312 C. P. HOWAED 



which presides over the vasomotor nerves of the thyroid gland and of the 

 intraorbita*! tissues; he infers from the very great constancy with which 

 the two symptoms of goiter and exophthalmos are found combined, that 

 the portions in question must be situated exceedingly close together. 

 This central or medulla oblongata theory was strengthened by the experi- 

 mental work of Filehne, who noted after injury to the restiform body in a 

 rabbit, symptoms suggestive of exophthalmic goiter ; namely, tachycardia, 

 goiter and exophthalmos. Moreover, according to von Leube, an affection 

 of the medulla oblongata as the original cause of Graves' disease is favored 

 by the clinical experience of the nuclear paralyses which have been posi- 

 tively demonstrated in the course of the disease, of the spasms, the pa- 

 ralyses and atrophies of the musculature, the melituria, etc. In one of 

 von Leube's cases of "exquisite Graves' disease," there existed besides 

 spasms, in all four extremities, slight disturbance of the hypoglossal 

 nerve and dysphagia. However, all must admit that the autopsies per- 

 formed on the bodies of patients succumbing to Graves' disease have 

 given, as yet, very few positive findings regarding anatomically demon- 

 strable changes of the medulla oblongata, while the absence of symptoms 

 of Graves' disease in various affections of the medulla is the rule. If, 

 therefore, we are not satisfied with the assumption of a functional bulbar 

 disturbance, in the conception of a neurosis similar to chorea and epilepsy, 

 we must admit that the theory of the medulla being the causative factor 

 is by no means satisfactory. 



Marie (a) points out the fact that Filehne's rabbits do not show Graves' 

 disease any more than the experimental production of glycosuria by 

 puncture of the floor of the fourth ventricle is to be considered true dia- 

 betes mellitus. Further, these central findings in the medulla, etc., are 

 not constant and are no longer considered as of importance. For want 

 of a better theory Marie and the French school considered exophthalmic 

 goiter as a general neurosis, and held that while paroxysmal diarrhea, 

 the bulimia, the vomiting, anginoid pain, polypnea, cough and the 

 cutaneous symptoms can all be explained by alteration of the vagus or 

 sympathetic nerves, this is not alone the cause. 



For many years an affection of the cervical sympathetic ganglion was 

 generally considered as the cause of exophthalmic goiter. It had apparent 

 support from both the pathological laboratory and the clinic. It does 

 riot, however, satisfactorily explain even the occurrence of the cardinal 

 symptoms in that, unless we proceed very artificially in the diagnosis, 

 we must assume for the different fibers of the sympathetic nerve either 

 paralysis (with consequent dilatation of the vessels and development of 

 goiter) or permanent irritation (with consequent tachycardia, palpitation 

 and exophthalmos to some extent) or functional integrity of the fibers 

 which cause dilatation of the pupils. Leube prefers the medullary theory 

 to this idea of an affection of the sympathetic system. 



