take place suddenly, but, as a rule, it is at first slight and
increases slowly. The degree of protuberance varies considerably in
different cases. When marked, the patient has a remarkable staring
expression. Both eyeballs are alike protuberant with very rare
exceptions.[8] The pupils are unaffected and {763} vision is not
impaired. The protuberance is sometimes so great that the globes cannot
be covered by the eyelids. Under these circumstances inflammation of
the conjunctiva ensues, and perforation of the cornea has been known to
occur. The eyeballs can be pressed backward into the sockets without a
degree of force which occasions pain, but the protuberance returns
directly the pressure is discontinued. In most, but not in all, cases
the consensual movements of the upper eyelid and the globe, when the
latter is moved upward or downward, are impaired; that is, the
movements of the lids do not follow those of the globes. That this
symptom is not to be accounted for by the exophthalmia is shown by the
fact that it is not a symptom when the protuberance of the eyeball is
caused by an intra-orbital tumor. The symptom therefore has diagnostic
significance. The ophthalmoscope shows the veins of the retina to be
dilated and tortuous, with, in some instances, visible pulsation of the
retinal arteries. Anatomical conditions to which the exophthalmia is,
in a measure at least, referable, are enlargement of the intra-orbital
vessels by hyperæmia and an increased amount of post-ocular fat.
Paresis of the straight muscles, induced by stretching, is probably an
important factor when the protuberance is great. These muscles have in
some instances been found to have undergone fatty degeneration.
[Footnote 8: Allan McLane Hamilton, in his work on _Nervous Diseases_,
cites a case reported by Yeo, in which the exophthalmia effected only
the left eye, and the goitre was limited to the right thyroid body.
Cases of unilateral goitre with bilateral exophthalmia have been
observed.]
Anæmia is usually associated with the foregoing cardinal symptoms. It
is sometimes wanting. This was true of a case recently under my
observation. If anæmia does not exist, the blood-murmurs referable to
the heart and vascular system may be absent. If anæmia exist in a
marked degree, there are present certain symptomatic phenomena
referable thereto--namely, neuralgic pains in different situations,
want of physical and mental endurance, hysterical manifestations,
depression of spirits, etc. Mental irritability is apt to be a
prominent trait of the affection. This may in a great measure be
referred to sensitiveness occasioned by the exophthalmia. Owing to
this, patients often avoid observation as much as possible. They
naturally, women especially, are led to brood over the calamity of such
a singular and conspicuous deformity. Breathlessness on exercise is a
symptom more or less marked according to the increase in the frequency
of the heart's action and the impoverishment of the blood. The appetite
and digestion may or may not be impaired, and hence there may or may
not be emaciation. It cannot be said that the affection is accompanied
by fever, although in a certain proportion of cases the temperature of
the body is half a degree or a degree above the normal range. Reports
of cases embrace a considerable number of concurrent symptoms which are
occasionally present, such as cephalalgia, insomnia, vertigo,
amenorrhoea, neuralgia, unilateral sweating, etc. These have no special
connection with the affection, but are incident to associated
pathological conditions.
DIAGNOSIS.--The three phenomena which distinguish this affection are so
obvious as well as characteristic that a diagnosis cannot well be
avoided, after a description derived from books or lectures, when the
first case presents itself in practice. The wonder is that the
affection had not been clearly pointed out prior to the writings of
Graves and Parry. Any difficulty in diagnosis relates to cases in which
either the exophthalmia or the enlargement of the thyroid body is
wanting, or to the incipiency of the affection when its characteristics
are not fully developed. The bilateral protuberance of the eyeballs,
the absence of local symptoms other than those caused by the exposure
of the conjunctiva when the eyelids fail to cover the globes, the
mobility and normal size of the pupils, the want of the normal
consensus in the movements of the eyelids and the globes, and the
replacement of the latter by moderate pressure, are the diagnostic
points which distinguish the exophthalmia in this affection from that
incident to intra-orbital tumor. The moderate increase of the thyroid
body, its softness to the touch, its notable variations in volume at
{764} different times, its pulsation and the auscultatory murmurs which
it generally furnishes, are diagnostic points distinguishing the
enlargement in this affection from that of bronchocele. The persistent
frequency of the heart's action is not less marked when either of the
two phenomena just referred to is wanting than when both are present.
