THE TREATMENT OF EXOPHTHALMIC GOITER. 
BY 
J MADISON TAYLOR, M.D., 
OF PHILADELPHIA ; 
PROFESSOR OF DISEASES OF CHILDREN IN THE PHILADELPHIA POLYCLINIC, AND 
IN THE MEDICO-CHIRUKGICAL COLLEGE; NEUROLOGIST TO HOWARD 
HOSPITAL, BTC. 
FROM 
THE MEDICAL NEWS, 
December 16 and 23, 1893. [Reprinted from The Medical News, Deer. i6and 23, 1893.] 
THE TREATMENT OF EXOPHTHALMIC GOITER} 
By J. MADISON TAYLOR, M.D., 
OF PHILADELPHIA; 
PROFESSOR OF DISEASES OF CHILDREN IN THE PHILADELPHIA POLY- 
CLINIC, AND IN THE M BDICO-CHIRURGICAL COLLEGE; 
NEUROLOGIST TO HOWARD HOcPITAL, BTC. 
Five years ago I wrote a brief paper on the early 
recognition of exophthalmic goiter and reported a 
number of cases.2 Since then other cases have come 
under my observation, both in my own practice and 
in that of friends. These I have carefully consid- 
ered, especially from the standpoint of curability. 
Most of my original cases are now well, and I shall, 
in brief, report their present condition and the 
means that were used to bring about this good re- 
sult. Others will be referred to as illustrating inter- 
esting features. 
In looking over the literature of exophthalmic 
goiter, I notice that there is a growing conviction, 
which I myself have always felt, that this disorder 
is a very manageable one. Undoubtedly some cases 
are not to be made well; certainly a large propor- 
tion can be most satisfactorily helped, and many 
entirely cured. The general measures that I have 
employed with advantage have chiefly the ele- 
ment of rationality to recommend them. It has 
been said, and rightly, that those disorders which 
have recommended for their treatment the largest 
array of medicines and measures are the ones of 
which we know least. Certainly a large and con- 
1 Read by title at the meeting of the American Medical Asso- 
ciation, June 6, 1893. 
7 Journal Amer. Med. Assoc., April 14, 1888. 2 
trary lot of remedies are urged for this disorder; 
some are claimed by their authors to be almost spe- 
cific ; others are backed up by a large array of cases; 
and yet few, to my mind, are, singly considered, 
much better than the rest. 
In looking over my paper referred to, certain con- 
clusions then formulated seem still to obtain with 
equal force. The most important measure is the 
early recognition of the symptoms that in their 
entirety represent the malady. I am inclined to 
doubt more strongly than ever that, with early re- 
cognition and judicious treatment, the disorder need 
at any time become so serious in its results as we 
have been led to believe. 
Without discussing the reasons at length, my con- 
victions are that exophthalmic goiter is a vasomotor 
disturbance, and not related to any specific disease 
of the thyroid gland. It has not been shown to 
have any connection with the functions of the thy- 
roid as a trophic organ, or at any rate to depend 
upon either an increase or a diminution of the 
normal secretions of that gland.' It has hap- 
pened that all of the symptoms of Graves’ dis- 
ease have come on with great suddenness, in conse- 
quence of profound emotion, and in persons with, 
presumably, normal thyroids, and have again disap- 
peared as abruptly. Unless further evidence shall 
be adduced to the contrary, I am inclined to regard 
the disorder as a cardio-vascular erethism,3 or, to 
use the term coined by my friend Dr. S. Solis-Cohen, 
as a “vasomotor ataxia.”3 
In this connection certain tropho-neuroses are of 
the deepest importance therapeutically. The group 
of trophic and vascular disturbances associated with 
enlargement of the thyroid gland, including exoph- 
thalmic goiter, myxedema, cretinism, and akrome- 
1 Putnam: Trans. Association of American Physicians, 1893. 
2 Dieulafoy : La France Medicate, August 19, 1892. 
3 Times and Register, March 18, 1893. 3 
galia, are receiving a good deal of attention, both 
as to their pathology and as to their treatment, and 
from this search light tendency of medical science 
much is to be hoped. I would be glad to believe 
that specific results could be hoped for from the 
absorption of thyroid juices and similar measures, 
and myself use these in suitable cases. Mean- 
while, my present purpose is to relate such meas- 
ure of success as has come to me, and indicate the 
lines upon which it has been obtained, holding in 
reserve the brilliant possibilities referred to. 
I am inclined to agree with Raymond and Ser- 
ieux,1 who consider exophthalmic goiter a bulbar 
neurosis, manifesting itself in an exaggeration and 
permanence of the physiologic phenomena of emo- 
tion, placing the emotional state at the foundation 
of the disease as a pyschic anomaly, a derangement 
of vasomotor centers, coinciding with analogous 
troubles in other centers of the cerebro-spinal axis. 
There are to be found in this disorder certain asso- 
ciated psychoses, with evidence of hereditary taint, 
signs of physical degeneration, mal-development of 
the facial area in the central cortex, vaulted palates, 
etc., seen in developmental neuroses. 
Of the three features that constitute the classic 
symptom-group of Graves’ disease, it is now admit- 
tedly possible for any two to be absent, or at least not 
constantly recognizable. It is common to find the 
thyroid enlargement absent; next most common to 
find exophthalmos not present; and possible, 
though rare, to find the circulatory disturbance to 
be practically wanting, in the presence of the ocular 
and thyroid symptoms. 
