EXOPHTHALMIC GOITER AND THE ADRENALS. 159 



though the effect of temperature 18 upon the patient might be 

 found to be of use, it being his present impression that those 

 who were unduly susceptible to cold would do well, and those 

 who were unduly susceptible to heat would do badly, under treat- 

 ment with thyroid preparations." 



If during the stage of overactivity the central vascular 

 trunks are contracted and the peripheral capillaries are over- 

 filled and dilated, we can readily understand why the patient 

 is "unduly susceptible to heat" and why thyroid preparations, 

 by adding to the stimulation, accentuate the symptoms. A case 

 reported by H. L. Winter 19 will serve to illustrate this fact. 

 The patient, a woman aged 32 years, had a pulse of 160, with 

 marked tremor and flushings, and was extremely irritable; the 

 goiter was firm and pulsating and the exophthalmos marked. 

 She was given thyroid extract, 5 grains daily; all the symp- 

 toms were exaggerated and she complained of severe frontal 

 headache. The thyroid extract was discontinued, and tincture 

 of digitalis, with a saline purgative, given; the next day there 

 was marked relief. Ten days later thyroid extract was again 

 exhibited, 2 Y 2 grains daily. All the symptoms steadily grew 

 worse; and at the end of two weeks the attacks of tachycardia 

 were so violent on attempting to sit or stand that she had to 

 keep to her bed, her pulse being 160. The extract was then 

 discontinued and a temporary improvement followed under 

 other methods of treatment. 



The opposite result may be expected when the patient is 

 "unduly susceptible to cold," because his central vascular 

 trunks are dilated and his superficial capillaries contracted as 

 the result of suprarenal insufficiency the characteristic of 

 advanced cases. In exophthalmic goiter, the "advanced stage" 

 means more, however, than it does in the average disease. The 

 first stage being due to overactivity of the thyroid, as soon 

 as the insufficiency of the adrenals appears, oxidation becomes 

 less active, and the thyroid, with all other organs, correspond- 

 ingly so. The main source of trouble thus gradually disappears 

 and is replaced by another form of toxamia, one resulting from 



18 All italics are our own. 



19 H. L. Winter: American Medico-Surgical Bulletin, July 11, 1896. 



