The Medical Treatment of Simple and Exophthalmic Goitre.

NZMJ, 1926

A paper read before the Annual Conference by

F. V. Bevan-Brown, M.D., M.R.C.P.

[Continued from 28 August 2026, 139(1641)]

The facts that women are far more susceptible to the disease than men, that they commonly develop it during their years of greatest sexual activity, and that X-rays amd radium directed to the ovaries afford relief in some cases, are all in keeping with the view of sympathetic stimulation, and with our present-day knowledge of the physiology of the sympathetic nervous sytem. Those people who regard Grave’s disease as primarily a disorder of the thyroid gland, and its symptoms as entirely due to hyperthyroidism, have a strong argument in the fact that thyroidectomy affords relief of symptoms in many cases. It is of course true that hyperthyroidism plays a conspicuous part in the clinical picture, but not the only part or the primary part, and we shall not get very far if this fact is lost sight of. Grave’s disease cannot be reproduced by excessive thyroid feeding, and one has the interesting fact, that I shall refer to again, that Kessell and Hyman, of New York, actually treated cases of Grave’s disease in acute crisis with thyroxin (the active principle of the thyroid gland isolated by Kendall), given intravenously, and their results were encouraging and suggestive. Their view that the thyroid gland is in a state of exhaustion is supported by chemical and histological evidence. Further, we have the fact that cases of Grave’s disease pass on imperceptibly into myxœdema, and symptoms of both conditions may be present in the same patient. We have the further fact to reconcile that the administration of iodine in small doses to true cases of Grave’s disease results in definite amerlioration of symptoms. The explanation of this may be in the fact that the thyroxin molecule, incompletely saturated with iodine, acts upon the tissues as a toxin. Another explanation may be that pathological organisms with a strong iodine affinity, occur in the small or large intestine, and administration of iodine acts in two ways—(1) By neutralising their toxic effect ; and (2) by sparing for the thyroid the body iodine that it is starved of by reason of the presence of such micro-organisms. Possibly, on the other hand, the success of thyroidectomy is accounted for by the fact that an over-secreting thyroid places heavy demands upon the tissues of the body for iodine. Removal of the gland spares the iodine, which is essential for the protection of the tissues in the presence of alimentary toxins, or of the micro-organisms from which they arise. This latter explanation I have not seen suggested, but it seems to me to be the only reasonable way in whic to maintain the view of toxic stimulation as a primary cause of the disease in face of the fact that cases get well with thyroidectomy alone, and without any attempt being made to eliminate the septic focus. One also assumes, and it is a reasonable assumption, that psychic traumata cannot precipitate Grave’s disease in the absence of a toxic factor. How frequently are we subject to shock, fright, fatigue and anxiety, and how rarely by comparison does Grave’s disease occur. In formulating or rather presenting these views, one is conscious all the time of weakness and difficulties as, for instance, the well-known fact of hereditary and constitutional predisposition. It is a highly complicated and very attractive problem, and I must confine myself only to this brief outline of the experimental and clinical evidence of the pathogenesis of the disease. A point of importance to remember is that the thyroid is not the only gland in Grave’s disease to be stimulated to hyperactivity. There is generalised increase of lymphatic tissue, including the thymus—the spleen may be enlarged and the liver show lymphatic deposits. The blood frequently shows an absolute leucocytosis and a relative lymphocytosis. Some observers hold that enlarged thymus is chiefly responsible for the dyspnœa and palpitation, but this view is not generally accepted. What part the other endocrine glands pay in Grave’s disease is still a matter for investigation. Finally, one must avoid dogmatism and assurance in regard to this disease, for we are still very much in the dark, and this fact is sadly emphasised when we learn from the most recent work of pathologists that there is no consistent microscopial appearance in thyroid glands from Grave’s disease, though hyperplasia is commonly present, and they tell us that it is impossible on examination of stained section to say in many cases to what class of goitre the particular gland belongs.