy is mentioned in a good many ■published cases. The association of the disease with other nervous dis- ■orders, such as epilepsy, hysteria, chorea, diabetes, and insanity, whether in the patient or in other members of the came family, has often been noticed. The disease itself sometimes occurs in several members of the same family; I have four pairs of sisters under my care now, while sisters of two other patients have been affected. Tavo sisters, a cousin, and an aunt;^ a mother and three sisters^; and three sisters;®—'have been reported as all suffering from the malady. Oesterreicher’s® case, however, puts all these in the shade. A hysterical woman had ten children, eight of whom suffered from the disease ; and one of the latter had four granddaughters also affected by it. The proportion of men to women is very variously stated. 'Charcot,'’ in a recent lecture, says the disease is only a little less freejuent in men than in women. Eulenberg® puts the proportion as one male to two females ; Trousseau® gives it as eight to forty-two; while Hardji®s^sthe disease attacks almost exclusively. It is difficult to explain these •differences. My own experience is that it is uncommon among men. Only three men, as against twenty women, have been admitted to St. Thomas’s Hospital during the last twelve years. The only case in a male I am able to show you is one of recovery. i Diseases of Nervous System, vol. ji. 2 Oph. Soc. Trans., 1886. Lheadle : St. George’s Hospital Reports, 1872-74. ■* Wild : Brit. Med. Jour., vol. i. 1886. 5 Hale White : Brit. Med. Jour., vol. ii. 1886. V r, *’ De.i^rine, Thfese d’Agregation, 1886. „ Gazette (l^es Hopitaux, 1885. » Ziemssen’s Cyclopedia. XT «Lectures, vol. i. lO Gazette des Hopitaux, 1883. No. 349tf. It is unnecessary for me to go over the old familiar ground and to describe to you the well known triad of symptoms. Of the three, by far the most important and most constant is the palpitation; next in consequence comes the enlarge- ment of the thyroid ; while the exophthalmos, which is the most obvious, is the least essential. I shall show you cases where there has never been enlargement of tbe thyroid, or where the enlargement has disappeared, and also cases where the same may be said of exophthalmos. Palpitation, how- ever, is not invariably experienced by the patient, and sometimes one finds a very rapid cardiac action without the patient being uncomfortably conscious of it. It is generally, however, the chief trouble they complain of, and in some cases is so conspicuous that they say their heart beats all over the body. I would remind you that the en- largement of the thyroid is nearly always more apparent on the right side than on the left. The thyroid is not an exactly symmetrical body ; the right lohe, according to Quain” (and this I have verified for myself), is larger than the left, and hypertrophy must magnify the disparity. I have said that of the three symptoms exophthalmos is the least constant. It was not mentioned in the three cases first described by Graves,^’ and I think, if present, he would have noticed it, for he immediately goes on to describe one in which it did exist. In three out of nine well-marked eases of the disease in the wards of St. Thomas’s Hospital of recent years it has been absent. It is probably on account of the mistaken idea that exophthalmos is essential that so many incomplete cases, in which absence is the rule, are not recognised. ’ When it does exist, exophthalmos is often not quite equal on the two sides, and several purely unilateral cases have been reported. Von Graefe’s sign— the lagging behind of the upper lid when the patient looks down—is by no means constant, but is useful sometimes as a confirmatory symptom. In one of the cases I shall show you it will be seen to be well marked, although there is no exophthalmos. The same may be said of Stellwag’s sign— the retraction of the upper lid. Time prevents me from dwelling on these so-called cardinal symptoms, which to many minds still constitute the whole of the disease. Let me remind you now of what Trousseau has said of their absence. “I believe,” he says, “ that the disease may be foreseen, and does really exist in a great number of instances without there being exophthalmos, bronchocele, or extreme frequency of the pulse.” The additional sym- ptoms the disease has been found to possess have made it much easier to recognise these incomplete forms, in which it frequently exists. First and foremostamongthese newsymptoms is trembling. The failure until a few years ago to recognise this really cardinal symptom is one of the most curious instances of intellectual blindness. If a patient the subject of this dis- ease hold out his hands, a tremor in them is very per- ceptible, consisting of vibratory movements of small ampli- tude, and with a period of about one-eighth or one-ninth of a second. It is exactly the same tremor which is noticed when the muscles are over-fatigued. The tremor is a com- municated one, affecting not the fingers individually, but the whole extremity, and sometimes the whole body, so that it may be observed in the lower extremity as well as in the upper. It usually affects both sides of the body; but in some cases it is limited to, or is very much more marked in, one extremity. Besides this tremor, which is more or less insensible, the patients generally suffer from attacks of trembling, either with or without palpitation, which attacks bear the same relation to the tremor that the palpitation does to the rapid cardiac action. The tremor is generally more obvious when the patient is flurried, and sometimes may be noticed only under such conditions. It is much more perceptible when the patient is sitting up than Yvhen lying down. It, as a rule, only interferes with the more delicate movements of the hand, such as writing or sewing, such an operation as carrying a cup to the lips being performed perfectly steadily. I have found this symptom a most valuable assistance to diagnosis, and it has generally first attracted my attention to the nature of the malady in the absence of exophthalmos. I have not yet met with a case in which it has been altogether absent. 'Thanks to Marie^® and Charcot,this symptom seems pretty well known in France, but as yet the same cannot be said of this country. Lately a case of Graves’ disease was shown at a provincial medical society and the n Anatomy, vol. ii. 1'2 Clinical Lectures. IS These de Paris, 1883. n Loc. cit. L