The degree of frequency varies, but more or less increase is a constant
symptom; and it is a symptom not likely to be present in either
exophthalmia or in goitre unassociated with Graves' disease.
Aside from the symptomatic triad, the clinical history offers in
different cases considerable diversity. The diverse inconstant symptoms
as they occur in other pathological conditions are without diagnostic
significance. A large proportion are incident to the anæmia so often
associated with the affection under consideration.
PATHOLOGY AND ETIOLOGY.--Inasmuch as the persistent frequency of the
heart's action is the first event in the order of time, the thyroid
enlargement and the protuberance of the eyeballs being epiphenomena, it
seemed a rational supposition that the latter events were dependent on
the cardiac disorder. This view was held by Graves and his colleague,
Stokes. A supposition much more rational is that the three events are
united by a common causation. Anæmia has been supposed to be the
causative condition. This supposition is disproved by the fact that
anæmia does not exist in all cases. Moreover, anæmia is a pathological
condition of frequent occurrence, whereas the affection under
consideration is extremely rare. It is, however, very probable that
anæmia may play an important auxiliary part in the causation, as it
does in all the neuroses. With the knowledge of the sympathetic and
vaso-motor nerves which has been acquired since the date of Graves'
discovery, the pathology seems clearly to involve these components of
the nervous system. This pathological view is perhaps generally held at
the present time. But to interpret all the phenomena satisfactorily by
reference to the known functions of these nerves is not easy.
Vaso-motor paresis will account for the dilatation of the vessels,
which is an important anatomical element in the enlargement of the
thyroid body and the exophthalmia. On the other hand, acceleration of
the heart's action is not an effect of paresis, but of excitation. To
account for this incongruity there have been different hypotheses,
which it does not fall within the scope of this article to discuss.
Some autopsies have shown anatomical changes in the cervical
sympathetic and its ganglia, but in others no morbid appearances have
been found. Whether the pathology involves peripheral nerves alone or a
central morbid condition in the spinal cord or the medulla oblongata is
an undecided question. For facts and arguments bearing on the different
points of inquiry relating to the pathological seat and character of
the affection the reader is referred to other works.[9] I will only add
that in view of the fact of the exophthalmia and the goitre being, in
the vast majority of cases, bilateral, it seems rational to suppose the
pathological nervous condition to be central rather than peripheral.
This is assuming that the three cardinal events involve a common
causative condition, and not that the exophthalmia and goitre are
dependent on the cardiac disorder. The termination in a certain
proportion of cases in recovery goes to show that the affection does
not necessarily involve structural lesions, and hence that it is
properly included among the neuroses. The constancy and prominence of
the disordered action of the heart render it proper to consider the
affection in connection with the neuroses of that organ.
[Footnote 9: For a résumé, vide article by Eulenburg in _Ziemssen's
Cyclopædia_, vol. xiv.]
In the etiology of Graves' disease sex and age have a decided
influence. In very much the larger proportion of cases the patients are
women. The proportion of 2 to 1, which is stated by some writers, is
not sufficiently large. Out of 20 or more cases which have fallen under
my observation, in 1 {765} only was the patient of the male sex. The
disease is extremely rare under puberty and after middle age. Between
these extremes of age there is no special predilection of the disease
for any particular period of life.
Of causes which are independent of sex and age we have no positive
knowledge. In particular cases the disease has been attributed to
traumatic causes, to fright or other kinds of mental excitement, to
sexual excess, etc. The evidence of a causative relation in these cases
is simply a post-hoc connection which obtains in but a single instance
or at most in a few instances. Etiological speculations, in the absence
of ascertained facts, are, to say the least, useless, and it is the
most politic as well as the fairest statement to say that in the
present state of our knowledge we have no adequate data for determining
the causation of the affection.