The most important phenomena of the disease are 
connected with disturbed circulation. One or an- 
other of the more pictuiesque symptoms may be tem- 
porarily absent; not seldom the thyroid irregularly 
enlarges and collapses ; the exophthalmos also comes 
1 Revue de Medecine, December, 1892. 4 
and goes; but in my experience there is seldom an 
absence of irregular or easily disturbed vascular con- 
ditions. In two cases I have seen the more dis- 
tressing symptoms quite disappear, but either slight 
exophthalmos or moderate thyroid enlargement, or 
both, remained. I have had two ladies under obser- 
vation for seven and ten years respectively, who are 
practically well, and in whom the exophthalmos per 
sists ; and another who has considered herself well 
for over a year, but whose thyroid is still noticeably 
large. The thyroid enlargement seems to me to be 
the first symptom to definitely disappear, although 
in the case referred to it has persisted after the sub- 
sidence of the other symptoms. 
The next most common feature is the relaxed state 
of the sweat-glands. This seems to be a uniform 
feature, and remains much the same in most cases. 
I have seen cases of slight vasomotor ataxia in which 
flushes came and went; but ordinarily there is a 
pallid, oleaginous appearance, which persists, giving 
the skin a macerated look, with rarely any offensive 
odor. Urination is not commonly disturbed ; hemo- 
globinuria is rarely seen ; purpuric areas occasion- 
ally appear ; and slight hemoptysis and hematemesis 
may take place; nor is it common to see edema. 
In one particularly severe case, which terminated in 
wild insanity, I have noted persistent edema; when 
it occurs it only appears intermittently. 
The temperature fluctuates considerably. In first 
interviews, which are attended with a certain element 
of nervous emotion, it is quite common to find the 
temperature above ioo° F. In the same individual 
a short time afterward, the temperature taken in the 
mouth may be subnormal. In such cases as I put 
to bed for systematic rest, a rise of temperature is 
almost always noted for the first three or four days, 
followed by a steady falling until the normal is 
passed, the temperature remaining subnormal for 
three or four days, and then creeping back to the 5 
normal, and remaining at this level, or a little below, 
for several weeks. 
The rapid variation in arterial tension accounts 
for the intermittent albuminuria, the mild polyuria, 
and other changes in the renal secretion, as well as for 
the occasional blood-spitting, together with distur- 
bances of special sense, as roaring in the ears, head- 
ache, fluttering of the heart, altered heart-sounds, 
dyspnea, etc. The tremor that Gowers refers to I 
have not often seen, except in the form of occasional 
tremulousness of the lip or tongue, and then mostly 
under excitement; but a more or less constant vibra- 
tile quality in the voice is always suspicious. The 
sensory disorders are not many, headache being the 
chief, as in one of the cases here related, in which 
this persisted throughout life, almost daily, worse in 
the morning and in certain attitudes, as stooping 
down, and sometimes suddenly becoming so severe 
as to cause vomiting. 
The Von Graefe lid-symptom seems to be re- 
garded as of less significance among clinicians as 
time goes on. Sharkey1 has examined 613 patients 
of all kinds, and among them found 12 that pre- 
sented this symptom. He states that in people of 
good health it can be frequently induced by staring 
fixedly. It constantly fails to be present in Graves’ 
disease, and its diagnostic significance is small. The 
electric resistance of the body, too, has failed of its 
early promise as a useful indication, as hopefully 
outlined by Norris Wolfenden. It had come to 
mean little to me long ago, and observers generally 
now regard it as of small account. H. W. Carduff2 
finds the electric resistance diminished in 15 of 20 
cases of exophthalmic goiter, and remarks that the 
phenomenon is worthless as a diagnostic sign, as it 
varies with the moisture of the skin. When we 
consider that the moisture of the skin is almost 
1 British Medical Journal, October 25, 1890. 
2 London Lancet, February 28, 1892. 6 
constantly marked in well-defined instances ot 
exophthalmic goiter, the only wonder is that much 
significance was ever attached to an alteration in 
the electric resistance as a symptom. 
The order in which the characteristic symptoms 
appear is not always easy to determine. I am in- 
clined to agree with Jaccoud,1 who puts it as follows : 
palpitation, dilatation of arteries, enlargement of 
thyroid, exophthalmos. A point that seems to me 
to be useful, though rather a result of the charac- 
teristic changes that take place, is the diminished 
respiratory range or chest-expansion pointed out by 
Fiske-Bryson.2 I had noticed that the respiratory 
movements of sufferers from exophthalmic goiter were 
almost as much disturbed as the cardio-vascular 
mechanism; and, purely from the therapeutic stand- 
point, had been accustomed to urge upon patients 
the use of forced inspiration. This s.ems to me a 
very tranquilizing measure, and one that is a proper 
part of systematic hygienic measures. In the more 
recent cases under my observation this limited ex- 
pansion of the chest has been observed. Bronzing 
of the skin is not common ; uniform changes, as 
pointed out in my original paper, such as a greasy, 
macerated-looking skin, are much more likely to be 
present, possibly as a result of the paretic condition 
of the surface-vessels. There seems also to be an 
excessive secretion of skin-oil, recognizable by the 
touch as well as the appearance. 
Stellwag’s sign—retraction of the upper eyelid—I 
have rarely seen. 
Charcot has somewhere directed attention to the 
importance of elevation of the temperature as a 
diagnostic point. In my experience, such an eleva- 
tion only persists when the patient is upon his feet 
and moving about. As I have pointed out elsewhere, 
1 New York Medical Journal, February 23, 1891. 
2 Ibid., December 14, 1889. 7 
when such a one is put to bed, the temperature 
subsides after a few days and becomes subnormal. 
