now my practice to try to separate my cases of neurasthenia into those with or without symptoms described as belonging to disturbances of the thyroid gland (Graves' disease). I will refer to the three theories which have held the boards in the etiology of this disease. Basedow promulgated the hæmatogenic theory, the disease, in his opinion, being due to a chloroanæmic condition. In 1879, Filehne showed that a lesion of the restiform body caused tachycardia, exophthalmos, sometimes goitre, and believed, therefore, that the disease is a nervous one. Later Jaboulay, of Lyons, and Abadie, of Paris, located the disease in the cervical sympathetic system. Möbius has propounded the thyreogenic theory, maintaining that the products of the thyroid gland either neutralize the tissue poisons or furnish a toxic material which reacts upon the nervous system. In 1897, Dr. Jaboulay, of Lyons, operated upon nine women suffering from exophthalmic goitre by division or resection of the cervical sympathetic. Adding to these nine operations those performed by Reclus, Gerard-Marchant, Quenu and Jonnesco under similar conditions, we arrive at a total of fourteen divisions or resections of the cervical sympathetic for the relief of Graves' disease. In all these fourteen cases the operation was simple and invariably resulted in improvement. The operation has never been followed by ill effects of any kind, there having been no trophic disturbances, no changes in any organ or tissue, and no impairment of the power of visual accommodation. Dr. Jaboulay thinks that the operation is more successful in aged persons than in young people, because the question of age appears to be connected with a physical condition of the moderating and accelerating systems of the heart, which differ according to the age of the subject, in that the accelerating system predominates in youth. He maintains that the imperfect recoveries after division of the cervical sympathetic are due to anatomical abnormalities. Sometimes there are two columns connecting the upper and the middle cervical ganglia. The former may be split in two. In such cases the operation should be repeated. He believes the operation indicated in those cases refractory to medical treatment and hydrotherapy, and especially where there is very marked exophthalmos. He insists that whatever may be the exact nature of Graves' disease, its effects are transmitted through the cervical sympathetic. Abadie explains the goitre through the vasodilatation of the arteries from stimulation of the cervical sympathetic, which furnishes too much. nourishment to the gland. Exophthalmos is due to vaso-dilatation of the retro-bulbar vessels. We all know that disease of the cervical sympathetic affects the heart through the pneumogastric, and Dr. that excessive stimulus produces diarrhoea; also that the vaso-motor system is affected by such derangement. Before this operation of Jaboulay's extirpation of part or all of the thyroid has been used in the treatment of the affection. Dr. Lejars removed the right lobe of the thyroid gland in a girl of eighteen, Oct. 12, 1896, who died in an attack of extreme dyspnoea soon afterwards. At the autopsy nothing abnormal was found. Dr. Quenu removed the entire thyroid gland in a case which recovered, but later developed myxoedema, which was successfully treated by means of thyroid. Dr. Tillaux pointed out that exophthalmic goitres due to the existence of a tumor in the thyroid gland which compressed the cervical bundle of blood vessels and nerves, should be operated upon by excision of the tumor, while exophthalmic goitre without intrathyroid tumors is not amenable to surgical treatment. Goris removed completely a goitre of the mediastinum without myxoedema and ending in recovery. Dr. Picque operated on a woman in 1894 by removal of the goitre, with recovery, and again in 1897 on another case, with the same result. Dr. Schwartz removed an intrathyroid tumor in the right lobe of the thyroid gland where symptoms of exophthalmic goitre existed, in May, 1896, resulting in a cure. Dr. Tuffier performed partial thyroidectomy in two cases, one on July 31, 1894, the other January 24, 1897. In the first a cure was effected; in the last only improvement. Prof. Poncet has operated on several cases, in some of which there have been severe nervous disturbances, and even death after the operation. Dr. Doyen reports removal of the entire thyroid gland in two cases, with complete and lasting subsidence of all symptoms. All operators are agreed that removal of the thyroid gland is a very dangerous operation, causing death from hemorrhage or toxæmia. Kocher advises ligation of three of the thyroid arteries in preference to thyroidectomy. He has treated thirty-one cases surgically and has seen varying degrees of improvement, sometimes even complete recovery. Of 187 cases surgically treated collected by Kinnicutt, thirteen died as a result of the operation, sixty recovered, forty-seven