Dangers of Rigid Diet.—There are more dangers in a rigid diet than in a certain amount of liberty in the consumption of starches and sugars. The craving for these becomes so strong as to make life intolerable to many people unless a certain amount of these substances is allowed. It is rather easy to manage limitation while it is almost impossible to be sure that [{500}] patients will practice absolute denial. Besides, the almost complete absence of starches and sugars, even though their place is supplied by the fats, always seems to predispose patients to the development of the acid intoxication which results in the coma often so serious an incident of diabetes. It is for this reason particularly that mild diet regulations are clinically more judicious than the absolute denial which on chemical and physiological grounds seems to be the scientific ideal. A rather good therapeutic method is to have the patients maintain a rigid diet for some ten, fifteen or twenty days and then leave them practically without restrictions for the rest of the month. Continuous restriction of diet becomes appalling. Looking forward to a period when they can eat as other people do relieves the tedium, and makes it much easier to keep the restrictions. The mental influence of this moderate treatment is very favorable and encourages the patients in the thought that after all their disease is not so serious. This is the most important element in psychotherapy.
CHAPTER II
GRAVES' DISEASE
Graves' disease, sometimes called Basedow's disease, though the Irish physician has a right to the name by priority, is often called exophthalmic goitre, because this term is descriptive of the two most marked symptoms. It must not be forgotten, however, that there are cases in which there is no exophthalmos and even no goitre, at least no enlargement of the thyroid gland that can be demonstrated externally. It is said that in these cases there must be an enlargement of the thyroid bound down by fascia and concealed by other structures of the neck so that it does not appear externally. It is probable, however, that there are cases of true Graves' disease without enlargement of the thyroid yet with the characteristic tremor, rapid heart and the mental symptoms of the affection.
Etiology.—The symptoms of the affection often develop after a period of excitement or worry, or at critical times in life, if sorrow or misfortune proves a burden. Responsibility sometimes has a like effect. I have seen a woman patient on several occasions in the last fifteen years develop marked symptoms of Graves' disease when she was placed in a position of responsibility involving worry, while in the intervals when pursuing a simple ordinary life without trouble of mind no symptoms were present. Occasionally a fright seems to be at least a predisposing cause for the development of the symptoms. Emotional strains, mental stresses, play a large part in occasioning Graves' disease, though the cause of it is probably deeper in some structural defect. In recent years nearly all the medical attention has become concentrated on the idea that the disease is primarily due to hyperthyroidization. More detailed study, however, has shown that other ductless glands are probably also concerned in the etiology. The adrenals particularly seem to be associated closely with the thyroid and Graves' disease may be due to some disturbance of the co-ordination between these glandular systems. The thymus gland is usually [{501}] persistent in these cases and this must represent something in the affection and at one time the use of thymus substance for therapeutic purposes seemed to confirm this idea. The parathyroids have also been called into question and their use in therapeusis seems to justify this to some extent, though probably we know too little about them to be able to say anything definite in the matter.
Even though the affection may be due directly to hypersecretion of the thyroid, it is possible that the mental and nervous state may be closely concerned in the etiology. Some patients have had an enlarged thyroid for years, without any symptoms of Graves' disease. Then during a time of stress and worry or anxiety and responsibility symptoms of the affection develop. The circulation of the thyroid is under the control of the cervical sympathetic. It is possible that this may be affected by states of mind to such an extent as to cause an increase of the circulation in the thyroid and as a consequence more of the thyroid secretion may get into the blood stream and produce its effect. Under these circumstances anything that would allay the excited mental condition and thus neutralize the unfavorable effect of the cervical sympathetic would cure or at least relieve Graves' disease.
The affection is about five times as frequent among women as it is among men. This has sometimes been attributed to the fact that there seems to be some more or less direct correlation between the sex organs in women and the ductless gland systems. It has often been pointed out that the thyroid is likely to be engorged at the time of menstruation and, indeed, there are those who have attributed some of the symptoms of tremulousness, irritability, and tiredness at this time to over-functioning of the gland. In women who have borne a child the thyroid is usually somewhat enlarged. Good authorities in obstetrics have insisted that they could pick out of a group of women in evening dress, those who had borne children, from the appearance of their necks. Probably this is an exaggeration, but there is no doubt that the thyroid is intimately related to the genital functions in women. It has been said that a direct connection could be traced between disappointments in love or in sexual matters and the development of Graves' disease. To put much stress on this would easily lead to mistaken conclusions, though it represents a principle that should be recalled in certain cases of the affection. The frequency with which slighter disturbances of the thyroid occur in connection with the common genital incidents of female life and their comparative insignificance for health or strength, should make for the holding of a not too serious prognosis in the affection.
Symptomatology.—There are four cardinal symptoms of the disease: rapid heart action, tremor, enlargement of the thyroid, and exophthalmos. At least two of these are largely dependent on mental influences. There are certain accompanying symptoms that are of importance and supposed to be connected directly with the disease, though oftener they can be traced to the influence of the state of the patient's mind upon the organism. Emaciation is common. It is due to the fact that the appetite is likely to be seriously disturbed by anxiety and solicitude. Anemia develops as a consequence and there may be slight fever which is sometimes inanition fever. Attacks of vomiting and diarrhea occur intermittently and sometimes there is constipation. The disturbance of eating consequent upon the affections seems largely [{502}] responsible for these. The disturbance of the vascular system gives rise to flashes of heat and cold and often to profuse perspiration. Certain of the symptoms of the menopause can be compared rather strikingly with those of Graves' disease and have been attributed to the disturbance of the external secretion of the ovaries which are now known to act as ductless glands as well as genital organs.
With the exception of the enlargement of the thyroid and the exophthalmos, all of the symptoms of Graves' disease are of a kind that can be produced in states of excitement with nothing more present than a functional neurotic condition. It is true that the tremor is characteristic and differs from that of hysterical patients, being finer and at the rate of a little more than eight to the second. The rapid heart action, however, and the disturbance of the general circulation which causes flushing and pruritus and the sense of nervousness, as if the patients were in a constant state of fright, are always characteristically neurotic. The changes in disposition, often in the line of irritability, sometimes with severe mental depression, seem in many cases to be only a mental reaction to the patient's solicitude. The weakness of the limbs which sometimes amounts to a giving away of the legs, is connected with the tremor, but seems to be neurotic rather than of any more serious character. In spite of all our study of the affection its place among the neuroses must still be reserved for it, at least as regards many cases, and its treatment must be conducted with that idea in mind.
Diagnosis.—The disease is easy to recognize when fully developed. At the beginning of cases, however, and in certain abortive types of the affection which the French have called formes frustes, the diagnosis may be difficult. Usually the first symptom is tremor and this of itself will often serve, especially in association with general symptoms of nervousness, to make the diagnosis. Tremor with tachycardia puts the case beyond doubt, as a rule, though of course it must not be forgotten that hysteria may simulate rather closely this much of the disease.
The abortive types of the affection are important because they masquerade as forms of psychoneurosis, hysteria, and the like, though the patients are not suggestible, have very definite, not variable, symptoms and get better and worse according to the variations in the underlying affection. Occasionally they seem to be associated with certain other forms of neurotic conditions, especially those with vascular disturbances. There may be tinglings in the ends of the fingers, occasionally with suffusion, erythromelalgia—Weir Mitchell's disease—and even a tendency to the white "dead fingers" as the French call them, of Raynaud's disease. It seems not unlikely that further study will show that many of these affections involving disturbances of the vasomotor system are connected in some special way.