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SINCE Listerine was first introduced to the profession, it has been variously used, in all forms of fever, as an adjuvant, and as an important part of treatment. Diluted half and half, or one part Listerine to four of water, it is administered in teaspoonful doses every two to six hours, as a febrifuge tonic and alterative antiseptic; it improves the condition of the stomach for the reception of nourishment, and tends to the relief of intestinal distention. It is admirable to introduce in the sponging and bathing so often advocated in typhoid conditions, and as a mouth-wash and gargle during the whole period of confine.

ment.

THE well known therapeutical properties of Antikamnia, Quinine and Salol make this combination desirable in such intestinal affections as fermentative dyspepsia, diarrhea, dysentery, duodenal catarrh, cholera infantum, and typhoid fever. The Antikamnia controls the pain as effectually as morphine, and yet is never followed with any of those undesirable effects so characteristic of opium and its derivatives. Freedom from pain saves an immense amount of wear and tear to the system and places it in a much better position for recovery. The Salol acts as an antiseptic and removes from the intestinal canal the first or continuing cause of the affections just mentioned. The Quinine acts as a tonic, increasing the appetitite, and thus contributing much to a speedy recovery. Hare says quinine is not only a simple bitter, "but also seems to have a direct effect in increasing the number of the red blood corpuscles." A tablet composed of Antikamnia two grains, Quinine Sulph. two grains, and Salol one grain, allows of the easy administration of these drugs in proper proportionate doses.

AN excellent method of treating small wounds of the face and extremities is as follows: After careful disinfection with a carbolized solution (4 per cent.) or a solution of corrosive sublimate, I to 2000, and drying with a pledget of absorbent cotton, sutures are applied if necessary, then Aristol is dusted on, which forms an antiseptic aud protective film. A layer of plain gauze and a bandage complete the dressing. A still simpler and equally efficient dressing is to paint the wound with 10 per cent. Aristol collodion, or after

dusting on Aristol powder to apply two or three thin layers of absorbent cotton and fasten each in place with collodion. These gauze strips, if properly applied, unite the lips of the wound as firmly as sutures, and primary union is as likely to take place. After their application Aristol powder is dusted thickly over the gauze and the dressing completed with a layer of cotton and a bandage. These simple methods of wound treatment, which may be modified according to the locality and character of the traumatism, have been suffici. ently tested to merit frequent employment, in the large class of cases of minor surgery of common occurence in general medical practice.

SO

PROFESSOR LABADIE-LAGRAVE has used antipyrin successfully in the treatment of certain uterine hemorrages. It is difficult to introduce powdered antipyrin into the uterine cavity, so it occurred to him to use antipyrin liquified with salol, thus producing a medicament at once hemostatic and antiseptic. The following is the mode of procedure: Equal parts of antipyrin and salol are placed in a test tube so as to occupy about one-third the space; they are then heated over an alcohol lamp, when the mixture is soon transformed into a clear liquid with a slightly brownish tinge. This is not the time to use the solution, for it will solidify too rapidly. The heating is continued until a well-defined brown color is noticed, when there is no longer any danger of its rapid solidification. The liquid is introduced by means of cotton soaked in it and rolled on a wooden applicator; after seeing that the liquid is not too hot, the application is made through the speculum. If the hemorrhage is excessive, two applications are made at the same sitting, after which a tampon soaked in glycerated creosote is placed in the vagina and the patient sent to bed. The applications are free from danger and occasion no pain. Their hemostatic action is rapid, sure and complete; the hemorrhage is quickly stopped and by the second day there is no trace of hemorrhage; it is rare that the application needs to be repeated. The method is efficacious against hemorrhages due to fungous metritis, to misplacements, fibromyomata and also to malignant tumors in the beginning, when the hemorrhage is due more to congestion than to ulceration.

MEDICAL JOURNAL

A Weekly Journal of Medicine and Surgery.

VOL. XXXIII.-No. 16. BALTIMORE, AUGUST 3, 1895.

ORIGINAL ARTICLES.

WHOLE NO. 749

SOME REMARKS ON EXOPHTHALMIC GOITER. READ BEFORE the Medical Society of the Woman's Medical College of Baltimore, APRIL 2, 1895.