PROGNOSIS.--Graves' disease has no direct fatal tendency. It may not
interfere with fair health for a long period. It diminishes the ability
to tolerate other diseases, and in this way indirectly it threatens
life. If it supervene upon organic disease of the heart, the gravity of
the latter is thereby increased and its progress hastened. It induces,
as a result of long-persistent increased activity of the action of the
heart, enlargement of this organ. Sooner or later, if the disease
continue, dilatation predominates over hypertrophy of the heart, and
then occur the evils incidental to the inability of this organ to carry
on the circulation adequately. Want of breath on exercise, and at
length constant dyspnoea, become sources of suffering. Generally,
dropsy finally ensues, and thus, indirectly, the affection leads to a
fatal result. In most cases, however, death is caused by some
intercurrent malady before the effect upon the heart is sufficient to
occasion grave symptoms. Aside from the effect upon the heart, the
affection does not seem to involve an intrinsic tendency to any
particular complication.
The affection tends to long continuance. I have not met with an
instance of its rapid development and its disappearance after a brief
duration. Instances of complete recovery are rare; that is, the
exophthalmia and the goitre do not disappear entirely, and the action
of the heart does not become perfectly normal. A close approximation to
complete recovery is not very infrequent, and in some instances all
traces of the affection disappear.
The cases offering most in the way of a favorable prognosis are those
in which there is not great acceleration of the action of the heart,
this organ being free from organic disease, and those in which,
exclusive of the affection under consideration, there are no marked
unhealthful conditions. Impaired appetite, lack of digestive power,
defective nutrition, and persistent anæmia are unfavorable prognostics.
Any important antecedent disease affects of course the prognosis
unfavorably.
TREATMENT.--From what has been stated in relation to the etiology of
Graves' disease, it follows that there are no known special causative
indications in the treatment. It is, however, a rational consideration
that anything in the habits and surroundings of patients which is
prejudicial to health has perhaps some agency either in causing or in
maintaining the affection. It is therefore an important part of the
treatment to remove all causes of ill-health which can be ascertained.
The treatment, in this point of view, will embrace injunctions
respecting mental occupations and excitement, a proper proportion of
time devoted to out-of-door life, an adequate diet, avoidance of
dietetic excesses, moderation in the use of alcohol, the disuse of
tobacco, the regulation of sexual indulgence, etc. Without going
farther into details, the object, in general terms, is to place the
patient under the best attainable hygienic conditions.
Any disorders which coexist may possibly be involved, if not in the
causation, in the persistence of the affection. They claim, therefore,
appropriate treatment. Diminution of appetite and difficulties relating
to digestion are {766} to be treated by measures which must vary
according to the circumstances in each case, and which need not be here
considered. Uterine troubles are to be removed. These have been
supposed to stand in a special causative relation to the affection. The
anæmic condition which is so frequently associated (in addition to the
removal of its causes, if these be ascertained and if they be
removable) calls for the long-continued use of chalybeate preparations
in conjunction with dietetic and regiminal treatment. In a case under
my observation in which recovery took place the patient took two grains
of reduced iron three times daily for three years. It is generally
advisable to change from time to time the preparation of iron, partly
for the moral effect of giving a new remedy in order to secure
perseverance on the part of the patient, and in part because,
irrespective of this effect, changes seem to be of use. The prevalent
idea that iron is not well tolerated is to be overcome by assurances,
argument, and, if necessary, by stratagem. It is certain that in most,
if not all, instances this idea is a delusion. The anæmia in this
affection, as in other pathological connections, is only to be overcome
by the long-continued, uninterrupted employment of chalybeates
conjoined with the other measures of treatment. This should be clearly
stated to patients in order to forestall discouragement and neglect of
the treatment advised.
Hydropathic packing and the needle-bath have been highly recommended. A
patient of mine who has recovered apparently derived benefit from daily
sea-bathing. The propriety of these measures is to be determined by the
glow and feeling of invigoration to which they give rise if they be
useful. Should these effects not follow, daily sponging of the body
with cold or tepid water, to which may be added sea-salt or alcohol,
may be substituted. Mental diversion is an important hygienic measure.
The patient should be urged to conquer the feeling of mortification
which prevents social enjoyments and disposes to brooding over the
malady.
