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that she was more easily fatigued than formerly ; when the protrusion of the eyes occurred, she found that her vision was uncertain, and that in some positions she saw double. She consulted an eminent oculist in Cincinnati, who recognized the difficulty at once, but gave a very discouraging opinion as to the results of treatment.
Status Præsens.- When she presented herself for my opinion I noted the following: Mrs. R. is rather pale and anæmic, but is otherwise in tolerable health. She has a marked degree of exoph thalmos. When she looks forward, a rim of dead-white sclerotic appears around the cornea, giving her countenance a weird aspect. When told to look down, the upper lid does not follow the movements of the globe, and a broad band of sclerotic is visible above the cornea. This is more marked in the left than in the right eye. The pupil is about the normal size, and reacts readily to the light. She suffers from occasional dizziness, and has a subjective sense of pulsation in the ears. Her special senses are otherwise normal, and motility and sensibility are entirely unaffected. Her neck is rather full, but it is difficult to say that the thyroid is enlarged. There is no perceptible pulsation in the glands, and the carotids do not beat more energetically than in most persons under the excitement of a médical examination. . She has occasional, but not fre. quent attacks of palpitation. The pulse is soft, but is much more rapid than is normal, and appears to range at about 80 when she is in repose. The area of cardiac dulness is not increased, and there are no murmurs audible over the heart.
Her appetite is not good, her digestion is rather feeble and slow, and her bowels have a tendency to be relaxed. She is still losing flesh, and her appearance is now decidedly anæmic.
The exophthalmos is always increased at the menstrual period.
She was treated with the constant galvanic current in the manner described in the two preceding cases, and in addition had a current from five elements passed through the eyes. The applications were made twice a week for a period of six months, with the result to improve ber general health, and to remove entirely the exophthalmos and the palpitations. After several applications the fulness of the neck disappeared for a time, to return again, but it finally ceased altogether, and she has seemed to be entirely well.
Commentary. This case illustrates the fact that the exophthal. mos may be almost the only symptom. It further confirms what is stated by all authorities, that many cases begin with great
abruptness, and that the attacks, frequently, are caused by chagrin or other depressing moral emotions. The less prominence of the cardiac symptoms and the very marked protrusion of the eyes are also notable facts.
Cases corresponding to II. and III. are, of course, not very numerous, but Case I. is a type of a larger number. I do not know that my experience has been exceptional; but it has certainly happened to me to encounter many of this kind, and I must believe that if their nature were rightly interpreted, other physicians would meet them as frequently.
General Remarks.—A disease so interesting at all points as exophthalmic goitre, invites speculation into its origin and nature. My time will not permit me to enter at any length into the consideration of these questions, but some observations as to the name by which this disease is known, and as to the pathology, may not be inappropriate.
As the cases which I have brought forward, clearly enough indicate, the term exophthalmic goitre is not a correct designation. The exophthalmos may not exist; the thyroid may not enlarge ; but the increased action of the heart, to a greater or less extent, appears to be a constant phenomenon. By Graves, this disease was alluded to in connection with palpitation of the heart. Trousseau, believing that Graves was the first to describe it, called it Graves' disease. In Germany it is known as Bosedow's disease, because this observer carefully studied its pathology, and indicated the seat of the morbid alterations on which the symptoms depend. By Virchow it is treated of in connection with “strumen," and is entitled struma exophthalmica. Lebert invented the barbarous term tachycardia strumosa. As no constant morbid changes have been observed, and as so many cases are remediable, I think it may be held that this disease is a purely functional disorder, and that the important alterations which in some instances have been studied are accidental.
Thus, M. Fereol communicated to the society of the hospitals the particulars of a case in which, in addition to exophthalmic goi. tre, there existed symptoms of a spinal sclerosis. (Bulletin Général de Thérapeutique, vol. lxxxvii. p. 473.) The changes in the thyroid, except the dilatation of the vessels, belong to ordinary goitre, so called.
The anatomical alterations in the ganglia of the sympathetic which have been observed are not found in all cases.
The functional troubles of the heart and of the cervical vessels do not therefore represent appreciable organic lesions. The disease should be named accordingly. Our systematic writers classify the disease differently. As I have already stated, Virchow (Die krankhaften geschwilste, dritter band, S. 1) classifies it under the head of "strumen," and discusses it in connection with strumous disease of the thyroid, with cretinismus, with strumous disease of the pituitary body and of the supra-renal bodies. This is the pathological standpoint. Clinicians usually regard it from the point of view of the most obvious and constant phenomenon, the hypercinesia of the heart, and class it with cardiac affections ; such is the arrangement of Trousseau (op. cit.) and of Jaccoud (Traité de Pathologie Interne, tome 1re, p. 665) amongst the French, of Niemeyer in Germany (Am. ed.), and Flint in our own country.
If we should undertake to assign exophthalmic goitre to its true nosological position, according to our present physiological knowledge, it should be placed, as has been done by Eulenburg and Guttmann, amongst the disorders of the sympathetic.
That the motor influence of the heart is in part, and of the vessels both of constriction and of dilatation wholly, derived from the sympathetic, must be admitted as established.
That the pneumogastric is the regulator of cardiac movements, seems equally positively determined. The clinical phenomena of Graves' disease indicate that both sources of nervous supply are disordered-are depressed in function.
At all events, it seems evident that the curative value of the galvanic current is explicable on no other theory.
NOTICE OF THE BIOPLASSON DOCTRINE.
No mention is made, in the following paper, of Beale's protoplasmic or bioplasmic theory, as it would necessitate explanations deemed too complicated and out of place. Beale's doctrine is the forerunner of what I believe to be the full truth; it is intermediate between the cell theory and that now presented. On some other cccasion I hope to show my appreciation of the merits of Beale as an investigator, a discoverer, and a reasoner, and shall then endeavor to do him historical justice.
I claim no credit for coining the word bioplasson, as the word "plasson" has been proposed and explained by Haeckel, and the prefix " bio” has been used by Beale in connection with the designation plasma or plasm.
The ideas of humoral and solidistic pathologists long continued to influence medical teachings after Schwann's discoveries of the elementary structure of tissues were generally acknowledged as correct, and more or less consistently applied. It was really not until Virchow promulgated his celebrated lectures on cellular pathology, less than twenty years ago, lectures which reached and deeply impressed the medical profession in every portion of the globe, that the cell doctrine has had undisputed sway.
In Lecture I., delivered February 16, 1858, Virchow said: "If we consider the extraordinary influence which Bichât, in his time, exercised upon the state of medical opinion, it is, indeed, astonishing that such a relatively long period should have elapsed since Schwann made his great discoveries without the real importance of the new facts having been duly appreciated. This has certainly