By Eugene F. Cordell, M. D.,

Professor of Principles and Practice of Medicine, Woman's Medical College, Baltimore.

EXOPHTHALMIC goiter is an affection characterized, when fully developed, by protrusion of the eyeballs, enlargement of the thyroid gland and inordinate action of the heart in varying relative degree and combination. Though recognized previously it was first fully described by Graves in 1835; hence it has been called "Graves' Disease." Somewhat later an account was given of it in Germany by Basedow; hence in that country it is commonly known as "Basedow's Disease."

Cases are far more frequent in women than men, Reynolds meeting with 48 females affected with it and but I male. I have seen male in 9 or 10 cases. It commences usually in early adult life. Occasional instances of inheritance have been reported, and several children in a family have been known to present evidences of the disease. A young Russian woman told me that two of her sisters and a brother had heart disease, nervousness and excitability. Much more commonly we find in the family of a patient evidences of neurotic tendencies in other directions, as epilepsy, insanity, etc. It has no relation to ordinary goiter. Whilst the affection may appear in persons in apparent health, it often succeeds some conditions of debility as pregnancy, abortion, childbirth, hemorrhage,

anemia, etc. "No immediate cause is so frequent," says Gowers, "as emotion, sudden terror or prolonged distress." In a case of mine it developed suddenly in consequence of the shock produced by the unexpected arrival of the dead body of the patient's husband, whom she had supposed well till that moment. In another case homesickness seemed to be the exciting factor. Usually, however, the onset is slow and gradual but not uniform in its rate of progress.

The heart symptoms usually are the first to appear and in the form of palpitations. Following this at an indefinite period are enlargement of the thyroid and prominence of the eyeballs. The heart is easily excited by emotion or exertion, and after a time the excited action becomes habitual, usually 120 to 140 or more, though often much exceeding this under the influence of exciting causes. The impulse may be diffused and cardiac dulness increased, indicating hypertrophy. Heart action is usually regular. A systolic murmur is often found, with greatest intensity at the base; it may be heard to the left of the nipple, indicating the relative insufficiency of the mitral valve due to dilatation of the left ventricle. There is increased pulsation seen and felt in the dilated carotids and thyroid vessels, often accompanied by a

thrill; a loud systolic murmur is heard in the same situation. The thyroid enlargement is usually slow but may occur within a few days. It varies from time to time and is moderate in degree. It is rarely entirely symmetrical, the right lobe preponderating in the increase. In one of my cases it alone was enlarged.

The prominence of the eyes is bilateral. It may be slight, amounting to a mere. stare, or considerable, so that the white sclerotic is visible above and below the cornea. In a still greater degree the movement of the balls is limited and the lids cannot meet over them. It is even said that the eyeball may become dislocated from the socket and have to be replaced with the finger. Inflammation of the conjunctiva and cornea and even sloughing may arise from exposure of the ball. A characteristic eye symptom, known as von Graefe's, is a failure of the upper lid to descend or a retarded descent when the eyeball is rotated downward. The pupils are almost always normal. Of the three chief symptoms no one is invariably present, and two of the three may be wanting. The cardiac disturbance is rarely absent; Gowers estimates that goiter is absent in onetwelfth and exophthalmos in one-tenth of cases. Patients are often anemic and exhibit loss of appetite and flesh. Amenorrhea is frequent. A moderate pyrexia is of common occurrence in advanced stages and occasionally profuse perspirations are met with. The patient is often unable to sleep and is depressed and very irritable. Fine muscular tremor, most marked upon movement, is common. Occasional symptoms, but less frequent than the above, are glycosuria, diabetes insipidus, albuminuria, enlargement of glands, loss or increase of the pigment of the skin, edema, insanity, especially mania, hysteria, paralyses, chronic spasms, diarrhea, epiphora and other vaso-motor disturbances.