The enlargement of the thyroid body naturally suggests the employment
of iodine. This local affection, however, is very different from
bronchocele or goitre occurring independently of Graves' disease.
Experience shows that iodine employed either topically or for its
constitutional effect is useless if not injurious. Many years ago a
case was related to me by a non-medical friend in which thyroid
enlargement had been treated by the application of iodine. Remarkable
prominence of the eyes soon followed, which was attributed to the
iodine, and the physician fell under censure which, as I suspect, he
was not prepared to meet by an acquaintance with Graves' disease. If
the thyroid enlargement be sufficient to occasion tracheal obstruction
or give rise to great deformity, the injection into the gland of a
solution of ergotin may be resorted to. William Pepper has effected a
complete reduction of the thyroid enlargement by this measure, in
addition to ergot given internally. He employed a solution of
ninety-six grains of ergotin to an ounce of distilled water, of which
from six to ten minims were injected weekly by means of a needle
introduced from half an inch to an inch in depth.
For the relief of the exophthalmia, gentle compression upon the eyes by
a compress and bandage during sleep has been recommended. Aside from
this, the indications for local treatment relate to the inflammation
which is liable to be produced by insufficient covering of the eyeballs
by the eyelids and by the impaired consensual movements of the latter
with the former. The patient should, as far as practicable, abstain
from reading, writing, and other uses of the eyes which involve strain.
Insomnia and general nervous irritability may call for palliative
treatment. Opiates should if possible be withheld, owing to their
effect upon appetite and digestion, and also on account of the risk of
forming the opium habit. Other hypnotics and nervines are to be
preferred, but it is best to be {767} chary in the use of these. The
bromides are perhaps the least objectionable of the remedies given to
tranquillize the nervous system and promote sleep, but their prolonged
use is detrimental.
The most important part of the remedial treatment relates to the
accelerated action of the heart. Cardiac sedatives are rationally
indicated, and experience confirms their usefulness. All writers
recommend digitalis in order to diminish the frequency of the heart's
action. A difficulty pertaining to this drug is its liability to
disturb the stomach, and the consequent necessity for discontinuing its
use. It is proper to give it a fair trial. In my experience aconite has
proved more satisfactory. In a case already referred to two grains of
reduced iron and one minim of the tincture of aconite constituted the
medicinal treatment. These remedies, without any increase of dose, were
continued for three years. At the end of this period the patient was in
excellent health and had gained in weight forty pounds; slight
exophthalmia and goitre only remained. In another case the treatment
consisted exclusively of the tincture of aconite in doses gradually
increased to seven minims three times daily. Chalybeates were not given
in this case, because the patient was not anæmic. The remedy was
continued most of the time for two years. The recovery is complete
except that the heart is irritable and moderate prominence of the
eyeballs remains. The treatment has been discontinued in this case for
the past two years. Of veratrum and gelsemium as cardiac sedatives,
which have been recommended in this affection, I have no practical
knowledge. In paroxysms of unusual violence of the heart's action
German writers recommend the application of cold to the præcordia by
means of the ice-bag.