Mackenzie 1 makes the statement that when the 
clinical picture of exophthalmic goiter is incomplete 
the disease is rarely fatal; but when the picture is 
well marked, the disease is dangerous to life. There 
are times when death occurs apparently from an 
overwhelming disturbance of circulatory balance 
—in short, a death from the disease itself; but it 
rarely seems to be due to trophic changes referable 
to the pathology of the thyroid gland. 
My conviction is that exophthalmic goiter is much 
less rare than is generally believed, and that it is also 
far more amenable to treatment than is usually taught. 
Unless there coexists serious structural disease, excel- 
lent results, in more instances a practical cure, may 
be looked for if the treatment be persistently and 
systematically pursued. The results in my own 
cases have taught me to give a favorable prognosis ; 
and if specific medication with thyroid juices and 
thyroid removal prove of value, these may add much 
greater possibilities. 
It has been my experience to see several cases 
not clearly definable as Graves’ disease, wherein 
the symptoms of cardio-vascular erethism were most 
distressing. These were often superadded to organic 
disorders and generally complicated with hysteria. 
The patients responded most promptly to tran- 
quilizing agents directed to the loss of vasomotor 
balance and, in so far as this feature went, were 
readily relieved. It is reasonable to assume that 
from such cases as these, full-blown instances of 
exophthalmic goiter may and sometimes do arise. 
A very important point clinically is that too often 
the significance of these symptoms is not recognized 
and treated, as well as that the difficulties in inducing 
such patients to persist in systematic measures for 
the long periods required are very great. 
1 London Lancet, September 20, 1891. 8 
The treatment of exophthalmic goiter is modified 
in various hands by the conception of the physician 
as to the nature of the condition, whether it be a 
blood, cardiac, neurotic, or thyroid disorder. It 
must be also recognized that a person suffering from 
this trouble is always on a lowered plane of health. 
The degree of this may be much more serious than 
would appear on the surface; certainly a modifica- 
tion of the ordinary activities of the patient must be 
outlined, and under most circumstances very little 
laborious work allowed. When it is possible, abso- 
lute rest in bed is indicated for a time. A diet of 
the most uniform and tranquillizing kind, such as 
milk, the regular milk-diet such as Kareli outlined, 
is usually of use to bring the disturbed circulation 
as soon as possible on an even plane. This may be 
amplified by a judiciously selected diet in propor- 
tion to the depression of nutrition that may exist. 
The diathetic element that may be back of the 
disorder needs careful consideration ; in some of 
my cases it was found to be lithemia. Along with 
attention to the diet there must be large care in the 
treatment of the skin. This may take the form of 
salt sponge-baths, given by another while the patient 
is in bed, and finally, as strength improves, taken 
by himself; a tablespoonful of salt in a basin of 
water regularly applied on waking in the morning, 
after some little fluid nourishment; this to be fol- 
lowed by a brisk, rough rub from head to heel; 
afterward breakfast. When the skin is greatly at 
fault, this may be repeated before bedtime with ad- 
vantage, or to supplement the skin-stimulation the 
dry salt towel may be used more or less often; 
again, an aromatic vinegar on a damp sponge may 
be applied to the more leaky parts, as the soles of 
the feet and the palms of the hands, about the small 
of the back. This aromatic vinegar can easily be 
made in any household by taking a pint of good 
white wine-vinegar and adding a dozen or more of 9 
cloves, allspice, and whole peppers, and allowing 
it to steep. A tablespoonful or more of this applied 
on a moistened sponge is very comforting and re- 
lieves the over-damp skin wonderfully. In giving 
massage it maybe important to use drying powders, 
such as talc or lycopodium, until the patient can 
endure the manipulations. A measure recommended 
by some, notably by J. L. Corning, for giving tone 
to the skin is hot bathing followed by cold ablution, 
but for my part I have rarely seen the need of it. 
During conditions of great restlessness, no doubt 
this would aid in securing sleep. The hot, salt sea- 
water baths might be very useful to this end, and I 
have, indeed, ordered them temporarily in a few 
instances, with advantage, but my dependence is 
rather upon the cool salt water, the aromatic vinegar, 
and systematic surface-rubbing, as well as upon 
such internal remedies as hyoscin hydrobromate in 
sufficient doses. 
Wool or silk should always be worn next the 
skin, inasmuch as the cause of the disorder is 
often closely related to surface-chill. The frequent 
changing of the underwear, too, is a minor point of 
large significance. It is bad enough for the surface- 
exudations to remain uneliminated, but it is worse to 
keep them locked in by the clothing. If skin-leakage 
be extreme, it is important to change the underwear 
several times a day, employing, if possible, a brisk 
dry rub each time. 
For the over-acting, tumultuous heart, there is 
nothing so certain to steady its beat and lower its 
frequency, and generally to tranquillize the whole 
cardio-vascular mechanism, as ice applied to the 
precordium. Care is needed, of course, lest some 
damage be caused by this very powerful agent. Ice- 
bags over the spinal region, too, exercise some 
value. In conditions of profound tumult of the 
heart this is valuable, and many times is useful as a 
more or less routine measure. Galvanization of the 10 
great sympathetic and faradization of the cardiac 
region are highly prized by a number of observers, 
but I have never seen them do the wonderful things 
that Charcot, Rockwolf, and Lewandowski have 
claimed for them, although I think I have seen 
them do distinct good in a few cases. I have given 
faithful trial to the carbazotate of ammonium, as 
recommended by Hammond1 and by Boaz,2 in three 
cases, with no noticeable result, while the offensive- 
ness of the drug is beyond description. 