The disease usually lasts several years. Acute cases have subsided in a few days and, on the other hand, have proven fatal in a few weeks. The career is subject to great variations. Prolonged periods of improvement and even entire disappearance of symptoms occur so that

in the latter the attacks appear to be entirely distinct. Improvement sometimes takes place during pregnancy, as in a case of mine, who insisted that the thyroid swelling had entirely disappeared during her three pregnancies. Permanent recovery may also occur, being most frequent in rapidly developing cases with cardiac symptoms preponderating over those of the neck and eyes. Gowers thinks that about onequarter of the cases recover, chiefly those of mild degree, but recovery is exceedingly rare in the severe cases. Improvement, however, often occurs in the latter. Death is due to disease of the heart or asthenia and may be hastened by exhausting diarrhea, tuberculosis or apoplexy.

Post-mortem, valvular lesions and dilatation are often found; the arteries are also dilated. The thyroid gland is hypertrophied. hypertrophied. In the orbit the fat is often increased. The cervical sympathetic is rarely the seat of disease (not once in 13 cases examined by Lewin). The lower cervical ganglion is most often affected. The central nervous system and medulla are generally free from any obvious lesions. In some cases congestion and even hemorrhages have been found in the medulla but they are not believed to possess any signifi

cance.

The symptoms of this affection point so strongly to the sympathetic system of nerves that it is natural to look to that source for their origin and explanation. Trousseau thought that he had found the seat of the disease in lesions in the lowest cervical ganglion. But his conclusion was hasty and has not received support from subsequent observers. The frequency of the heart's beat, we know, may be increased by irritation of the cervical sympathetic. But to explain the dilatation of vessels we must have recourse either to a paralysis of the vasoconstrictor fibers or persistent irritation of the vaso-dilator fibers; on the first supposition we must assume a partial affection of the sympathetic, on the second, an opposite disturbance of its different elements. Either seems incompatible with the idea of irritation or inflam

mation. Gowers suggests that the vagus may have some share in the cardiac disturbance. Hence pathologists have recently been disposed to look to the central nervous system for the primary morbid change. Gowers finds support for this view in the law discovered by Marey, viz.: that frequency of the heart's action and diminished blood pressure are physiologically associated. The sympathetic system is under central control and especially of the centers in the medulla oblongata. In the absence of definite lesions, therefore, pointing in other directions, we must for the present accept the view that the affection is a neurosis of the medulla oblongata dependent upon changes that baffle our powers of investigation but for which we have analogies in other neuroses, as hysteria. Some confirmation of this view has been obtained by Filehne, Doudouffis and Bienfait, who divided the anterior fourth of the restiform bodies and thus produced exophthalmos and sometimes enlarged thyroid and even cardiac excitement. It has been pointed out that excited heart, dilated vessels and wide-open, staring eyes are often caused by emotions, especially great fear, and many cases of exophthalmic goiter are on record where this suddenlydeveloped group of symptoms has been continued permanently. Möbius has advanced the view that exophthalmic goiter is due to increased secretion of the enlarged thyroid gland producing a toxic blood state, and points to the idiocy of cretins for proof of the malign influence of enlargement of the thyroid. The occasional benefit from excision of the gland seems to lend some support to this view. The influence of the thyroid is now well recognized, since the relations of myxedema with atrophy and excision of the gland and the effect of treatment of that disease by feeding with the gland of animals are so well appreciated. But, as Gowers states, the great discrepancy between the condition of the thyroid and the other elements of the disease seems to exclude it from any direct or indirect influence on the symptoms; and the occasional benefit of excision may be due to the profound in

fluence of the operation upon the nerve centers. Finally, Begbie has advanced the theory of a primary pathological blood state, but no facts are as yet available for the support of such a theory. The explanation of the mode of origin of the special symptoms is involved in difficulty. The dilated heart may be due to its rapid action and incomplete systole by which residual blood gradually produces over-distention. The enlarged thyroid may be ascribed to dilated vessels and to some extent to hypertrophy from increased blood supply. The exophthalmos is favored by the dilated vessels and increased fat in the bottom of the orbit, and possibly by hypertrophy of the unstriated muscular fibers of Müller, which run from the eyelid to the membranous lining of the orbit and are innervated by the sympathetic. Von Graefe's symptom was ascribed by him to spasm of the fibers of Müller, but by Gowers to spasm of the levator from central disturbance. The rare symptoms, abnormal vascularity of the skin, pigmentation and diarrhea, are referred by Gowers to the sympathetic; in the case of the latter, from extension of the disease to the abdominal plexuses.

