NZMJ, 1923

(Delivered before the Wellington Division, British Medical Association, on 1st June.)

The great weakness of modern medicine is that everyone is so busily occupied in acquiring new facts, recording observations, trying out new methods and developing new theories that one often forgets to think. This is further conduced to by the bewildering multiplicity of modern developments in the many sciences which are now the handmaidens of medicine. We are so preoccupied in studying the charms of these ladies that we are apt to forget that one function of the priest is to withdraw into the temple at times and indulge in meditation. Sir William Gairdner wrote a delightful essay some 50 years ago in which he asked in all seriousness whether medicine had made any advance at all since the days of Hippocrates, and he answered the question in the negative. One of the most brilliant researches made in recent times is the work of Marine and Kemball showing that endemic goitre can be prevented in school children by giving iodine, but Hippocrates had anticipated this, because he gave the ash of seaweed, which is rich in iodine, in order to reduce the goitrous neck. His knowledge was probably derived in turn from the Vedic physicians who practised on the tablelands of Asia 1000 years before Hippocrates. The great Greek physician also recommended in cases of consumption that the patient should drive a cow up to the hilltops and live there, drinking the milk of the cow. Up till quite recently we had made no advance on this treatment. Some 30 years ago a small band of Russian scientists went to Thibet to find out if there was anything in the fabled wisdom of the East. They had to study laboriously for years before they gained admission to the monasteries, and what they learnt there interested them so much that they stayed 30 years, and during that time attracted 25 more of their countrymen to study with them. The two leaders have now returned to Europe, and have set up a school of philosophy in the forest of Fontainebleau. They say that in three subjects of study the East is far ahead of the West. These subjects are :—First, Psychology (and when you think how puny are the efforts of even our best psychologists in elucidating the working of the human mind, that is not surprising). The second is Music, and they say that Mozart was a child in rhythm and harmony compared to the Yogis. The third subject is Medicine, and that is a staggering statement. How can the priests in a Thibetan monastery have greater knowledge than the awe-inspiring masters of European medicine? Well, Gurdieff explains it in this way. He doesn’t say that they can cure an ordinary cold by means of a vaccine for ₤20, or that they can remove a healthy appendix for double that sum, but he says that we know that the pneumococcus and other germs, which we all harbour as domestic pets, occasionally turn and rend us by causing pneumonia. We do not know why, but the Yogi does. We know that out of 100 hyperplastic thyroids a few only will cause Graves’ disease, and the Yogi can tell us why. And these statements are made, not by gullible ignoramuses, but by a band of men who knew everything that Western science could teach before they went to study in far Cathay.

I am sorry that I cannot expound this Forest Philosophy. All that I propose to do to-night is to try to take stock of our knowledge of exophthalmic goitre, and it is an inviting subject of study because it appeals alike to the pathologist, the biochemist, the epidemiologist, the radiologist, and, further, it furnishes one more jousting-place where the surgeon and the physician in turn throw down the glove to each other.