Many writers say that digitalis will not modify the 
heart’s action. Alone probably not, and yeti have 
had very good results from digitalis. Strophanthus 
seems to do better, although physiologically one 
might not expect it. Spartein sulfate may be even 
better yet. Many different kinds of vascular tonics 
are useful in this disorder, and it cannot always be 
predicated which will do best. The one drug that 
has served me best of all, and to which I look 
with great confidence in modifying the discomforts 
and dangers of this disorder, is hyoscin hydrobro- 
mate. This serves to tranquillize the overwrought 
emotions, puts the economy into a reposeful state, 
dries the surface over-secretions, oftentimes without 
causing uncomfortable drying of the throat, relieves 
the feeling of chilliness by checking surface-moisture, 
exercises a beneficial effect upon the renal vaso- 
constrictors, and in many ways may be regarded as 
a most useful ally. In one case here reported this 
was the chief agent employed in subduing a head- 
ache that had existed for half a lifetime and for 
which much medication had been endured ; to be 
sure, galvanization of the thyroid was also used, and 
some general measures directed to the patient’s 
nutrition and relief from laborious occupations en- 
forced. In the case of this poor woman, who was 
compelled to do a large amount of daily work, to 
1 New York Medical Journal, January 25, 1891. 
2 Western Medical and Surgical Reporter, September, 1891. 11 
prepare her own food and her husband’s, and to 
sustain and carry on many responsibilities, prompt 
recovery took place from a condition that had per- 
sisted for many long and weary years. I will not 
say too much about the value of hyoscin hydrobro- 
mate, because the notes of my cases show this well 
enough. Dr. S. Solis-Cohen gets excellent results 
from picrotoxin.1 
Certain ones, as Kummell,1 have removed the 
thyroid in cases of exophthalmic goiter, leaving 
part of the left lobe, with favorable results. It 
does not seem to me that all of the good attri- 
buted to this operation lies in the removal of the 
thyroid, much of it possibly being the enforced rest 
and regulation of living. Nevertheless, I should 
welcome any specific agency, such as the surgical 
removal of an offending part, or the use of thyroid 
juices internally, if we could by this means radically 
negate the effects of errant thyroid activities. 
Chevalier3 maintains that the tachycardia is due to 
an affection of the nucleus of the vagus, the struma 
and exophthalmos being dependent upon the tachy- 
cardia, and declares the cause of the disease to be 
1 Extract from letter of Dr. S. Solis-Cohen : “ Concerning my 
use of picrotoxin in cases of Graves’ disease and other forms of 
vasomotor ataxia, I would remind you that I learned the practice 
from Prof. Bartholow, having seen the good re ults in a case of 
exophthalmic goiter, attended with purpura, treated at the Jeffer- 
son Medical College Hospital during my service as Chief Clinical 
Assistant. I give from one-eightieth grain to one-twentieth grain 
thrice daily, the indications being found principally in the vas- 
cular phenomena of the cutaneous and mucous surfaces and 
glands; that is to say, sweating, profuse discharge of saliva, 
coryza, and tendency to heat and redness of the skin, suggest 
the use of this drug. In cases showing constriction rather than 
relaxation of vessels, it is less applicable. I have sometimes found 
the combination of ergot and picrotoxin better than picrotoxin 
alone ; in other cases barium chlorid (one-eighth grain) has been 
combined with it. . . At the same time I have considerable con- 
fidence in picrotoxin as a tonic to the taxic power, or center, in 
these cases of vasomotor disorder." 
2 Deutsche med. Wochenschr., May 15, 1891. 
8 Neurolog. Centralbl., September, 1892. 12 
an intoxication of the nervous system through by- 
products of the thyroid. Many tonics might be 
considered in this connection. Iron is frequently 
indicated, especially the more digestible forms, as 
the carbonate, Flint’s chalybeate pill, the vegetable 
salts, the malate, and the old-fashioned and reliable 
lactate. However, it is needless to go over a list of 
tonics suited to varying conditions and cases. 
Nutrient tonics are the best; good diet, very care- 
fully adjusted to the needs of the patient. This at 
first may, with advantage, consist largely of milk, 
then enlarged by graduated increments, as the case 
demands, with aids to digestion, and then malt 
and cod liver oil. The mechanical tonics, massage 
and faradic electricity, are of great value. The 
entire environment of the individual should be 
carefully reviewed, emotional disturbances rigidly 
excluded, and, when possible, physical and mental 
strains removed. The isolations of a complete rest- 
treatment probably offer the very best opportunities 
of all; and finally, graduated activities in the form 
of Swedish exercises, systematized outings, and 
restful life in a dull country-place. The correction 
of refractive errors of the eye is always of the 
greatest value. 
A review of the cases is herewith appended : 1 
Case I.—Graves’ disease; enlarged thyroid; 
marked circulatory disturbince; no exophthalmos; 
dyspnea; convulsions, originally perhaps epilep- 
tiform, but later hysteric. 
The cause was found to reside in a neurotic 
tendency, conjoined with repeated exposure to 
cold, and sitting in wet shoes during work, at 
the age of nineteen, culminating in a pro- 
found attack of exhaustion, nervous chill, rapid 
heart-beat, and overwhelming sense of suffocation. 
From this time on the heart was markedly disor- 
dered. There were present, together with several 
hysterical manifestations, repeated hemoptysis, 
1 Journal of the American Medical Association, April 14,1888. 13 
cough, and progressive emaciation. An alarming 
attack of blood-spitting sent her to a hospital for 
four weeks, where she was treated for pulmonary 
tuberculosis. Soon afterward the urine was sup- 
pressed for three days, without pain; then a dark, 
offensive fluid passed, and gradual recovery followed. 