improved, eleven unimproved and in twenty-five the result is unknown. I will not burden you with theories favoring the thyreogenic or the nervous origin of this affection more than to point out that the pathological condition in simple goitre and exophthalmic goitre are apparently identical as far as the gland is concerned; that nervous shock is a frequent exciting cause of exophthalmic goitre; that Graves' disease occurs most frequently in women (4.6 to 1.7), the sex that suffers most from neuropathic conditions; that the symptoms of the disease can well be explained by an affection of the sympathetic system (cervical sympathetic), | and finally, that operations on the cervical sympathetic and those on the gland producing the same effect on the sympathetic fibres distributed to it, seem to cure the disease. The fact that exophthalmic goitre is the antithesis of myxodema does not prove anything more than that in the last there is loss of function and in the first apparent hyperfunction; but why not the same. symptoms from simple goitre? And how about Basedowified simple goitre? But how shall we explain the non-occurrence of cachexia strumipriva in cases where apparently complete removal of the thyroid has been practised? The simplest explanation is, probably, that the parathyroids have not been completely removed, and it would seem that the operations upon the thyroid gland for the relief of exophthalmic goitre should be limited to cases of neoplasm occurring in the same. The remarkable results following resection of the cervical sympathetic bid fair to throw new light upon the causation of the disease, and give us a successful mode of treatment. I append a table of eleven cases of exophthalmic goitre treated by me during the last three years. From this table it will be seen that this disease predominates in the female-nine out of eleven cases. From the ages it will be seen that the discase is one of middle life, and strangely enough, one case which developed in a woman of seventy-one years. Among the causes it will be noted that heredity in these cases has played no role. In five out of the eleven there have been mental causes. In the form of worry (three cases); fright (two cases); la grippe (two cases); chronic diarrhoea, general nervousness, each one case; no causes (two cases). In the eleven cases both lobes were pretty symmetrically enlarged in seven cases, the right usually a little larger than the left; in one case no enlargement; in two cases the left lobes were enlarged; in one case, slight enlargement both lobes. In two of these cases the pulse was practically normal as regards rate, but the rhythm was disturbed in all by the least excitement. In nine out of the eleven cases Graefe's symptom was present; in two it was absent. In one case the remarkable difficulty existed that the patient could hardly turn the eyes downward from the horizontal plane. In six out of the eleven cases exophthalmos was present. In five of these cases (numbers one, two, four, five and seven), the administration of thyroid produced a marked exaggeration of all the symptoms on the part of the nervous system. In other cases it was not tried. In cases four and seven, which were the worst and most marked, galvanization of the neck with administration of thymus resulted in remarkable improvement, seemingly coincident with the use of the thymus, but since I have used with it galvanism (a treatment of great value), my cases are of little value in the elucidation of the question as to whether the thymus gland is of value in the treatment of exophthalmic goitre. In case ten, great improvement has occurred after four months thymus treatment alone. I think that we can safely say that the administration of the thyroid gland produces a reaction in cases of exophthalmic goitre in cases where the gland is apparently hyperfunctionating. The symptoms are those of a sensation of heat (rarely cold), headache, tremor, irritability of the nervous and circulatory systems, and nausea, sometimes vomiting. The mode of administration that I have. adopted consists in giving the capsules of pulverized thyroid or compressed tablets just before meals upon an empty stomach, followed by a half-glass of hot water, hoping thus to secure a more complete and speedy absorption of the remedy. The tabloids I have used are those of Parke, Davis & Co. OBESITY. The elimination of nitrogen and carbonic acid in large quantities of urine and its effect on the pathological fat deposits in cretins led to a trial of thyroid extract in cases of this kind, and many cases have been reported in literature where great diminution of weight has occurred from its use. My own experience is limited, owing to failure of my cases to report results. In one case I administered five grain tablets four times a day for two weeks without appreciable result, then the dose was increased to eight tablets a day. with a loss of two pounds in a week. The next week twelve tablets daily caused a further