The function of the thyroid is to control the metabolism of the body and to mobilise its resources for any emergency, and it seems clearly established that it cannot do these things without a sufficient supply of iodine, which it utilises in the form of thyroxin or organic iodine. Marine and Kemball have proved beyond the cavil that the development of goitre in school children can be prevented by the exhibition of iodine. They give it as iodine of sodium, grs. 30, twice a year, or it can be given merely by hanging up a wide-mouthed jar containing tincture of iodine in the classroom. The thyroid does not need a great deal of iodine as one hundredweight of fresh gland yields only 7 grains of thyroxin, nor is it expended rapidly. Now let me outline briefly our present knowledge of the thyroid. We know that all goitres occur more frequently in women than in men in the proportion of about 4 to 1. In women the thyroid increases in size at puberty, during menstruation, at marriage, during pregnancy and lactation and at the menopause. That is to say all conditions which make an extra demand on the sexual and nervous apparatus of women result in over-activity of the thyroid gland, and, as the sexual changes are much more important in women, it is easy to see why they should be more liable to goitre. We know, further, that the function of the thyroid is stimulated by infective conditions, especially by syphilis, by diseased teeth and tonsils, and by alimentary toxæmia, and also by all emotional shock or nervous strain. We know that a goitrous mother is apt to bear children who are goitrous or who later become either myxoedematous or Basedowian. Above all, we know that pure dysthyroidism is not the usual condition, but that other glands such as the adrenals, the pituitary or the gonads share the disordered function of the thyroid. Quite recently a new light has been shed on our knowledge of thyroid disorders by the investigations of McCollum, McCarrison and the Mellanbies. Let me summarise what has been elicited by these workers. First there is the confirmation of the observation that feeding iodine diminishes goitre, and prevents the formation of it. This does not prove that goitre is due solely to a deficiency of iodine. There are many things that will make a jibbing motor-car go smoothly besides filling the petrol tank, but still I think it is extremely likely that iodine is the motor spirit of the thyroid gland, calcium is the lubricating oil, and the vitamines are the sparking plugs. We should remember that it is only a few years since the experiments of McCarrison, in feeding goats on the fæces of goitrous patients, seemed to prove that goitre was simply an infection. McCarrison now realises that when iodine deficiency is present an infection may act as the determining cause of goitre. Then Mellanby has shown that cod liver oil is the only fat which keeps the thyroid normal or nearly normal, which is an interesting scientific justification for what some clinicians had recently come to regard as the unnecessary punishment of growing children. Mellanby has found that if you feed puppies on flour and butter or any fat containing free oleic acid, the resulting hypertrophy of the thyroid is five times as great if you substitute cod liver oil for the butter. If you increase the butter still more the hypertrophy is 14 times as great, and in all cases the increase in the size of the gland is not a simple hypertrophy but an actual hyperplasia such as is met with in Graves’ disease. Cod liver oil contains iodine, but that is not the only factor, because if chopped fresh green stuffs are added to the diet of the puppies, there is much less hypertrophy, showing that vitamines are essential for normal thyroid activity. Cod liver contains more vitamine than butter and is probably less apt to cause a relative deficiency in iodine. The most interesting observation of all was that puppies which got plenty of fresh air and sunlight developed goitre to a much less extent than those which were confined. The great practical lesson which emerges from all this is that we must insist on better hygienic conditions for our children in the schools if we wish to rid the Dominion of the disfiguring and disabling goitres which are now so common. Further, we must encourage the use of an anti-goitrous dietary, which should contain iodine and be rich in vitamines. The article of diet that stands highest in these respects is spinach, and it has the advantage of being pleasant to eat if cooked in the French way, but not if boiled á la New Zealand in an excess of water. Moreover, it grows practically all year round, and its cultivation should be encouraged in school gardens along with salad plants because iodine is better taken in an organic form along with vitamines than swallowed from a medicine bottle.

I do not propose to discuss the pathology of the goitre further than to insist that pathology is chiefly of interest to clinicians when it is characterised by altered function. Thus an adenomatous thyroid may disorder function by mechanical pressure on the trachea or oesophagus producing dyspnoea or dysphagia, on the laryngeal nerves producing cough or dysphonia or by becoming toxic and thus leading to hyperthyroidism. But as a rule goitre does not mechanically cause gross change in function in the same way as an enlarged pituitary does.

Clinically, hyperthyroidism may be considered under three heads. The first is simple hyperthyroidism, which is undoubtedly very common, and this is not surprising when we remember that goitre is so common, and that dietary changes alone may cause not only increase in the size of the gland but actual hyperplasia with irregular acini and a change in the cells from cuboid to columar. It has been suggested to distinguish this group from Graves’ disease by the absence of eye symptoms, but von Graefe’s sign is not uncommon in the forms frustes or simple hyperthyroidism; or again by a pulse limit of 120 with an increased basal metabolic rate of 40 per cent. But I think if any hard and fast line must be drawn it should be at the commencement of definite myocardial change. When the heart begins to dilate the case is definitely one of Graves’ disease, and not of simple hyperthyroidism and I think Lewis is right in regarding percussion as a very fallacious method of determining cardiac dilatation. He relies on the orthodiagram, paying special attention to the A-B ratio, and it is the left ventricle, or B area, which first increases in Graves’ disease. Lewis has found, by checking his observations with the orthodiagram, that the point of maximal impulse at the apex is the most reliable guide to the border of the left ventricle. If the cardiac condition is untreated the case may go on to auricular fibrillation or paroxysmal tachycardia, with the development in either case of extreme myocardial degeneration, loss of reverse force, oedema, ascites, etc.