Finally, another profound over-exertion, five years 
ago, brought her under my care. The examination 
then showed a pale, thin, unmarried woman, aged 
twenty-three; the respiration from 24 to 30; the 
pulse fairly regular, from 130 to 135; constant 
cough, throbbing carotids; pupils widely dilated. 
There was complete mydriasis, but no lesion of the 
fundus. The heart was laboring; a loud, musical 
murmur was heard over the base ; the apex-beat was 
displaced downward and outward; bruit de diable 
was heard. The thyroid gland was enlarged, 
especially the right, and conveyed a thrill to the 
hand ; the neck measured inches in cir- 
cumference; the skin was pale and oily-looking; 
sweating occurred readily, and chilliness caused 
distress; the legs were edematous ; menstruation had 
been absent for three years ; the bowels were con- 
stantly loose ; the urine was small in amount, bright- 
red with blood, and had a specific gravity of 1009; 
no casts; the knee jerks were excessive. 
Treatment wras as systematic as the circumstances 
would permit: carefully regulated feeding and rest; 
simple, diluent drinks ; iron in the form of Basham’s 
mixture and digitalis; hot hip-baths; belladonna- 
plasters over the excited heart; later, cod-liver oil 
and bromids with digitalis. In a week the pupils 
became responsive to light, the cough greatly mod- 
erated, the urine was only smoky, and the heart- 
sounds better defined. Her circumstances at home 
were exceedingly unfortunate; dominated by a fierce 
virago of a stepmother, and perpetually under dis- 
tressing domestic environment. However, in six 
months the girl seemed practically well. Twice 
since treatment the pupils have been widely dilated 
on catching a slight cold, and once only the urine 
showed albumin again. The menstruation has ap- 
peared twice; the pulse has been reduced to 85 or 
90 in the erect posture. 
The subsequent history of this case I followed 14 
throughout three or four years at varying intervals. 
Electricity was used for a time, but she would not 
continue it. General measures directed toward 
improving her health and relieving her troubles, 
domestic and physical, were satisfactorily pursued, 
and when the girl passed out of sight, I think by 
moving to a distant part of the country, she con- 
sidered herself perfectly well of the original diffi- 
culty. The skin-activity returned until nothing was 
left to mark the original seat here but a slight 
tendency to leakiness. The pulse maintained a fair 
equilibrium, the thyroid enlargement had entirely 
disappeared, and I regard the case as cured, in spite 
of the very unfavorable attendant circumstances. 
The woman made a very unfortunate marriage with 
a man who drank and who abused her. She lived 
with him for six or eight months, then finally 
abandoned him, and took up several different kinds 
of laborious work, maintaining htrself comfortably. 
At last accounts, in the year 1891, she was going to 
live with relatives in a distant place. 
Case II.—Mrs. H., aged twenty-eight, gave no 
neurotic history. She had two living children ; 
there was marked exophthalmos, with the presence of 
Von Graefe’s sign ; irregular, excitable circulation ; 
steady loss of vigor; slight, though well defined, 
thyroid enlargement. She had been under my 
observation since 1881. The difficulties for which 
I originally treated her had to do with menstrual 
derangements and great dyspnea; the pulse varied 
constantly with the smallest emotional changes, 
and slight exertion caused it to run up to nearly 200 
and produce distressing trouble with the breath. 
This lady was in comfortable circumstances, but, 
nevertheless, her responsibilities as a mother could 
not be entirely ignored—certainly she would not 
obey directions as I would have liked—nevertheless, 
I enforced as much of systematic feeding, rest, and 
other measures as possible. The medicinal measures 
consisted chiefly of digitalis and ergot, together with 
iron and other tonics, and in six or eight months 
there remained only the dusky, oily skin, the eye- 
symptoms and the lid-symptoms, and a somewhat 
irregular heart. Relapses occurred now and then, 
but in the main steady improvement took place, 15 
and was greatly increased, I am inclined to think, 
by carefully adjusted glasses, immediately after 
which the exophthalmos materially lessened. 
It is interesting to mention that although a dis- 
tinguished obstetrician, whom I had in consultation 
with this lady, pronounced it impossible for her to 
bear a living, healthy child again, yet I subse- 
quently delivered her at term of three fine children, 
each of which she suckled for a full year, and at the 
time of the report then given there was no heart- 
trouble and no goiter. This lady has been under 
my observation ever since. She has grown stronger 
year by year, and is to-day a more vigorous person 
than when first married. 
Case III.—Well-marked Graves’ disease ; extreme 
nervousness; cardiac distress; exophthalmos; thyroid 
enlargement. 
Mrs. R., aged thirty-six years, married, with 
one child, at the age of thirty-four setmed in per- 
fect health. She weighed 130 pounds, and was sur- 
rounded by every luxury and care. She had sustained 
no shock or fright and had suffered no exhausting 
disease. While sitting in perfect health in a theater 
she suddenly had, from no known cause, a nervous 
chill, and from that time her disorder rapidly grew. 