Well marked cases are easily recognized. The disease is apt to be overlooked in the early stage and in undeveloped cases. Under these circumstances it is likely to be supposed to be mere nervous excitement or organic heart disease. A persistently rapid pulse-rate should always excite suspicion and lead to careful examination. Ordinary goiter is recognized by absence of the symptoms relating to the eye and heart and by the great degree of enlargement. In some cases an ordinary goiter may compress the sympathetic in the neck, producing one-sided exophthalmos, dilatation of the pupil on the same side and excited action of the heart. Early diagnosis is of the greatest importance in view of the prospect of permanent relief being chiefly to be anticipated then.

The prognosis varies greatly. Some acute cases subside entirely in a few days or gradually subside into a chronic career. Death has been known to occur

in a few weeks in an unusually violent attack, but usually the career of the disease is protracted through many years. and it is noteworthy how few cases terminate fatally under observation. I have met but one such case in which death was due to gradually progressive organic heart disease with anasarca. In fully developed cases cure is rarely effected, improvement being all that is to be expected and in some this even is not, secured. Relapses are common. In milder cases complete or nearly complete recovery is occasionally seen. The existence of organic heart disease and emaciation are unfavorable symptoms. It is better in women than in men ; also when there is a remittent tendency. Gowers thinks that a family tendency, in a case in the early stage, improves the prospects of the patient. A distinct and removable exciting cause has the same significance. Predictions as to progress in any case are hazardous, as unexpected and even prolonged periods of improvement or arrest or, on the other hand, of unexpectedly rapid development, may occur.

The prognosis is better among the wellto-do than the poor. The natural tendency of the disease should be duly considered and "it is never right to exclude the hope of ultimate improvement and even of possible recovery." (Gowers.)

Rest of mind and body should be secured as far as possible. In acute and severe cases it may be justifiable to confine the patient for a time to bed. Exercise should be avoided; if the patient suffer for the want of it, gentle massage may be substituted. Change of air, especially to the seashore, is often

beneficial. Drugs are uncertain and are to be used tentatively; a remedy which benefits one case may prove useless or hurtful in another. Digitalis, strophanthus, aconite, antipyrine, sulphonal, the bromides, and especially belladonna, have proven more or less useful as heart sedatives. Iron, quinine, arsenic, the iodides and strychnine are recommended as tonics. Iron should not be used until severe symptoms have moderated. Belladonna and digitalis diminish arterial dilatation. A combination of these with iron, using the belladonna in full physiological doses, with occasional full doses of bromide of potassium, probably constitutes the best drug treatment available. For the palpitation and dyspnea Hoffman's anodyne and morphia are applicable. Galvanization of the cervical sympathetic is often highly useful, producing marked slowing of the pulse and sometimes diminution of the size of the thyroid. The effect is transient and therefore the application has to be repeated several times a day, one pole being placed over the nape of the neck and the other moved up and down along the anterior margin of the sterno-mastoid muscle. To be effective the patient should procure a small battery and be instructed in its use so that he can apply it himself. Excision of the thyroid, although occasionally successful, is too uncertain and involves too many risks, both immediate and remote, to be considered a reliable procedure; moreover, it is only warrantable in the early stage when remedial treatment offers a fair prospect of cure or great improvement.

THE INFLUENCE OF SYPHILIS ON LOCOMOTOR ATAXY. Cardarelli (British Medical Journal) says that possibly a third of the cases of locomotor ataxy may be of syphilitic origin. Ataxia

coming on twenty or thirty years after primary syphilis, and not preceded by any decided syphilitic manifestation during this time, is probably not syphilitic. So-called syphilitic ataxia has no definite characteristics of its own, such

as belong to cerebral syphilis. Antisyphilitic treatment as a rule does more harm than good in tabes, and in any case in which this form of treatment did no good in fifteen to twenty days, the author thinks it useless to persevere with it. On the whole Cardarelli thinks that the importance of syphilis as a cause of tabes has been greatly exaggerated.

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