The general symptoms are unfortunately familiar to everyone, and I need not discuss the tremor, the exophthalmos and eye signs, the skin changes, leukoderma, vitiligo, etc., dry mouth, dank hands, palpitation, nausea, diarrhoea, loss of hair, pigmentation, dermographism, increased pilomotor reflex, polyuria, glycosuria and the increase in the gland itself which it is well to remember may be masked. In the nervous system there are no organic changes but the reflexes are brisk, the pupils dilated and, in fact, the response to all stimuli—physical, mental or aesthetic—is increased as in all sympatheticotonic people. There is always some mental change which may vary from mere irritability and loss of memory and concentration to the fully developed hyperemotive syndrome of Dupré, and in about 10 per cent. of cases there is a definite psychosis which may take the form of melancholia, fixed delusions, or even delirium, but the commonest condition is that of anxiety neurosis. The symptoms of anxiety neurosis are practically those of Graves’ disease with the addition of terrifying dreams, and this has led Stoddart, who used to be a sound alienist, to enunciate the extreme view that Graves’ disease is anxiety neurosis and nothing else. The extreme view on the other side is that of some physiologists, biochemists and laboratory workers, who hold that all goitres, including the exophthalmic form, are simply a deficiency disease and that the nervous symptoms are secondary manifestations of a lack of iodine. All extreme views are unsound. Emotional shock alone never causes Graves’ disease nor does want of iodine, but hypersecretion must be due in the first place to nervous influence. The via media is the safest course to pursue. Nervous strain causes Graves’ disease in people whose thyroids have become hyperplastic from iodine or other deficiency, and the symptoms may be relieved by treating the anxiety condition.

“J.R., a young married woman, was admitted to Dunedin Hospital for acute Graves’ disease. On being questioned she admitted frequent dreams, but would not describe them as they were so silly. On being pressed she said they were all about kissing, and that in her dreams she saw her husband kissing another woman. This worried her as she and her husband were very fond of each other and very happy. As her dreams dated from six months previously she was asked to carry her mind back to that period and try to remember if she had been jealous of her husband at that time. After a little she recollected having been jealous of a young girl, but, as she trusted her husband implicitly she deliberately drove the idea out of her mind, and that, of course, is the usual way in which the seeds of an anxiety neurosis are sown. When the cause of her disturbing dreams was explained to her she rapidly improved, and left the hospital in less than a week.”

Many such cases should be quoted illustrating the value of psycho-therapy in Graves’ disease, especially when anxiety symptoms are prominent. With regard to diagnosis, it is claimed by Crile and others that this can be determined only by finding an increased basal metabolism. But some of these workers have shown, in an analysis of several thousand cases, that the pulse rate increases pari passu with the basal metabolism while the weight varies inversely, so that the pulse chart and the weighing machine can safely be relied on to save the use of the apparatus and calculations required for working out the basal metabolism rate. Estimation of the urea N, and the ammonia and xanthin base N, may be used as a further check. For these reasons I do not think that the estimation of the basal metabolism is ever likely to become a popular clinical diversion. What is necessary is to exclude other causes of tachycardia such as gross lesions of the heart and lungs. Diabetes is the only other disease in which loss of weight is accompanied by increased appetite, and it is easily excluded. In exophthalmic goitre carbo-hydrate tolerance is lowered, the blood sugar is increased, and the kidney threshold for sugar is raised so that the mobilised sugar will not be lost, but one is likely to confuse the occasional glycosuria of Graves’ disease with true diabetes. In early tuberculosis there is usually diminished appetite and the basal metabolism is lowered. Cases of D.A.H. simulate exophthalmic goitre very closely, and present considerable difficulty. Every now and then one comes across cases of supposed Graves’ disease in which rest in bed does not reduce the tachycardia, and in such cases the exercise tolerance is usually found to be good. They are best treated by a short intensive course of digitalis (using a standardised preparation), and then putting the patient on to graduated exercises first in bed and then outside. You will often get improvement in this way showing that, whether hyperthyroidism is present or not, much of the tachycardia is due to D.A.H., and should be treated by physical jerks. Where neurasthenia is confused with exophthalmic goitre it is probably what Hurst calls hormone neurosis, i.e., a mixed case of neurasthenia and Graves’ disease.

For treatment all cases of definite Graves’ disease should be given prolonged rest in bed on light diet. Any anxiety element should be treated secundum artem. I usually give digitalis as recommended by Trousseau and Mott, not simply to slow the heart, but because digitalis, in stimulating the vagus, acts in a way as the physiologic antidote to an irritated sympathetic. I have never been able to fathom the reason for giving adrenalin in Graves’ disease, as it stimulates the sympathetic, but probably it acts as small doses of iodine often do, i.e., by lessening the symptoms and increasing the size of the goitre, on the principle I suppose of a hair of the dog that bit him. Thymus gland has a distinct action in diminishing the size of ordinary goitre. Arsenic is of undoubted value, especially if given with phosphoric acid, or it may be given as the iodide of arsenic. Bromides may be given, but should not be pushed too far, and the best preparation to use is hydrobromate of quinine. I have never seen much benefit result from the use of the vaunted serum preparations. The diet should be light and easily digestible, avoiding too much meat. Electrical treatment is of distinct benefit, and may be used in the form of galvanism by passing a current beginning at one milliamp, and not exceeding three milliamps, through the neck. The first case in which I tried this some 15 years ago gave marvellous results, but I must confess that this promise has not been fulfilled. Faradism may be used in the form of baths with good effect and a useful variant is to use tampons on the heart, the neck, the carotids and even on the eyes. Light massage is useful in treating restlessness.