The chills recurred frequently, changing to what 
she described as waves of feeling up and down the 
body. On the slightest exertion a sense of con- 
striction in the chest and sweating of the skin would 
occur. The bowels were loose; the sleep broken, 
the woman lying awake for hours with a feeling ot 
deadly fear. She had fallen to 110 pounds in weight, 
and presented a frightened, restless expression. The 
eyes were slightly prominent; Von Graefe’s sign 
was present in slight degree; the cornea was in- 
jected. The voice and hands were tremulous on 
movement, and there was a general restlessness of 
manner. The carotids throbbed and the pulse was 
from 125 to 135 in the recumbent posture. An 
irregular, loud, musical murmur was heard in the 
precordia. The skin was bronzed and glistening, 
the hands and feet chilly. The enlargement of 16 
the thyroid was symmetrical, coneying a thrill to 
the hand. Some improvement followed rest and 
tonics. After passing from under my observation 
she fell into the hands of a gynecic surgeon, and, 
under a slight operation, suddenly sank and died. 
No autopsy was allowed. 
This case is interesting from the sudden, unex- 
plainable onset, there being literally nothing upon 
which to place the finger, except*the sudden chill, 
as stated, and the progression of the disease. The 
nature of the disturbance was not recognized or 
treated, and my recollection of the case is quite 
vivid. The family physician had urged “gentle 
exercise, simple food, and change of scene.” I 
had an opportunity of seeing the woman for only a 
very short time, while she was under the care of 
Dr. Weir Mitchell, who endeavored to do what could 
be done, but for some reason or other she passed 
over into the hands of the surgeon, as stated. 
Persistent careful treatment in the right direction 
would probably have saved this woman for many 
years of useful, comfortable life. 
Case IV.—Graves’ disease ; slight exophthalmos ; 
slight th) roid enlargement; irregular cardiac action ; 
delusions; rapid loss of flesh ; began a year previously 
to lose flesh rapidly during a severe dysentery ; 
aged thirty-nine; had had ten children in rapid suc- 
cession. 
The symptoms present were slight delusions; 
vertigo; prominent eyes ; injected corneal vessels ; 
restlessness of expression; tremor of voice and 
hands; clammy and glistening skin; dyspnea; 
thyroid enlargement; noisy musical cardiac murmur; 
no valvular defect; very emotional; albumin and 
muco-pus in urine. The case was sent to me as 
convalescent by Dr. Mitchell. 
General treatment was pursued, with systematized 
rest and tonics. The woman gained forty pounds 
in three months and seemed to be in perfect health, 
barring a readily disturbed emotional balance and 
a not yet very vigorous heart. The subsequent 17 
history, of which I knew something for many months, 
was to the effect that this gain was maintained and no 
relapse occurred to my knowledge, and had it done 
so, I should almost certainly have known it. 
Case V.—Graves’ disease; slight exophthalmos; 
thyroid enlargement, the neck being fully an inch 
and a half fuller at the base than normal; slight 
cardiac disturbance; tremulous voice; recovtry; 
still under observation, and perfectly well. 
Miss R., aged twenty-five, presented no neurotic his- 
tory. One sister has some valvular defect of the heart, 
but seems now to be fairly well. This patient at ten 
years of age had enteric fever; at eleven severe 
dysentery, after which she was long in regaining 
her health. She had had much headache until the 
age of nineteen years, w'hen an illness occurred, 
accompanied by neuralgia in the face and profound 
prostration. Then she noticed rapid breathing on 
slight exertion. The eyes were soon remarked as 
being “ curious-looking. ” She tried to gain strength 
by exercises in the open air. In March, 1882, she 
consulted Dr. Seguin, who pronounced the affection 
Graves’ disease and gave an unfavorable prognosis. 
At that time there was edema of the legs. Digitalis 
a'd quiet were ordered. In the following November 
the woman grew better, after having been partly in 
bed for several months. In December, 1883, she 
saw Dr. Gray, of Utica, who also pronounced un- 
favorably, and relieved an increasing diarrhea. 
From May, 1881, to May, 1884, the woman menstru- 
ated only twice; thereafter irregularly until 1887; 
since then she has been fairly regular. Her weight 
was about 135 pounds; the skin was leaky; the lip and 
voice tremulous; Von Graefe’s sign was present in both 
eyes ; the pupils w'ere normal; the corneal vessels 
were much injected; the woman flushed readily— 
a rather unusual feature ; she was rarely pale ; the 
heart was tumultuous; there was no valvular defect; 
the pulse intermitted one beat in three or seven ; the 
thyroid enlargement was symmetric; there w'as 
well-marked thrill; a loud bruit could be heard in 
the right neck; there was subjective buzzing in the 
back of the head, and frequently a throbbing in the 
back. 
The pa'ient was placed upon systematic treatment 18 
with regulated living, digitalis, belladonna, tonics— 
iron, etc.—and attention to the skin, and for periods 
of from three to six weeks, two or three times 
applications of galvanism were made to the thyroid 
and the heart. The urine was found loaded with 
uric acid, and simple measures directed to this 
difficulty always produced marked relief. My 
report of 1888 goes on to say that the improvement 
was very marked at that time. The eyes had been 
examined by Dr. de Schweinitz, who found a slight 
hypermetropic astigmatism, but no lesion of the 
fundus. 
The subsequent history of this case, which is still 
under my observation, is, I think, interesting, and 
consists briefly in a pursuance more or less regularly, 
of the various measures already described, includ- 
ing galvanism two or three times a year, for periods of 
from a month to six weeks, and until the last year 
or two. Instead of the belladonna, I found that 
hyoscin hydrobromate was a much more useful 
remedy, and as the strength grew I systematized the 
use of exercise, both for the eyes, the mind, and 
the body, and the improvement has been uniform 
and more rapid of late, and now this lady declares 
herself to be perfectly well, and nearly as strong as 
most people. The intermittent action of the heart has 
almost entirely ceased, although the organ is still 
irritable. I recently listened to her heart, and there 
was a beat or two omitted in about 250 or 300 beats. 
