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white and glistening; her appetite was poor, digestion slow and painful, and constipation alternated with attacks of colic and diar. rhoea. She experienced great depression of spirits, was wakeful at night, bad attacks of dizziness and singing noises in the ears, and her vision became dim and uncertain. She was altogether so miserable as to declare herself indifferent to life.
During this period she received the usual tonic and chalybeate medicines without any marked relief. Nine months ago, during one of her paroxysms of palpitation, I observed that her eyes had a somewhat staring look, and, when told to look down, the diag. nostic sign, so much insisted on by Graefe, had become evident, i. e., the upper lid did not follow the downward movement of the globes. Close examination of the neck disclosed an abnormal full. ness of the thyroid region, especially on the right side; but it was by no means well-marked or conspicuous. The character of the case was now made plain. Abandoning all medicines, and directing a suitable hygiene, I used the constant galvanic current as the remedial agent. I applied twenty elements of Siemens and Halske, the negative pole being placed on the epigastrium, and the positive being so applied as to include the cervical sympathetic, the pneumogastric, and the cilio-spinal region within the circuit. The seances were ten minutes in duration. The immediate effect of the application was to slow the action of the heart to about the normal, and several applications caused the almost total disappearance of the unpleasant symptoms. Acting by my advice, she has occasional applications made with a view to prevent the recurrence of the symptoms.
Commentary.—This case perfectly exemplifies the observation of Graete that in many subjects, women especially, exophthalmic goitre may exist for a long time without any other symptom being present-beside the increased action of the heart--than incoördi. nation of the ocular globe and the upper eyelid. When a marked increase in the action of the heart continues for a long time without apparent cause in a young woman, and is accompanied by more or less anæmia, this fact alone is strongly indicative of that pecu. liar modification of the functions of the sympathetic system to which we apply the term exophthalmic goitre. The usual tonic medication employed in these cases, changes in the social state, and various moral influences may arrest the further development of such cases, and they may never proceed to that point in the manifestation of their objective signs which will determine their
proper nosological classification; yet in their essential nature they rest upon precisely the same modifications in the functions of the sympathetic system.
The quick and lasting improvement which followed galvaniza- tion of the sympathetic is another striking effect illustrative of the proper method of treating such cases. As the functional disorder of the heart, the anæmia, and the other objective and subjective phenomena, are dependent on a change in the sympathetic, and, probably, also the pneumogastric, it is certainly more rational to act upon the pathological cause than to commence by treating the effects of the central lesion.
CASE II.—Palpitation and Increased Action of Heart; Goitre of many Years' standing; Pigmentary Discolorations of Neck and Hands; Cachexia, etc.
Personal History.—Mrs. R., æt. 54. Dark hair and eyes, full habit, and weighing one hundred and fifty-two pounds. A widow, mother of two children. A lady of very considerable culture, refined, and having an excellent social position. Having had ample means she has lived a rather luxurious life, entertained largely during the life-time of her husband, and has always been engaged, often very closely, in various social and religious enterprises.
Since the death of her husband, four years ago, she has had a great deal of anxiety, some business and pecuniary troubles, and has changed somewhat her mode of living. During her whole married life she has been remarkably active, cheerful in disposition, and free from bodily ailments, except the derangements to be presently described.
She passed through the climacteric period without accident, and has had since no troubles in the pelvic viscera. There is no history of hereditary neuroses.
Disease History.—For about fifteen years she has had a considerable tumor of the thyroid, and attacks of palpitation of the heart of great violence. The size of the goitre has varied from time to time, and she bas always observed a considerable enlargement during the attacks of palpitation. The paroxysms of cardiac ex
. citement have usually lasted twenty-four hours, and the maximum number has been three in each week. She has observed that her pulse- beat has, during the whole period of the existence of the cardiac trouble, been much above the usual rate. The condition
of the thyroid and the attacks of palpitation have varied a good deal during the years in which they have existed, but a decided increase in them has been observed since the climacteric, especially within the last two years.
Status Present.—Mrs. R. is extremely well-preserved for her years. She is very slightly gray, has no arcus senilis, and the arteries at the wrist are not rigid.
Brain and Nervous System.--She has occasional attacks of vertigo and strange sensations in the head, but suffers most from the intense beating of the carotids. During the attacks of palpitation her sleep is disturbed by the noises in the ears and the strong whizzing pulsations. Her special senses are normal, and there is
, no alteration in the sensibility to touch, to pain, and to temperature. There is no exophthalmos, and no defect of coördination in the movements of the ocular globe and the upper lid. Her face has, however, a somewhat startled look, but I am assured that no alteration of expression has been observed by her friends.