And now we come to the vexed question—when to operate? I suppose all are agreed that a toxic adenoma when present should be dealt with surgically. By this is meant an adenomatous enlargement of the thyroid which has been present for some time and has suddenly taken on a toxic aciton, usually under the influence of stress or shock. But it is not always easy to say clinically what is an adenoma, and there is some danger of the phrase—toxic adenoma—becoming a sort of magic touchstone to excuse surgical rashness. In all cases where medical treatment has been fairly tried and failed or where relapse has soon occurred, recourse should be had to operation, with this proviso, in which I think all surgeons will concur, that it is not safe to operate on cases which are rapidly becoming worse, in which there is high blood pressure (especially high diastolic pressure) or in which serious involvement of the myocardium has already taken place. It may also be stated that manual workers need operation more than brain workers. Crile is quite frank in his statement of the case for surgery. He says that the indication for operation is the diagnosis of hyper-thyroidism. That, I think is a doctrine which is absolutely indefensible. I would as soon think of recommending excision of the ileum at the commencement of a typhoid fever. As there seems to be reasonable hope of preventing, or at least enormously diminishing, the incidence of goitre in the next generation, surely the present one may be allowed to work out its own salvation without resort to such an heroic measure. In suitable cases where the choice lies between prolonged and repeated periods of rest in bed and a speedy relief by safe operation, I think few people would hesitate, especially in view of the impatient temperament that usually accompanies the disease. But radiology offers a middle course. This treatment is not favoured by the surgeon, in fact it is roundly condemned by Crile, on account of the resulting fibrosis which renders a subsequent operation much more difficult. We must then enquire whether radiology is a safer process than surgery, and whether the end results are at least equally satisfactory. I have been using radiology much more often lately, and on the whole have had very good reason to be satisfied with the results. My cases are not numerous enough or of sufficiently long standing to justify the quotation of statistics, and so I prefer to give you those of Professor Murray of Manchester. But first let me quote two cases.

“G.R., 45, farmer. Unable to work for a year. Exophthalmos medium. Pulse 120. L.. ventricle ¾ inch outside nipple line. Came to town for operation, but decided to try treatment. After three applications of X-ray was able to resume full work on farm. Reported well three months later.”

“M.T., married woman, 31. Marked goitre and exophthalmos. Pulse 144. Heart one inch outside nipple line. Refused treatment and went to Naseby against advice (as these cases do badly in the rarified air of high inland country). Returned with orthopnoea, oedema, auricular fibrillation and increase dilatation. Went into nursing home for two weeks and had intensive course of digitalis. Has since had two applications of X-ray and is now (six weeks later) walking about feeling quite well.”

Murray finds that under rest and medicinal treatment about 25 per cent. of cases are fatal, the same number recover and the other 50 per cent. improve more or less. Of 100 cases treated by X-ray all are living, and 76 recovered completely or regained good functional activity suitable for ordinary life. Myxoedema occurred in only one case, so that too much has been made of that bogey, and moreover it sometimes follows exophthalmic goitre without the intervention of X-rays. In the matter of dosage Murray is almost surgical. He gives two full doses in the first week, continues with weekly doses for some time, and extends his treatment to as many as 100 doses. Probably it is safer to rely on three-weekly doses for three or four sittings but Murray does not mention any cases of burning in his 100 cases. Radium is also used, but statistics are not given. It is undoubtedly true that operation often gives a rapid cure and thus saves serious damage to the myocardium, but we must not forget that a number of cases, varying from two per cent. upwards according to the climate, make note a rapid cure but a rapid exit. Some cases are on record of aggravation and death after X-ray treatment, but apparently Murray had none. I asked to see one such case just before he died, but he had auricular fibrillation and had had no preliminary medical treatment. It is claimed that it is difficult to dose the X-rays so as to avoid over-treatment, but the same thing applies to surgery, where it is difficult to decide exactly how much gland to remove in each case. Murray quotes on case which still had marked symptoms ten years after two partial thyroidectomies had been performed, and the symptoms subsided under X-rays. Moreover, symptoms do recur after operation just as after medicinal treatment. I believe that our hopes for the future lie in prevention and in early treatment by X-rays.