Slight exertion did not seem to increase this, 
although starting her heart into a more rapid activity 
than perhaps a normal heart would show. This lady 
can walk up and down hill for five or six miles with- 
out distress—indeed, with comfort. She lives an 
ordinarily useful life of a single woman of comfort- 
able means. The exophthalmos has entirely disap- 
peared. There is still an excessive injection of the 
corneal vessels, and the skin has almost regained its 
tone. A very recent letter describes her condition 
to be that of a perfectly well and thoroughly happy 
woman. 
Case VI.—A girl of twenty-four, with a decidedly 
neurotic family history, and whose mother was queer, 
presented well marked Graves’ disease. The cause 
seemed to me to be an attack of dysentery three 19 
years previously. This was followed by alarming 
heart-symptoms, vertigo in sitting or walking, pro- 
found weakness, dyspnea, extreme nervousness, 
poor sleep, sweating skin. There was also much 
intolerable itching, roaring noises in the head, and 
edema of the legs. In March, 1886, the thyroid 
enlargement was observed; in May the exophthal- 
mos ; then developed the full picture of injected 
sclerotic, puffed lids, bloated face, livid, greasy 
skin ; thyroid enlargement in three directions, 
mostly on the right. The heart-sounds were clear, 
with a heaving impulse, and a systolic murmur. The 
pulse was regular but frequent; the bowels were 
loose ; the voice was tremulous. The eyes, carefully 
refracted by Dr. Hansell, showed some accommo- 
dative defects, but no lesion of the fundus. The 
urine was albuminous. The patient had pronounced 
delusions. No improvement has taken place up to 
date. 
This young woman would submit to no regular 
treatment. She was practically insane when seen, 
and grew exceedingly religious, and tried to become 
a nun, but the Sisters rejected her. She fell into a 
condition that I should judge was one of religious 
melancholia, although I saw little of the case, except 
from time to time, learning of it chiefly through her 
sister. The girl is now in an insane asylum. 
Case VII.—A girl of sixteen, and a sister of Case 
VI, presented thyroid enlargement, with a very irre- 
gular heart, no exophthalmos, a leaky skin, chilly 
extremities, roaring in the ears. The heart-sounds 
were quick and feeble; a muffled bruit was heard 
over the right clavicle and through the thyroid, 
also a marked thrill. The carotids pulsated visibly. 
The girl’s appearance was pale and cadaverous. 
This girl was treated as well as the circumstances 
would allow, her necessities requiring that she 
should labor daily for her maintenance. She re- 
fused to submit to much treatment, which she pur- 
sued irregularly, with steady improvement how- 
ever. I learn that she is now pretty well. The 
greatest relief was had from hyoscin hydrobromate, 
which controlled the nervousness and vascular irre- 
gularities. 
Case VIII.—Mrs. S., aged forty-six, presented 20 
marked exophthalmos, with pronounced thyroid 
enlargement, and Von Graefe’s sign distinctly. 
Her trouble began five years previously, after a 
financial shock and an attack of typhoid fever. 
The latter was followed by an abscess of the abdo- 
men, and this was opened in two places. 
The woman was mentally depressed, had diarrhea, 
roaring in the ears, irregular menstruation, which 
soon after the beginning of her trouble ceased 
altogether. She was strongly built; her skin was 
muddy and dusky; the left eye was exceedingly 
prominent, the right less so ; Von Grsefe’s sign was 
present in both eyes; the carotids throbbed; the 
heart-sounds were clear, and a distinct slight bruit 
could be heard ; the pulse was irregular and frequent. 
After eight or nine months of treatment, consisting 
in the administration of digitalis and iron, and large 
doses of belladonna, the woman was greatly im- 
proved. She is still under my observation. I used 
so much of systematized measures as her circum- 
stances will allow, but this was not much. The vas- 
cular disturbances are best controlled by hyoscin 
hydrobromate, strychnin and other tonics being 
occasionally used. The chief feature in her case 
is mental depression, slight melancholia readily 
setting in after any unfavorable news or distressing 
circumstances, to which, unfoitunately, she is fre- 
quently subjected. There was, in addition to the 
trouble described, a considerable catarrhal disorder 
of the upper air passages, which received careful 
treatment. I have seen this patient within a few 
days, after her return from a trip to Florida, under- 
taken for her health, and she now seems in all 
respects a perfectly vigorous, active woman. 
Case IX.—Mrs. J. S., thirty nine years old; mar- 
ried sixteen years, with no children; a good family 
history, and of stationary weight; had had headaches 
of varying intensity all of her life; she has had no seri- 
ous illness. Menstruation was regular. She suffered 
with flatulent dyspepsia and irregular bowels, with 
loose, frequent, slimy stools. Sleep was only fair, 
being disturbed by bad dreams. The headaches, 
which had persisted since childhood, were usually re- 
lieved by sleeping, and in the morning werelocalized 
to the back of the head. This pain was greatly in- 21 
creased on leaning forward, and if this attitude were 
persisted in, vomiting would often result. The eyes 
were never comfortable. The woman could not sew 
or read at night without greatly increased pain. 
There was also slight lateral nystagmus. The skin 
was characteristically flabby ; frecjuent flushes were 
felt; the countenance was anxious; the tongue 
tremulous and marked by the teeth ; there was a 
vibratile tremor of the voice ; the neck was markedly 
enlarged on the left side; the heart-sounds were 
feeble and a musical bruit could be heard. The 
pulse was from 140 to 150 in the sitting posture; its 
action was irregular. There was great dyspnea on 
exertion or excitement. 
