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ever, the progress in each is rather different. The following exhibits the most important points of difference:
Dropsy generally slight, and occurs late. Dropsy occurs early, and is extensive.
Tumor in the flanks.
In some cases of hydro-nephrosis, especially when both kidneys are involved, it may be impossible to distinguish that disease from cystic degeneration, but ordinarily the following points will suffice for a differential diagnosis:
Cystic degeneration occurs in persons Hydro-nephrosis occurs usually in perafter thirty years of age.
Tumor soft, solid, not fluctuating.
sons less than thirty years of age.
Tumors persistent and unchanging, ex- Tumors subside suddenly at times, with
cept by gradual increase.
coincident copious discharge of urine. Less so.
The differential diagnosis between cystic degeneration and cancer of the kidney is established by attention to the following points:
2. Tumor may be large.
1. Generally unilateral.
2. Tumor attains an enormous size, much larger than is ever reached in cystic degeneration.
3. Tumor movable; it rises and falls with 3. Tumor stationary, and does not move
4. Runs a rather slow course.
5. No cachexia.
with the diaphragm.
4. Runs a more rapid course.
5. Cachexia sets in early, and is well marked.
The prognosis in cystic degeneration is always unfavorable, and death occurs, from arrest of the action of the kidneys, either by coma, as in the case above reported, or by sudden convulsions.
The treatment is very unsatisfactory and entirely unavailing to effect a cure. The object of the physician should be to relieve dyspepsia, to maintain and improve nutrition, to promote the action
of the kidneys, or to compensate for their incapacity by exciting the skin and bowels to vicarious action. The means tending to further these results are familiar to all intelligent practitioners, and it is probable that by their judicious employment the patient's condition may be ameliorated and the unfavorable termination delayed.
SOME PRACTICAL OBSERVATIONS ON EXOPHTHALMIC
GOITRE, AND ITS TREATMENT.
BY ROBERTS BARTHOLOW, A.M., M.D.,
PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE, AND OF CLINICAL MEDICINE, IN THE MEDICAL COLLEGE OF Ohio, etc.
No case of Graves' or Basedow's disease can be considered complete without the presence of three characteristic phenomena: irregular and rapid action of the heart, enlargement of the thyroid body, and exophthalmos. This group of symptoms is so familiar under the designation of exophthalmic goitre, that it would be a reflection on the intelligence of this body to occupy time with an account of its clinical history. But many cases are met with in which but one or two of the typical symptoms are present. As regards the relative frequency of the physiognomical characteristics, the increased action of the heart stands first, the enlargement of the thyroid second, and the exophthalmos third. It is no doubt true that many cases of rapid action of the heart, with paroxysmal palpitations, have their origin in the same pathological state; but owing to causes at present unknown, the other symptoms are not produced, and the cases do not proceed to their full development.
It is equally certain that many cases of so-called goitre are really examples of Graves' disease-the enlargement of the thyroid only attracting attention. The capital distinction between goitre and Graves' disease is this: in goitre there exists a hypertrophy or hyperplasia, or both, of the proper gland elements; in Graves' disease, the increase in the size of the thyroid is due largely to dilatation of the vessels, and to the hypercinesia of the heart, and any increase in the size of the gland elements is secondary and non-essential. In the one, enlargement of the gland is continuous or uniform; in the other, it is subject to great fluctuations. need hardly stop to suggest the important bearing which these facts have on the treatment of the two states, and the necessity
which exists in every case of apparent goitre to study the action of the heart and the cervical vessels. It must be evident, I think, that the use of the word goitre, to designate this peculiar malady, is unfortunate; for true goitre, except in the single symptom of swelling of the thyroid, is in every respect unlike exophthalmic goitre.
Graves, who first described this malady, distinctly recognized the difference in the character of the thyroid swelling in the two diseases. (Clinical Lectures on the Practice of Medicine, ed. by Néligan, vol. ii. p. 193.) He, no doubt, correctly indicated the nature of the change in the thyroid in the following remarks:-`
"The sudden manner in which the thyroid used to increase and again diminish in size, and the connection of this with the state of the heart's action, are circumstances which may be considered as indicating that the thyroid is slightly analogous in structure to the tissues properly called erectile."
This explanation of the enlargement of the thyroid, and of the changes in size which it undergoes, has been made by Henock, Bullar, Laycock, and others. By Henock the change in the thyroid has been designated struma aneurysmatica (Virchow's Geschwülste), and by Laycock, bronchocele vasculosa. Virchow, who distinctly affirms the changes which take place in the vessels of the thyroid, also calls attention to the hyperplasia of the gland elements, and to the cystic, calcareous, and fatty degenerations which frequently coexist with the vascular dilatations. (Die Krankhaften Geschwülste, dritter band, erste haelfte, s. 72, et seq.) At p. 12 of the same volume, he gives a drawing of a struma exophthalmica varicosa. By Dr. Bullar, two cases were reported under the title of "pulsating bronchocele." (Medico-Chirurgical Transactions, vol. xliv. p. 37.)
Trousseau, in an admirable clinical lecture on this disease, states that in addition to the hypertrophy of the gland elements, great development of the blood vessels of the gland may be made out clinically. (Clinique Médicale, vol. ii. p. 458.)
We have the high authority of Von Graefe for the assertion that cases of this disease may exist in which there are present merely rapid action of the heart, and such a slight degree of exophthalmos that it is observed only in certain movements of the eye and of the eyelids. When such patients are told to look down, the upper lid does not follow the movement of the ocular globe, and a white rim of the sclerotic comes into view.
This defect of co-ordination is independent of the exophthalmos, and is caused, according to Graefe, by spasm of the superior palpebral muscles of Mueller, which are innervated by the sympathetic. In cases of palpitation of the heart, and a sustained elevation of the pulse-rate occurring in women, although the thyroid may be unaffected, and exophthalmos be absent, the defective movement of the eyelid will indicate the nature of the symptoms.
CASE I.-Paroxysms of Palpitation of the Heart; Constant Elevation of the Pulse-rate; Intercostal Neuralgia; Occasional Fullness of Thyroid, and Slight Exophthalmos.
Personal History.-Mrs. H., a Jewess; in complexion a brunette; æt. 32; married, and the mother of four children. She has always enjoyed good health, and is not aware of the existence of any hereditary ailments in her family. She has been subjected to various trials within a few years, in the sickness of some of her children, but more especially in the business failure of her husband.
Disease History.-The symptoms of her present ailment began during lactation, about three years ago. She had more or less constant pain in the right side, chiefly in the intercostal space between the fifth and sixth ribs. About the same time she began to experience attacks of palpitation, lasting several hours. These frequently came on at night, and she was often awakened out of her sleep in a condition of great terror. During the attacks of palpitation she experienced a feeling of extreme anxiety and apprehension, independently of the cardiac disturbance, and an unpleasant suffocative sensation about the throat and neck. When she first consulted me for these troubles I did not realize the real nature of the cardiac disturbance, and supposed the intercostal pain and the paroxysms of palpitation to be manifestations of hysteria merely. For more than two years, and after weaning her child, these symptoms continued without any new developments, the paroxysms of palpitation becoming somewhat more frequent, and the pulse at times ranging much above the normal level. During one paroxysm I found the pulse had risen to 140, and the volume and rhythm were extremely varied. At all other times the pulse-rate continued at 86 to 90. During this period her general health declined. She got out of breath on slight exertion; her lips and tongue were pale, and the selerotic became pearly