‍

NZMJ, 1923

(Delivered before the Wellington Division, British Medical Association, on 1st June.)

The great weakness of modern medicine is that everyone is so busily occupied in acquiring new facts, recording observations, trying out new methods and developing new theories that one often forgets to think. This is further conduced to by the bewildering multiplicity of modern developments in the many sciences which are now the handmaidens of medicine. We are so preoccupied in studying the charms of these ladies that we are apt to forget that one function of the priest is to withdraw into the temple at times and indulge in meditation. Sir William Gairdner wrote a delightful essay some 50 years ago in which he asked in all seriousness whether medicine had made any advance at all since the days of Hippocrates, and he answered the question in the negative. One of the most brilliant researches made in recent times is the work of Marine and Kemball showing that endemic goitre can be prevented in school children by giving iodine, but Hippocrates had anticipated this, because he gave the ash of seaweed, which is rich in iodine, in order to reduce the goitrous neck. His knowledge was probably derived in turn from the Vedic physicians who practised on the tablelands of Asia 1000 years before Hippocrates. The great Greek physician also recommended in cases of consumption that the patient should drive a cow up to the hilltops and live there, drinking the milk of the cow. Up till quite recently we had made no advance on this treatment. Some 30 years ago a small band of Russian scientists went to Thibet to find out if there was anything in the fabled wisdom of the East. They had to study laboriously for years before they gained admission to the monasteries, and what they learnt there interested them so much that they stayed 30 years, and during that time attracted 25 more of their countrymen to study with them. The two leaders have now returned to Europe, and have set up a school of philosophy in the forest of Fontainebleau. They say that in three subjects of study the East is far ahead of the West. These subjects are :—First, Psychology (and when you think how puny are the efforts of even our best psychologists in elucidating the working of the human mind, that is not surprising). The second is Music, and they say that Mozart was a child in rhythm and harmony compared to the Yogis. The third subject is Medicine, and that is a staggering statement. How can the priests in a Thibetan monastery have greater knowledge than the awe-inspiring masters of European medicine? Well, Gurdieff explains it in this way. He doesn’t say that they can cure an ordinary cold by means of a vaccine for ₤20, or that they can remove a healthy appendix for double that sum, but he says that we know that the pneumococcus and other germs, which we all harbour as domestic pets, occasionally turn and rend us by causing pneumonia. We do not know why, but the Yogi does. We know that out of 100 hyperplastic thyroids a few only will cause Graves’ disease, and the Yogi can tell us why. And these statements are made, not by gullible ignoramuses, but by a band of men who knew everything that Western science could teach before they went to study in far Cathay.

I am sorry that I cannot expound this Forest Philosophy. All that I propose to do to-night is to try to take stock of our knowledge of exophthalmic goitre, and it is an inviting subject of study because it appeals alike to the pathologist, the biochemist, the epidemiologist, the radiologist, and, further, it furnishes one more jousting-place where the surgeon and the physician in turn throw down the glove to each other.

