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ity in general paralysis vary greatly according to different men. Kraepelin finds a heredity in about 50% of his cases; Pilcz in only about 18% of his cases, and a fair average may be about 40%. On this basis it seems fair to assume that the mental heredity is strikingly large in our cases. With a mental heredity, then, in 63% of the cases, and a psychopathic or neuropathic make-up in 32 of the cases, together with the fact that 15% of them have previously had a psychosis, it does not seem unreasonable to conclude that we are dealing with individuals in whom a psychosis might have been expected to develop even in the absence of Graves' disease, perhaps without any tangible cause, or at least with only such causes as appear to be of etiological significance in the ordinary functional psychoses. That is, the Graves' disease is only an exciting cause, although perhaps an especially strong one.
At first glance, the fact that in 32 cases the onset of the psychosis was practically simultaneous with the onset of the Graves' disease, might be taken to indicate that etiological relationship was much stronger. It is among these simultaneous cases, however, that we find the highest predisposition to mental disease; 85% of them showing bad heredity, as against 36% of the cases with later onset of the psychosis; and only 15% of the simultaneous cases show a good heredity, as against 36% with good heredity among those with a later onset of the psychosis. Again, it will be remembered that 19% of the simultaneous cases had had previous attacks, as against 11% of the cases with the later onset.
The fact that, among four improved and ten recovered cases, the improvements and recoveries from the psychoses in all but two instances took place without any or only slight improvement in the symptoms of Graves' disease, argues against any fundamental relation between Graves' disease and the psychosis. The two exceptions were cases where thyroid had been taken and where both the physical and mental symptoms disappeared on withdrawal of the drug. The inference to be drawn from these two cases is perhaps somewhat contradictory to the above, and seems to indicate a very definite relation between cause and effect, but after all we are here dealing with an artificially produced condition.
Unfortunately the statistics of any considerable number of cases are not at my command concerning the proportion of cases with
Graves' disease which never develop a psychosis. It seems very probable that many cases, at least, go for years without psychoses, and even among the cases here considered the interval was in several instances from ten to twenty years. Syllaba, in a paper on the prognosis in Graves' disease, while not considering the psychiatric side to any extent, yet notes in a general way improvement and recovery in 62% of 50 cases which he followed throughout their lifetime.
In view of the facts already presented it would seem that in a majority of cases where a psychosis does develop, the time of origin of the psychosis after the onset of the Graves' disease is somewhat proportional to the predisposition of the individual to insanity, the most susceptible losing their mental balance at once. We must, of course, acknowledge that the strength and quantity of toxines, if such be present, may vary in different cases and have its own significance. Objectively, however, the physical and mental symptoms are not always proportional.
Finally, we must consider the possibility of common etiology for both physical and mental symptoms. Until we know more about the etiology of Graves' disease and the etiology of abnormal mental conditions, this question can hardly be settled. In many cases the course of the physical and mental symptoms is sufficiently independent to make it at least questionable.
Before leaving the etiological considerations attention may be called to the fact that among general medical men there is a tendency to consider mental grief and worry as a possible etiological factor in Graves' disease. In the cases here considered, for the most part no such condition preceded the Graves' disease, but accompanied or followed it.
If we turn next to a consideration of the mental picture in the psychoses associated with Graves' disease, we find a predominance of certain symptoms, depression, apprehensiveness, irritability, and excitement, characteristics which are usually found to a lesser degree in the sane with Graves' disease. On the whole we find that the mental pictures may vary greatly; there were many cases essentially depressions, some essentially exhilarations and vice versa, others showed in their course depressions followed by exhilarations, and still others were essentially delusional conditions. There were some cases of acute delirium; practically as much variation as is
found in the functional psychoses not associated with Graves' disease. It is interesting to note that only two cases demented, and that on the whole the course of the psychoses, apart from the prominence of hallucinations, does not resemble that of dementia præcox. In one of my own cases, however, which has had three acute attacks with perfect recovery, so as to resume her work as a school-teacher in the intervals, the mental picture was strikingly dementia præcox like. Not only were hallucinations prominent, but the mood was more or less apathetic, autochthonous ideas and ideas of reference were prominent to a marked degree, and there were many impulsive acts, and other phenomena of disintegration of the personality. The course alone was not typical, and now after about ten years the patient is in no way demented. A large number of the cases were depressed and a greater part of the depressions showed a motor activity instead of a retardation. Apprehensiveness and irritability were unusually frequent, and hallucinations were much more common than is usual in depressions. The prominence of this latter symptom suggests the possibility of strong toxic influences.
With regard to the outcome, while some cases improved and more recovered, on the whole the prognosis of the mental symptoms associated with Graves' disease seems to be more serious. In many instances the Graves' disease seems to furnish enough to produce at least chronicity, although few dementias. The rapidity with which death followed the onset in many cases was quite striking. In these cases delirium and excitement were conspicuous and the death rate much larger than in the ordinary manic excitements, even of similar severity, and it seemed much more difficult to cope with the exhaustion. It would for this reason seem probable that in addition to the exhaustion from the excitement there is some direct toxic influence from the Graves' disease which is of considerable prognostic significance.
I would conclude briefly that in many cases Graves' disease is rather an exciting than a fundamental cause of the psychosis, and that the psychoses themselves are not essentially different from the ordinary recognized functional psychoses, except as modified by the prominence of those symptoms seen to a lesser degree in the sane with Graves' disease. The prognosis is on the whole much more grave and is especially bad in the delirious cases.
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