Described many years ago by Parry, Basedow, and by others more recently, it is much better understood and more widely known than formerly.

Opinions differ radically as to its real nature. The best modern authorities regard it as a pure neurosis, and functional only in character, although organic changes often develop during its course in the heart, thyroid gland, and elsewhere. Some still speak of it as due to changes in the medulla oblongata; others again look upon functional and structural changes in the thyroid gland as the real cause of the malady. My own experience inclines me to view it as a neurosis pure and simple, although marked and characteristic structural changes supervene during its course, and may become permanent. Probably in the near future we shall learn more as to its exact nature. Already it is satisfactory to note that cases are far earlier and more frequently recognized, and that their treatment is more successful.

From their first appearance its special features attract attention. These are few in number, and easily borne in mind: 1. An unusual and more or less constant rapidity of the heart's action; 2. The early presence of more or less protrusion of the eyeballs; 3. A marked enlargement of the thyroid gland; a tendency to tremors or tremblings under very little, and sometimes no excitement, although this always increases it. It is not surprising that these indications of exophthalmic goiter which develop more or less rapidly and become often most distressingly marked, should cause much anxiety to the patients and their friends, as well as to their medical attendants.

With regard to the duration of ordinary chronic cases (for acute ones are seldom met with), what has been the experience of those who may read this article? I have never met with an acute case, but have seen months and one or two years pass before there was more than a partial improvement.

One case, a very bad one, in which the patient's circumstances were so poor that she worked on during her illness, when she should have had care and rest, recovered completely. But so serious was this case, that the sight of both eyes was entirely lost from the excessive protrusion of the eyeballs during the disease. When I first saw her, which was years after her recovery, the story of her case was intensely interesting, but most sad.

Then as to the frequency with which relapses occur in this disease, it would be interesting to get the experience of good men. Many speak of relapses being frequent, even after apparently complete recovery has taken place. Others think them not of so common occurrence.

There are also many points of great interest in connection with the prognosis. One of these is the probability of the recovery being perfect. My own experience has been that the lighter or milder the case the greater the probability of a perfect cure.

Another matter of interest is in connection with cases in which the symptoms greatly abate, the health indeed appearing to be perfectly

restored, but in which the exophthalmos and thyroid enlargement continue noticeable; whether in such patients very slight causes may not lead to a return of the disease. From what I have seen, the conclusion appears correct, that provided the heart's action is normal as to frequency, and not too easily disturbed, these cases are not specially likely to have a second attack, which is tantamount to saying that, provided the heart's action has become normal, any other relic of the illness is comparatively unimportant.

I have observed, too, more or less scleroderma present when the attack has not been by any means of a serious character, and when afterward the general health became all but perfectly restored. This is an interesting concomitant. It would be desirable to have others give their experience as to its occurrence in cases they may have attended.

Then as to the effects of pregnancy during the course of the disease; some high authorities speak very strongly as to its great danger. Others remark that the affection has improved during gestation. This is another matter on which fuller information would be most useful.

As to the percentage of fatal cases, this is hardly as yet to be determined so as to be useful to the practitioner. My own cases have led me to the conclusion that every particular case has to be regarded per se, that is, if the symptoms are light and comparatively trifling, and show signs of abating, the prognosis is favorable, while under an opposite state of things it is the reverse.

As to treatment, what has succeeded best in my hands has been enjoining upon patients the necessity of a great deal of physical rest, at least ten or twelve hours a day if possible, and the avoidance of all mental worry. On this, great stress should be laid. These patients require abundant nourishment. Galvanism in my hands has been found most useful; employed twice a day and so applying the poles that the current may go from the back of the neck through the thyroid gland, and the heart, and even (the current being made very weak) through the eyeballs. This current has been continued for months, and in some cases for a year and a half, with good effects. Sometimes tincture of digitalis has been useful in moderate doses, ten or twelve minims three times in twenty-four hours, in some cases, and useless in others. Iron has been found of great value and persisted in for a long time. As a nerve-tonic, strychnine in small doses has been exceedingly beneficial. Quinine, if used, should, unless malaria complicates the case, be used in small doses only, such as 11⁄2 grains three times a day, with the iron and strychnine.