The function of the thyroid is to control the metabolism of the body and to mobilise its resources for any emergency, and it seems clearly established that it cannot do these things without a sufficient supply of iodine, which it utilises in the form of thyroxin or organic iodine. Marine and Kemball have proved beyond the cavil that the development of goitre in school children can be prevented by the exhibition of iodine. They give it as iodine of sodium, grs. 30, twice a year, or it can be given merely by hanging up a wide-mouthed jar containing tincture of iodine in the classroom. The thyroid does not need a great deal of iodine as one hundredweight of fresh gland yields only 7 grains of thyroxin, nor is it expended rapidly. Now let me outline briefly our present knowledge of the thyroid. We know that all goitres occur more frequently in women than in men in the proportion of about 4 to 1. In women the thyroid increases in size at puberty, during menstruation, at marriage, during pregnancy and lactation and at the menopause. That is to say all conditions which make an extra demand on the sexual and nervous apparatus of women result in over-activity of the thyroid gland, and, as the sexual changes are much more important in women, it is easy to see why they should be more liable to goitre. We know, further, that the function of the thyroid is stimulated by infective conditions, especially by syphilis, by diseased teeth and tonsils, and by alimentary toxæmia, and also by all emotional shock or nervous strain. We know that a goitrous mother is apt to bear children who are goitrous or who later become either myxoedematous or Basedowian. Above all, we know that pure dysthyroidism is not the usual condition, but that other glands such as the adrenals, the pituitary or the gonads share the disordered function of the thyroid. Quite recently a new light has been shed on our knowledge of thyroid disorders by the investigations of McCollum, McCarrison and the Mellanbies. Let me summarise what has been elicited by these workers. First there is the confirmation of the observation that feeding iodine diminishes goitre, and prevents the formation of it. This does not prove that goitre is due solely to a deficiency of iodine. There are many things that will make a jibbing motor-car go smoothly besides filling the petrol tank, but still I think it is extremely likely that iodine is the motor spirit of the thyroid gland, calcium is the lubricating oil, and the vitamines are the sparking plugs. We should remember that it is only a few years since the experiments of McCarrison, in feeding goats on the fæces of goitrous patients, seemed to prove that goitre was simply an infection. McCarrison now realises that when iodine deficiency is present an infection may act as the determining cause of goitre. Then Mellanby has shown that cod liver oil is the only fat which keeps the thyroid normal or nearly normal, which is an interesting scientific justification for what some clinicians had recently come to regard as the unnecessary punishment of growing children. Mellanby has found that if you feed puppies on flour and butter or any fat containing free oleic acid, the resulting hypertrophy of the thyroid is five times as great if you substitute cod liver oil for the butter. If you increase the butter still more the hypertrophy is 14 times as great, and in all cases the increase in the size of the gland is not a simple hypertrophy but an actual hyperplasia such as is met with in Graves’ disease. Cod liver oil contains iodine, but that is not the only factor, because if chopped fresh green stuffs are added to the diet of the puppies, there is much less hypertrophy, showing that vitamines are essential for normal thyroid activity. Cod liver contains more vitamine than butter and is probably less apt to cause a relative deficiency in iodine. The most interesting observation of all was that puppies which got plenty of fresh air and sunlight developed goitre to a much less extent than those which were confined. The great practical lesson which emerges from all this is that we must insist on better hygienic conditions for our children in the schools if we wish to rid the Dominion of the disfiguring and disabling goitres which are now so common. Further, we must encourage the use of an anti-goitrous dietary, which should contain iodine and be rich in vitamines. The article of diet that stands highest in these respects is spinach, and it has the advantage of being pleasant to eat if cooked in the French way, but not if boiled á la New Zealand in an excess of water. Moreover, it grows practically all year round, and its cultivation should be encouraged in school gardens along with salad plants because iodine is better taken in an organic form along with vitamines than swallowed from a medicine bottle.

I do not propose to discuss the pathology of the goitre further than to insist that pathology is chiefly of interest to clinicians when it is characterised by altered function. Thus an adenomatous thyroid may disorder function by mechanical pressure on the trachea or oesophagus producing dyspnoea or dysphagia, on the laryngeal nerves producing cough or dysphonia or by becoming toxic and thus leading to hyperthyroidism. But as a rule goitre does not mechanically cause gross change in function in the same way as an enlarged pituitary does.

Clinically, hyperthyroidism may be considered under three heads. The first is simple hyperthyroidism, which is undoubtedly very common, and this is not surprising when we remember that goitre is so common, and that dietary changes alone may cause not only increase in the size of the gland but actual hyperplasia with irregular acini and a change in the cells from cuboid to columar. It has been suggested to distinguish this group from Graves’ disease by the absence of eye symptoms, but von Graefe’s sign is not uncommon in the forms frustes or simple hyperthyroidism; or again by a pulse limit of 120 with an increased basal metabolic rate of 40 per cent. But I think if any hard and fast line must be drawn it should be at the commencement of definite myocardial change. When the heart begins to dilate the case is definitely one of Graves’ disease, and not of simple hyperthyroidism and I think Lewis is right in regarding percussion as a very fallacious method of determining cardiac dilatation. He relies on the orthodiagram, paying special attention to the A-B ratio, and it is the left ventricle, or B area, which first increases in Graves’ disease. Lewis has found, by checking his observations with the orthodiagram, that the point of maximal impulse at the apex is the most reliable guide to the border of the left ventricle. If the cardiac condition is untreated the case may go on to auricular fibrillation or paroxysmal tachycardia, with the development in either case of extreme myocardial degeneration, loss of reverse force, oedema, ascites, etc.