Galvanization of the sympathetic is strongly advocated by German
writers--namely, Eulenburg, Dusch, Guttmann, Von Chvostok, Meyer,
Leube--and in this country by Bartholow and others, as not only useful,
but sometimes effecting a cure. The following extract from a treatise
by Bartholow embraces rules for the employment of this therapeutic
agent: "Recent cases treated efficiently by galvanism are relieved
permanently or their course and progress much modified. During
exacerbations, which constitute a prominent feature of the clinical
history, the passage of a sufficient galvanic current through the
pneumogastric immediately lessens the cardiac excitement. In the
treatment for curative results a mild current is held to be most
efficient (Chvostok). An electrode--the anode--is placed in the angle
behind the jaw, and the cathode on the epigastrium, and a stabile
current is allowed to flow for three to five minutes. The cervical
spine should also be galvanized. It may be included in a circuit by
placing the anode over the vertebræ in turn whilst the cathode rests on
the epigastrium. Stabile may be varied by labile applications. The
faradic current may be used successfully. An instance of this kind has
come under my notice. The first published cases illustrating the
curative value of galvanism were those of Chvostok (1871), who followed
with a series of examples the next year, when Meyer also reported
several cases. In 1874, I read a paper before the medical section of
the American Medical Association advocating this plan of treatment, and
illustrated its advantages by the details of five cases. In 1878,
Vizioli, in a paper on electropathy, amongst others narrated several
cases of Basedow's disease cured. In making the claim for the curative
power for electricity the reader should understand that uncomplicated
cases only are referred to."[10] Rosenthal gives the following
directions: "The ascending stabile galvanic current, from one to ten
elements, is passed through the cervical sympathetic (the anode in the
mastoid fossa and the cathode upon the upper cervical ganglion) for
eight to ten minutes at a time. The current is also directed
transversely across the thyroid tumor, or an ascending current may
{768} be applied to the cervical and upper dorsal vertebræ."[11]
Guttmann states that temporary reduction of the frequency of the
heart's action is first produced, but by persisting in the electrical
treatment the reduction becomes permanent, together with progressive
improvement as regards the exophthalmia and the thyroid
enlargement.[12]
[Footnote 10: _Medical Electricity_, by Roberts Bartholow, M.D., LL.D.,
etc., Philadelphia, 1881.]
[Footnote 11: _Clinical Treatise on the Diseases of the Nervous
System_, by M. Rosenthal, translated by L. Putzel, M.D., New York,
1878.]
[Footnote 12: Vide article entitled "Basedowsche Krankheit," in
_Real-Encyclopedie_, Wien and Leipzig, 1880.]
{769}
DISEASES OF THE PERICARDIUM.
BY J. M. DACOSTA, M.D., LL.D.
Pericarditis.
The diseases of the pericardium, with a few exceptions, belong to the
inflammatory variety, and, as a rule, are the consequences or
accompaniments of other inflammatory diseases of the circulatory system
or of parts near the heart. The most common of the pericardial
affections is pericarditis, which may be simple or secondary, and acute
or chronic.
Pericarditis may occur upon either the visceral or the parietal layer
of the membrane, and may attack any portion or several or all parts at
the same time, being thus circumscribed or general. Usually, the whole
or a large part of the pericardium is affected. Pericarditis is further
characterized by effusions or exudations, which may be either fluid or
semi-solid, and in consequence of the varied character of these
exudations subdivisions are often made, such as the serous, fibrinous,
sero-fibrinous, purulent, sero-purulent, and hemorrhagic forms.
Pericarditis is generally marked by an effusion of fluid, the exception
being designated as dry pericarditis, in which serum or other thin
exuded material is almost or entirely absent.
Simple acute or idiopathic pericarditis is comparatively rare, and some
authorities doubt its existence, believing that the pericardial
inflammation is always secondary, plausibly supposing that the primary
affection has escaped detection. Bamberger and Hayden, for instance,
are of this opinion. I am, however, certain that I have met with
several instances of true acute idiopathic pericarditis. Cases of
so-called simple pericarditis are really often due to injury. It may
not be easy in many cases to determine the traumatic or other condition
in which the apparent simple acute pericarditis originated. The weight
of evidence is so much in favor of traumatism as a preceding and
efficient cause of simple acute pericarditis that a diligent search
should always be made for the same. But even these doubtful examples
are comparatively rare; and pericarditis is in the vast majority of
instances secondary, and not difficult to identify as such. By some,
traumatic pericarditis is classed with simple pericarditis as a
variety, although not idiopathic.
Inflammation of the pericardium is governed by all the laws which
control inflammatory processes elsewhere, being either acute, subacute,
or chronic. The subacute form probably exists frequently, but escapes
detection on account of the latency of the symptoms. The acute form is
the most readily recognized. If not relieved, it passes into the
chronic disease, which may be of long duration. The passage from one
kind to the other is so gradual as to make it almost impossible to
determine when one stops and the other begins, though it may be stated
that after an acute attack has continued for from two to three weeks
the chronic form is established. The chronic affection may begin,
however, insidiously, or develop out of the subacute variety.