Circulatory System.-The action of the heart is at all times heav. ing. The area of cardiac dullness is increased in all directions, but there are no murmurs. Under the most favorable circumstances as to quiet, her pulse is never less than 96, and, during the paroxysms of palpitation, rises to 120 and even to 140. It is irregular as to rhythm, but there are no intermittences, true or false. The sphygmographic traces exhibit the following peculiarities: the length of the pulse waves varies considerably, the summits are rounded, the dicrotism is but faintly marked. There is an obvious difference in the energy of the radial as compared with the carotid pulsations. The carotids, especially the right, at all times pulsate strongly, but in one of the paroxysms the pulsation is vehement. The thyroid has a distinct expansile movement of great force, which, during the attacks of palpitation, has the vigor of an aneurism. A low wbizzing murmur is heard when the stethoscope is applied to the thyroid. The size of the gland is greatest when the paroxysms occur, and it shrinks somewhat in the interval, but it is at all times quite voluminous. The greatest variations in its size take place on the right side; the left side remains pretty constantly enlarged, and the isthmus, which is very prominent, appears to have undergone considerable hyperplasia, and is decidedly firmer than the rest of the organ.
Mrs. R. has suffered from huskiness of the voice, and the vocal register is greatly diminished, so that she is no longer able to sing. She says her voice has become “weak.” She experiences at times also a sense of suffocation, and a constant feeling of weight and uneasiness about the throat. She finds herself becoming fatigued very easily, and she gets out of breath on making any slight exertion. She has no cough nor other pulmonary trouble.
Digestion and Nutrition.—Mrs. R. has a very good appetite, but she suffers from various disorders of digestion. She regurgitates her food at times, and has considerable flatulence and acidity. Her stools are rather light in color, and appear to be deficient in bile. Her urine is high-colored, charged with urates, and rather scanty than excessive. She has lately been losing a little in flesh. Within a year she has observed a change going on in the color of her skin. Large pigment deposits are taking place about the neck and sternal region, and on the hands. The latter are symmetrically placed on the dorsal aspect of the hands, are about two inches in diameter, and are surrounded by abnormally white integument (leucoderma). The skin of these pigmented spots is rough and gives off fine furfuraceous scales.
Progress of the Case.-Recognizing the case as the chronic form of exophthalmic goitre, I commenced at once the treatment by the constant current, using fifteen to thirty elements of Siemens and Halske on alternate days. The applications were made as in the case already detailed. An immediate improvement took place in the paroxysms of palpitation, and in the pulsations in the neck, and the thyroid rapidly diminished in size. The isthmus still
. remains hard, and is yet prominent, but the rest of the gland appears now, after four months' treatment, to be normal in size and firmness. The expansile movement of the gland has entirely disappeared, and the unpleasant beating of the carotids is no longer felt. The disorders of digestion have almost entirely ceased, and the color of the stools is becoming normal, and she is beginning to gain slowly in weight. There has been no decided change in the abnormal pigmentation. The paroxysms of palpitation are less frequent, and much less severe. She is still under treatment, receiving, however, now but one electrical application each week.
Commentary.--The long existence of these symptoms without the exophthalmos is remarkable, but the other symptoms are eminently characteristic. The strange look about the eyes, although not very definite, must be regarded as the beginning of a change which would finally have eventuated in exopbthalmos. M. Dujardin-Beaumetz (Bulletin Général de Thérapeutique, tome lxxxvii., p. 521) has recently related a cose of this disease in which vitiligo existed, and which he considered a trophic change, referable, of course, to the derangement in the functions of the nervous system. The abnormal pigmentation is an accident, and is not a necessary. symptom, and may have some relation to the disturbance of the hepatic function. Various troubles of the nervous system may coexist with exophthalmic goitre, as also changes in the heart and great vessels, and in the thyroid, but these are complications, and not essential symptoms.
The remarkable change in the goitre under the influence of the galvanic current, is an important fact. The electrolytic treatment of goitre has proved extremely disappointing; occasionally very brilliant results are obtained. It is
It is very probable that in these successful cases the thyroid was enlarged by the dilatation of its vessels, and by effusion of serum into its substance-conditions removable by galvanism; of course, when cystic and calcareous degenerations have taken place in the thyroid, galvanism as well as the other remedial measures will prove futile. In the above case the goitre proved rebellious to a long.continued course of iodineinternally and locally—a fact, in respect to true exophthalmic goitre, which Trousseau has observed, and on which he has commented in his interesting lecture on this topic.
CASE III.— Very marked Ecophthalmos of two Years' Duration; Slight Enlargement of Thyroid; Palpitation and Increased Pulse. rate.
Personal History.—Mrs. B., a tall fine looking woman of fifty years; married and the mother of four children. She is in humble circumstances, and has suffered social reverses. She is cheerful in disposition, bustling in manner, and quick in all her movements. Her complexion is fair, eyes blue, hair dark brown; her general health has always been good; she is still regularly menstruating, and is free from pelvic disorders of any kind.
Disease History. After suffering a night of considerable anxiety two years ago, her friends, next day, called her attention to a protrusion of her eyes. On looking into a mirror she was startled to observe that her countenance had a wild staring look, due to an unnatural prominence of her eyes. Previously to this she had noticed that the action of her heart was occasionally rapid, but there had been no enlargement of the thyroid ; she had also observed that she was losing flesh, that she had become pale, and