The general symptoms are unfortunately familiar to everyone, and I need not discuss the tremor, the exophthalmos and eye signs, the skin changes, leukoderma, vitiligo, etc., dry mouth, dank hands, palpitation, nausea, diarrhoea, loss of hair, pigmentation, dermographism, increased pilomotor reflex, polyuria, glycosuria and the increase in the gland itself which it is well to remember may be masked. In the nervous system there are no organic changes but the reflexes are brisk, the pupils dilated and, in fact, the response to all stimuli—physical, mental or aesthetic—is increased as in all sympatheticotonic people. There is always some mental change which may vary from mere irritability and loss of memory and concentration to the fully developed hyperemotive syndrome of Dupré, and in about 10 per cent. of cases there is a definite psychosis which may take the form of melancholia, fixed delusions, or even delirium, but the commonest condition is that of anxiety neurosis. The symptoms of anxiety neurosis are practically those of Graves’ disease with the addition of terrifying dreams, and this has led Stoddart, who used to be a sound alienist, to enunciate the extreme view that Graves’ disease is anxiety neurosis and nothing else. The extreme view on the other side is that of some physiologists, biochemists and laboratory workers, who hold that all goitres, including the exophthalmic form, are simply a deficiency disease and that the nervous symptoms are secondary manifestations of a lack of iodine. All extreme views are unsound. Emotional shock alone never causes Graves’ disease nor does want of iodine, but hypersecretion must be due in the first place to nervous influence. The via media is the safest course to pursue. Nervous strain causes Graves’ disease in people whose thyroids have become hyperplastic from iodine or other deficiency, and the symptoms may be relieved by treating the anxiety condition.

“J.R., a young married woman, was admitted to Dunedin Hospital for acute Graves’ disease. On being questioned she admitted frequent dreams, but would not describe them as they were so silly. On being pressed she said they were all about kissing, and that in her dreams she saw her husband kissing another woman. This worried her as she and her husband were very fond of each other and very happy. As her dreams dated from six months previously she was asked to carry her mind back to that period and try to remember if she had been jealous of her husband at that time. After a little she recollected having been jealous of a young girl, but, as she trusted her husband implicitly she deliberately drove the idea out of her mind, and that, of course, is the usual way in which the seeds of an anxiety neurosis are sown. When the cause of her disturbing dreams was explained to her she rapidly improved, and left the hospital in less than a week.”

Many such cases should be quoted illustrating the value of psycho-therapy in Graves’ disease, especially when anxiety symptoms are prominent. With regard to diagnosis, it is claimed by Crile and others that this can be determined only by finding an increased basal metabolism. But some of these workers have shown, in an analysis of several thousand cases, that the pulse rate increases pari passu with the basal metabolism while the weight varies inversely, so that the pulse chart and the weighing machine can safely be relied on to save the use of the apparatus and calculations required for working out the basal metabolism rate. Estimation of the urea N, and the ammonia and xanthin base N, may be used as a further check. For these reasons I do not think that the estimation of the basal metabolism is ever likely to become a popular clinical diversion. What is necessary is to exclude other causes of tachycardia such as gross lesions of the heart and lungs. Diabetes is the only other disease in which loss of weight is accompanied by increased appetite, and it is easily excluded. In exophthalmic goitre carbo-hydrate tolerance is lowered, the blood sugar is increased, and the kidney threshold for sugar is raised so that the mobilised sugar will not be lost, but one is likely to confuse the occasional glycosuria of Graves’ disease with true diabetes. In early tuberculosis there is usually diminished appetite and the basal metabolism is lowered. Cases of D.A.H. simulate exophthalmic goitre very closely, and present considerable difficulty. Every now and then one comes across cases of supposed Graves’ disease in which rest in bed does not reduce the tachycardia, and in such cases the exercise tolerance is usually found to be good. They are best treated by a short intensive course of digitalis (using a standardised preparation), and then putting the patient on to graduated exercises first in bed and then outside. You will often get improvement in this way showing that, whether hyperthyroidism is present or not, much of the tachycardia is due to D.A.H., and should be treated by physical jerks. Where neurasthenia is confused with exophthalmic goitre it is probably what Hurst calls hormone neurosis, i.e., a mixed case of neurasthenia and Graves’ disease.

For treatment all cases of definite Graves’ disease should be given prolonged rest in bed on light diet. Any anxiety element should be treated secundum artem. I usually give digitalis as recommended by Trousseau and Mott, not simply to slow the heart, but because digitalis, in stimulating the vagus, acts in a way as the physiologic antidote to an irritated sympathetic. I have never been able to fathom the reason for giving adrenalin in Graves’ disease, as it stimulates the sympathetic, but probably it acts as small doses of iodine often do, i.e., by lessening the symptoms and increasing the size of the goitre, on the principle I suppose of a hair of the dog that bit him. Thymus gland has a distinct action in diminishing the size of ordinary goitre. Arsenic is of undoubted value, especially if given with phosphoric acid, or it may be given as the iodide of arsenic. Bromides may be given, but should not be pushed too far, and the best preparation to use is hydrobromate of quinine. I have never seen much benefit result from the use of the vaunted serum preparations. The diet should be light and easily digestible, avoiding too much meat. Electrical treatment is of distinct benefit, and may be used in the form of galvanism by passing a current beginning at one milliamp, and not exceeding three milliamps, through the neck. The first case in which I tried this some 15 years ago gave marvellous results, but I must confess that this promise has not been fulfilled. Faradism may be used in the form of baths with good effect and a useful variant is to use tampons on the heart, the neck, the carotids and even on the eyes. Light massage is useful in treating restlessness.