I know that many of the matters I have mooted in this paper have been quite recently discussed by Drs. Ord and McKenzie, of London, in an excellent article on exophthalmic goiter in the fourth volume of the new System of Medicine edited by Allbutt, but a still wider discussion on the matters alluded to, and on many others, by practitioners who have met with and treated such cases, will do much good, and tend to make the care of such cases more pleasant and the results of treatment more satisfactory. Walter B. Geikie, M. D., C. M., D. C. L., in Philadelphia Medical Journal.

DANGERS OF THE NASAL DOUCHE.-Lichtwitz (Sem. Med., November 26, 1897,) deprecates the routine prescription of the nasal douche in all cases of hypersecretion of the nasal mucous membrane. Irrigation is called for only when the nasal fossæ require clearing of pus and crusts, for instance in idiopathic ozena. This affection is mainly limited to the nasal fossæ properly so called, and irrigation is in such a case the most fitting form of procedAn ordinary syringe or enema syringe with suitable nozzle should be used. In all other nasal affections irrigation is inadequate or useless; it is even dangerous. Repeated flooding of the mucous membrane may give rise to olfactory lesions. Antiseptics are highly injurious and pure water is badly borne; the physiological solutions of sodium chloride, sod. bicarb. or sod. sulph. are the only harmless liquids. In numerous cases irrigation has caused the sense of smell to be temporarily or permanently diminished or lost. Distressing frontal or occipital headache may result owing to the liquid passing into the sinuses. The injection of irritating liquids may even set up inflammation of these cavities. The most skilful and careful irrigation is insufficient in many cases to prevent the resulting headache. A very grave complication is the penetration of the liquid into the middle ear, suppurating otitis media occasionally supervening. In acute coryza, especially in children, douching should never be practiced. In one such case known to the author mastoiditis followed irrigation of the nasal cavities. The predisposition to otitis is increased after retro-nasal operations, in particular after ablation of adenoid vegetations. For eight years the author has given up all irrigation after pharyngo-tonsillotomy, and during that period has met with no case of post-operative complication.-British Medical Journal.

ANTIPYRIN.-In July of this year the antipyrin patent, held by the Hochst color-works, will expire by limitation, it having run its course of fifteen years the span of life a llowed to a German patent. During these fifteen years the monopolists have sold the drug at about $12.50 a pound, but it will, of course, fall considerable in price the moment the manufacture and sale are permitted competitors. It is anticipated that it will shortly fall to at least half its present price, when the usual convention of the principal competitors will be called and the inevitable trust formed, leading to a consequent rise in price. It is rumored that a number of chemical works are busy with the manufacture of antipyrin, so as to be prepared with it immediately upon the expiration of the patent.-Philadelphia Medical Journal.

Professor ROBERT KOCH has been invited by the Indian Government to make another stay in India for the purpose of studying the epidemic and endemic diseases of man and beast so prevalent there. Koch is now engaged on work that will keep him in German East Africa for some time, probably about a year, and does not think of leaving until he has concluded it.

Special Notices.

RHEUMATOID ARTHRITIS.-Rheumatoid arthritis is a chronic progressive disease with an almost hopeless prognosis as regards a complete cure. The most that can be hoped for is to arrest its progress for a longer or shorter time, and to render the patient's life more tolerable by improving his health and relieving the pains in the affected articulations. Galvanism, massage, baths, and an invigorating diet have been found of more or less value, as well as the administration of cod-liver oil, ferruginous preparations, and the iodides. A comparatively new remedy that seems to have a promising future before it in the treatment of this disease is Lycetol. Judging from the observations thus far published its use in rheumatoid arthritis is capable of effecting considerable improvement. One of its distinct advantages is that, owing to its pleasant taste and freedom from irritating effects, its administration can be kept up for a long time, a point of great importance in the treatment of chronic affections, in which remedies must be given for a prolonged period before beneficial results can be expected. In two cases recently reported by Dr. Paul Norwood (Times and Register, November 6, 1897), one being a very bad one of chronic rheumatoid arthritis, the results were very encouraging. A slow but steady improvement occurred in the second case, while in the first the patient provoked a recurrence by discontinuing the treatment. In view of the obstinate character of the affection and its resistance to the remedies heretofore in use, Lycetol should be certainly considered an eligible remedy in these cases.

