The pathology and treatment of Graves's disease / by W.H. Thomson.

  • Thomson, William Hanna, 1833-1918.
Date:
1893
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Licence: Public Domain Mark

Credit: The pathology and treatment of Graves's disease / by W.H. Thomson. 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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    /h74Cri- M- THE NEW YORK MEDICAL JOURNAL, Juxe 3, 1893. Original Communications. [S' THE PATHOLOGY AND TREATMENT OF GRAYES’S DISEASE * By W. H. THOMSON, M. D., PROFESSOR OF MATERIA MEDICA AND OF NERVOUS DISEASES, UNIVERSITY OF THE CITY OF NEW YORK ; PHYSICIAN TO BELLEVUE AND ROOSEVELT HOSPITALS. The progress of pathology often illustrates the disad- vantage of the premature naming of diseases after some of their common or prominent symptoms, for further knowl- edge may show the disease to have much wider relation- ships than at first suspected, and in some cases to exist with- out these symptoms being present. If such be the case, the symptomatic name may then operate to prevent a cor- rect diagnosis. Locomotor ataxia is a good example of the concealing power of such names, for I have known of an elaborate diagnosis being made of a tumor in the optic thalamus to account for the optic atrophy of a tabetic pa- tient who, though wholly blind, yet had no ataxic gait, while in other patients with this disease the significance of painsi or of gastric crises has been similarly misinter- preted, because the motor symptoms were so little devel- oped. In like manner the name exophthalmic goitre has had much the same influence in preventing the recognition of Graves’s disease in many instances, and still more in confusing the views of its pathology. In reading the nu- merous contributions on the pathology of this interesting affection, it is striking to note how predominantly the con- ception of some textural lesion in the nervous system that would account for the exophthalmia and the goitre has di- rected either the investigation or the speculation, in seeming forgetfulness of the fact that these symptoms are not essen- tial to the affection, because they may be both present with Graves’s disease absent, or both absent with Graves’s dis- ease present. The safest rule to follow in pathological problems is to seek first for the most constant characteristics of a given complaint, rather than for the most obtrusive ones, for, when the latter are found to be wanting in some real cases of a given affection, they sink at once from the rank of a primary to that of an accessory relationship to its true pathology. Having found the most constant characteristic of the disease, we must even then keep to what is most constant about the characteristic itself when we come to analyze it, lest we be again turned aside from the right course by non-essential accompaniments. Thus the most uniform condition in Graves’s disease is what may be cor- rectly described as a state of marked agitation. In many instances it is for long a purely physical state, not involving the mind or the spirits, and yet the patient acts as if great- ly alarmed about something. This has led many writers to pronounce fright to he a leading cause of the disease, and how far this hypothesis may be pushed is illustrated by Dr. Hector W. Mackenzie, in his excellent lectures on Graves’s disease (Lancet, September, 1890), when he sums up its pa- thology by saying that if we can not show in each case that the patients themselves have so started from a fright, yet some of their ancestors may once on a time have been greatly terrified, and thus laid the foundation for Graves’s disease in a descendant by what he terms an unconscious heredi- ary memory. We are thus at the outset diverted from the study of a truly characteristic condition to that of a most occasional element in the clinical history of the affection, and which is then made to do duty as a guide to its true pathology. The parallel instance of chorea, where fright is so often spoken of as a cause of the disease, naturally suggests the desirability of a new technical meaning of the term “ cause ” in medicine. It would be a great gain to restrict its use only to some element, discovered or to be discovered, in the aetiology of a disease without whose presence the disease would not exist, while for all variable factors to employ some such term as occasion. Thus fright may be the occasion of the first manifestation of chorea or of Graves’s disease, a blow the occasion of the development of a mammary cancer, a chill from exposure to cold the occasion for the development of a croupous pneumonia or of a pulmonary phthisis, but it is only a hindrance to our progress toward a correct pathology of either of these dis- eases to put down any one of the very varying occasions of its first manifestation as its cause. It would be better to defer rating anything that is occasional in a disease until its proper and quite subordinate place is settled by the due precedence being determined of the few constant over the many occasional elements. This is particularly the case with such a convenient cause to allege as fright in nervous patients, for not infrequently it may prove on examination that the patients had been for months in a state of true physical agitation before the accident of a mental impres- sion occurred which they describe. In my last eight con- secutive cases of Graves’s disease in private practice not one of them would ascribe the initiation of the complaint either to fright or to any other emotional cause. Of course it is impossible to say what may have happened to their ancestors, but I think that a much nearer source of their bodily agitation may be found in their present living frames than in the dead past. The first of the above-mentioned patients presented at her first visit a complete picture of the constant, in distinction from the occasional, symptoms of Graves’s disease. I had known her well for some time, from having attended other members of her family, but she had always been healthy be- fore, so that I had not seen her for some months. She showed no sign of either exophthalmia or goitre, but, as she now began her story, she seemed as if about hesitatingly to divulge some great cause of mental distress. Her voice trembled as if choked with emotion, her hands trembled, and her respiration was hur- ried and catching. She said, however, that she had had noth- ing to make her so nervous, nor could she imagine why she was so, except that she had had diarrhoea all summer, but that other people had diarrhoea without being as nervous as she was. As soon as I examined her pulse, which was over 140, with a nor- mal temperature, and noted that the muscular tremor was so