And now we come to the vexed question—when to operate? I suppose all are agreed that a toxic adenoma when present should be dealt with surgically. By this is meant an adenomatous enlargement of the thyroid which has been present for some time and has suddenly taken on a toxic aciton, usually under the influence of stress or shock. But it is not always easy to say clinically what is an adenoma, and there is some danger of the phrase—toxic adenoma—becoming a sort of magic touchstone to excuse surgical rashness. In all cases where medical treatment has been fairly tried and failed or where relapse has soon occurred, recourse should be had to operation, with this proviso, in which I think all surgeons will concur, that it is not safe to operate on cases which are rapidly becoming worse, in which there is high blood pressure (especially high diastolic pressure) or in which serious involvement of the myocardium has already taken place. It may also be stated that manual workers need operation more than brain workers. Crile is quite frank in his statement of the case for surgery. He says that the indication for operation is the diagnosis of hyper-thyroidism. That, I think is a doctrine which is absolutely indefensible. I would as soon think of recommending excision of the ileum at the commencement of a typhoid fever. As there seems to be reasonable hope of preventing, or at least enormously diminishing, the incidence of goitre in the next generation, surely the present one may be allowed to work out its own salvation without resort to such an heroic measure. In suitable cases where the choice lies between prolonged and repeated periods of rest in bed and a speedy relief by safe operation, I think few people would hesitate, especially in view of the impatient temperament that usually accompanies the disease. But radiology offers a middle course. This treatment is not favoured by the surgeon, in fact it is roundly condemned by Crile, on account of the resulting fibrosis which renders a subsequent operation much more difficult. We must then enquire whether radiology is a safer process than surgery, and whether the end results are at least equally satisfactory. I have been using radiology much more often lately, and on the whole have had very good reason to be satisfied with the results. My cases are not numerous enough or of sufficiently long standing to justify the quotation of statistics, and so I prefer to give you those of Professor Murray of Manchester. But first let me quote two cases.

“G.R., 45, farmer. Unable to work for a year. Exophthalmos medium. Pulse 120. L.. ventricle ¾ inch outside nipple line. Came to town for operation, but decided to try treatment. After three applications of X-ray was able to resume full work on farm. Reported well three months later.”

“M.T., married woman, 31. Marked goitre and exophthalmos. Pulse 144. Heart one inch outside nipple line. Refused treatment and went to Naseby against advice (as these cases do badly in the rarified air of high inland country). Returned with orthopnoea, oedema, auricular fibrillation and increase dilatation. Went into nursing home for two weeks and had intensive course of digitalis. Has since had two applications of X-ray and is now (six weeks later) walking about feeling quite well.”

Murray finds that under rest and medicinal treatment about 25 per cent. of cases are fatal, the same number recover and the other 50 per cent. improve more or less. Of 100 cases treated by X-ray all are living, and 76 recovered completely or regained good functional activity suitable for ordinary life. Myxoedema occurred in only one case, so that too much has been made of that bogey, and moreover it sometimes follows exophthalmic goitre without the intervention of X-rays. In the matter of dosage Murray is almost surgical. He gives two full doses in the first week, continues with weekly doses for some time, and extends his treatment to as many as 100 doses. Probably it is safer to rely on three-weekly doses for three or four sittings but Murray does not mention any cases of burning in his 100 cases. Radium is also used, but statistics are not given. It is undoubtedly true that operation often gives a rapid cure and thus saves serious damage to the myocardium, but we must not forget that a number of cases, varying from two per cent. upwards according to the climate, make note a rapid cure but a rapid exit. Some cases are on record of aggravation and death after X-ray treatment, but apparently Murray had none. I asked to see one such case just before he died, but he had auricular fibrillation and had had no preliminary medical treatment. It is claimed that it is difficult to dose the X-rays so as to avoid over-treatment, but the same thing applies to surgery, where it is difficult to decide exactly how much gland to remove in each case. Murray quotes on case which still had marked symptoms ten years after two partial thyroidectomies had been performed, and the symptoms subsided under X-rays. Moreover, symptoms do recur after operation just as after medicinal treatment. I believe that our hopes for the future lie in prevention and in early treatment by X-rays.

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