EXOPHTHALMIC GOITRE. 275 



diminish. In some patients there may be cough, oppression, and 

 anxiety; in others the skin is warm, dry, and affected with obstinate 

 pruritus ; abscesses may develop in the subcutaneous connective tissue 

 in different regions. Other troubles of cerebro-medullar origin may 

 also be present : at first there is insomnia, in consequence of over- 

 excitement of the brain ; at a later stage there may be change in 

 character and unusual irritability or depression. Polyuria, albuminuria, 

 and glycosuria are frequent. 



Basedow's disease is not invariably characterised by all the appear- 

 ances I have just mentioned. In some instances even the triad of S)'m- 

 ptoms which are usually so suggestive fail to appear. In the obscure forms 

 enlargement of the thyroid and prominence of the globes of the eyes 

 are little pronounced, or absent ; in one variety goitre is little marked, 

 and abnormal projection of the eyes altogether wanting ; in another 

 there is marked hypertrophy of the thyroids, and exophthalmia is 

 scarcely noticeable ; in others again only tachycardia and trembling 

 movements are seen. Cardiac disturbance is constant ; it constitutes 

 the first and predominant symptom of the disease. 



In by far the greatest number of cases exophthalmic goitre is a 

 chronic affection. Its development is slow, interrupted by paroxysms 

 in which palpitation and hypertrophy of the thyroid are particularly 

 well marked. At the very outset development may be acute ; the 

 disease may appear suddenly, and almost immediately be accompanied 

 by palpitation, hypertrophy of the thyroid, and exophthalmia ; but its 

 after progress is slow. Rapidly progressive cases are rare. 



After continuing for a period varying between a few months and 

 ten, twelve, or fifteen years, the disease may terminate in recovery, or 

 prove fatal. Death sometimes results from cerebral haemorrhage, 

 sometimes from exhaustion, usually preceded by intractable diarrhoea, 

 or from intercurrent infectious disease. 



The post-Jiwrteni examination of persons who have died of exoph- 

 thalmic goitre does not always show lesions in the more important 

 organs sufficiently explaining death. The heart is normal, dilated, 

 or hypertrophied ; in the last case hypertrophy may either be total, 

 or limited to the left ventricle. The valves are normal or thickened ; 

 sometimes the calibre of the carotids is increased. 



The thyroid arteries are dilated and sinuous. The thyroid gland 

 is enveloped in a layer of connective tissue, penetrated in all directions 

 by large venous channels ; its tissue varies in consistence and colour, 

 but is usually of a deep tint, very vascular, and in exceptional cases 

 fibrous or sclerosed. 