MEETING OF AMERICAN Medical PubliSHERS' ASSOCIATION. - The Fifth Annual Meeting of the American Medical Publishers' Association will be held in Denver, on Monday, June 6, 1898 (the day preceding the meeting of the American Medical Association). Editors and publishers, as well as every one interested in Medical Journalism, cordially invited to attend and participate in the deliberations. Several very excellent papers are already assured, but more are desired. In order to secure a place on the program, contributors should send titles of their papers at once to the Secretary. CHAS. WOOD FASSETT, St. Joseph, Mo.

OBSTINATE CONSTIPATION.—I used Chionia, a teaspoonful three times a day and at bed times, in a case of long standing obstinate constipation. The first three nights I directed a hot water enema to be given every night. This treatment brought about regular and spontaneous evacuations, and resulted in a complete cure.

Lickton, Tenn.

E. T. BAINBRIDGE, M. D.

THE phosphates of iron, soda, lime, and potash, dissolved in an excess of phosphoric acid, is a valuable combination to prescribe in nervous exhaustion, general debility, etc. Robinson's Phosphoric Elixir is an elegant solution of these chemicals. (See advertisement.)

LABOR SAVING: The American Medical Publishers' Association is prepared to furnish carefully revised lists, set by the Mergenthaler Linotype Machine, as follows: List No. I contains the name and address of all reputable advertisers in the United States who use medical and pharmaceutical publications, including many new customers just entering the field. In book form, 50 cents.

List No. 2 contains the address of all publications devoted to Medicine, Surgery, Pharmacy, Microscopy, and allied sciences, throughout the United States and Canada, revised and corrected to date. Price, $1.25 per dozen gummed sheets.

List No. 2 is furnished in gummed sheets, for use on your mailer, and will be found a great convenience in sending out reprints and exchanges. If you do not use a mailing machine, these lists can readily be cut apart and applied as quickly as postage stamps, insuring accuracy in delivery and saving your office help valuable time

These lists are furnished free of charge to members of the Association. Address CHARLES WOOD FASSETT, Secretary, cor. Sixth and Charles streets, St. Joseph, Mo.

THE

VOL. XXV.

"NEC TENUI PENNÂ."

LOUISVILLE, KY., FEBRUARY 15, 1898.

No. 4

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than any thing else.-RUSKIN.

Original Articles.

SOME OBSERVATIONS IN INTERSTITIAL NEPHRITIS.*

BY FRANK C. SIMPSON, M. D.

I am not going to tell you any thing new, nor tell you how to cure this always fatal disease. I only want to bring out some facts that I have met with. What is meant by interstitial nephritis is sclerosis or cirrhosis of the kidney. We usually meet with it as an independent or primary disease; I mean that it has a chronic tendency from the outset.

We find it a slow-creeping degeneration of the kidney substance; each tubule is attacked separately, and this variety is so latent, when we first recognize the disease the kidney is practically destroyed; this accounts for the slow involvement of the whole kidney. In a great many cases no satisfactory cause can be assigned. I have found that those females who are changing life suffer from this variety, and set it down as the most frequent cause of cirrhotic kidney in the female. Among factors that will account for the majority of cases is worry or mental strain. In other words, the cause of 90 per cent of this trouble comes from some nervous impression.

It is the general opinion that males are more frequently attacked than females. My experience has been the other way, and to go back will say that all the female patients that have come under my observation have been at the menopause or making the change.

In the majority of these cases the attack is latent and not recognized until the occurrence of one of the serious or fatal complications. There may have been no symptoms to suggest to the physician an existence of any serious trouble of the kidney.

* Read before the Louisville Medico-Chirurgical Society December 17, 1897. For discussion see p. 142.