The treatment consisted in the administration of 
hyos in hydrobromate, in small dose, every two or 
three hours, till the skin became drier. Galvanism 
was applied to the neck, the mode of living regulated, 
and more rest enjoined. In a week the headache 
was less than for many years; in two weeks it was 
entirely gone. Iron was then given with strychnin. 
In two months the woman was able to resume her 
labors, and in six months she was scarcely recog- 
nizable. 
Case X.—Mrs. S., twenty-four years; married 
one year, with no children ; as an infant was rather 
weakly. She had scarlatina at ten years of age, and 
thereafter had a slight swelling of the neck. Her 
general health then remained good, and at the age 
of seventeen she weighed one hundred and twenty- 
eight pounds, and was so circumstanced as to be 
compelled to do a large amount of hard work on a 
farm. This necessitated general and prolonged 
physical exertion, competent observers estimating it 
as the work ample for three individuals. This was 
kept up for two years and the woman then began to 
run steadily dowm. To the influence of this excessive 
labor I think may safely be ascribed the develop- 
ment of the malady. For four years this excessive 
work was kept up and soon afterward she was 
married. In December, 1889, she had a sharp 
attack of influenza, with cerebral and laryngeal 
symptoms. Subsequently marked dyspnea appeared 
and persisted. Headaches had been a life-long 
trouble, but six months before coming under ob- 22 
servation she had been properly refracted. The 
headaches thereafter almost, but not entirely, dis- 
appeared. Menstruation was usually regular. 
The woman was tall and spare. There was very 
slight prominence of the eyeball. The skin had a 
characteristic pasty, leaky look; the hands and feet 
sweat readily. The heart was rather irregular in 
action, and a loud systolic murmur was audible 
over the aorta and the right clavicle; the pulse was 
ioo and more in the sitting posture. The tongue 
was clean ; the appetite was capricious. Both lobes 
of the thyroid gland were enlarged. 
Galvanic electricity was employed for a fortnight 
only. Then hyoscin hydrobromate, -j-J-g- gr., was 
given thrice daily. Rest in bed was enjoined, 
together with a careful diet. Rapid improvement 
followed. 
At the present writing the woman is in the fifth 
month of pregnancy, and quite stout and vigorous. 
The pulse is 85 in the sitting posture. The thyroid 
enlargement is probably greater than before. Thera- 
peutically, the patient is taking a dry extract of 
thyroid gland. 
Case XI.—Mrs. N. K. S., thirty-three years old. 
Her parents are living; her mother suffers with 
rheumatism, and presents chalky deposits. The 
family history is otherwise good. The patient is 
the first child; the labor was normal; she was care- 
fully fed; she had whooping-cough and chicken- 
pox in infancy, and measles, diphtheria, and pneu- 
monia later. An attack of pink eye three years 
ago seems to have injured her myopic eyes. The 
patient was never robust, convalescing slowly from 
illnesses. She was always nervous. Two years ago 
she had a mild attack of chorea. As a schoolgirl 
she was excitable and easily worried. She men- 
struated at fifteen, and quite regularly until a year 
ago ; the flow is now rather scanty; six years ago 
there was amenorrhea, probably from anemia, with 
swelling of the lymphatic glands on the posterior 
aspect of the neck. The woman took up teaching 
seven years ago, and kept it up for five and a half 
years. Two years ago she had a sharp attack of 
influenza, which left her in a very nervous condi- 
tion. She continued teaching, however, for six 23 
months, and then was married, about eighteen 
months ago. She seemed very well then until the 
spring of 1892, when nervousness set in again, partly 
as a result of the strain in nursing her ill mother. 
This caused evil dreams at night, and fear of thunder- 
storms, etc. ; she has been getting gradually more 
nervous and hysterical; she has never been pregnant. 
The patient is a rather small, dark-complexioned 
woman, the hair streaked with gray, the expression 
anxious, the eyes prominent, and the pupils respond- 
ing well to light and in accommodation. She is 
highly myopic; vision O. D. = 20/cc; O. S. = 20/c. 
The ophthalmoscopic appearances are not unusual; 
there is a slight posterior staphyloma. The chest is 
shallow, the respiratory sounds feeble, the heart 
irritable. A rapid clanging is audible, but no murmur. 
A venous hum is heard in the neck, and propagated 
down the sternum. The thyroid not very large but 
pulsates visibly ; it presents no thrill. The pulse is 
xoo; the skin is very leaky, especially upon the 
hands, and this condition is aggravated by excite- 
ment. The station is good; the gait is irregular. 
The knee-jerks are exaggerated ; there is no clonus. 
The voice exhibits the characteristic vibratile quality. 
The treatment consisted in rest in bed ; massage; 
hyoscin hydrobromate, gr. four times daily, and 
increased as needed. 
Two weeks later the headache had almost entirely 
disappeared ; the nausea was much more tranquil; 
the digestion was good ; and she was sleeping quietly. 
She was then taking hyoscin hydrobromate t. i. d. 
In the third week the hyoscin was withheld, and 
a tonic given in the form of elixir of iron, quinin, 
and strychnin. In the fourth week the woman re- 
garded herself as well ; her temperature was normal; 
she began gradually to sit up. She remained at the 
hospital forty-three days, and was discharged as 
cured. She had greatly increased in weight, vigor, 
and equipoise. The temperature followed the char- 
acteristic curve. At the present writing the patient 
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