loss of one pound, and the next week sixteen tablets a day produced irritability of mind, sense of heat, nervousness, asthenia and tremor; and the tablets were reduced to three daily for two more weeks with subsidence of the nervous symptoms and also a loss of weight down to fourteen pounds less than it was at the beginning of the treatment. The urine was greatly increased all the time. My data are incomplete in other cases that I have treated, and I shall not weary you with a recital of them. I think that the future will discover that obesity is of various kinds. on the basis of its eiology, and that certain cases will be adapted to thyroid therapy, as an adjuvant to removal of the cause. Under thyroid therapy after a discontinuance of the treatment relapse follows if the cause of the obesity be not I removed, and small doses must be continued indefinitely. The heart should always be watched. The study of the subject of the internal secretions has forced upon me the view that the physiological function of the ductless glands of the body is one of intimate connection with the sympathetic system which presides over vegetative life; over nutrition, broadly speaking. We have seen what an important part the thyroid bodies. play in the economy; the adrenals either directly (?), or more probably indirectly through the abdominal sympathetic have also an important place (in nutrition be it remarked), as evidenced by the disturbances following pathological conditions (Addison's disease, etc.); the testicles and ovaries must exert a profound influence on the nutrition of the body, as their period of activity corresponds to nutritional changes of profound nature: growth of the hair, change in the voice, etc.; and their ablation produces a retrograde change in the individual: a return to a lower type corresponding to that existing before puberty, and not, as generally stated, to the opposite sex, i. e., masculine to feminine, etc. The hypophysis of the brain, like the thyroid, is a compound tubular gland with excretory ducts in foetal life, which later, also like the thyroid, becomes ductless. Disease of the hypophysis is associated with, if not the cause of the nutritional diseases we call acromegaly and giantism, where a peculiar overgrowth of bone exists. The thymus gland has its mysterious function to perform in foetal life, the period of most active morphological change, and later it disappears. All these glands are richly supplied with nerves from the sympathetic system. Recent histological research indicates that the secreting cells of organs have nerves ending directly in them. Nearly all we know of the animal organism indicates that its activities, including also the vegetative, are liberated by and performed through the nervous system, and any view which does not take cognizance of this fact, like the one now so glibly popular, that because feeding the body gland substance which is absent from the organism restores function, therefore, these glands are to be looked upon as small chemical laboratories, where substances are produced which sail around in the blood stream to find places that need repairing, or to antagonize toxines. How much more in accord with what we know of the human economy to assume that these glands provide substances which act upon the body through the sympathetic, just as the carbonic dioxide of the blood acts upon the respiratory centre, stimulating it to increased activity. How radical a change to suppose that the cells of the body increase or decrease their activity because of a humor carried about in the blood stream. The conclusions that I should like to draw after this fragmentary consideration of the thyroid are as follows: First. The thyroid gland produces a secretion of the greatest importance to the metabolism of the body. Absence of function produces cretinism if congenital, myxedema if acquired. Second. Simple hyperplasia (simple goitre) does not produce marked pathological disturbances, but I believe it to be a larvated form of exophthalmic goitre, and I think that so-called "nervousness" can be found in the vast majority of cases. Third. Hyperplasia associated with disturbance of the cervical sympathetic is the disease known as exophthalmic goitre. Fourth. Surgical interference in diseases of the thyroid gland should be limited to the removal of neoplasms; thyroidectomy in exophthalmic goitre is unphysiological, irritational and dangerous. Fifth. In the majority of cases of exophthalmic goitre, medicinal and hygienic treatment, rest, galvanism through the neck (two to five M. A.), tonics, sodium phosphate and thymus gland will effect amelioration. In cases refractory to medical treatment where life is threatened, section of the cervical sympathetic should be practised. Sixth. Many cases of neurasthenia are cases of masked exophthalmic goitre and should be treated accordingly. Seventh. Thyroid therapy is specific in sporadic cretinism, myxedema and simple goitre, and removes obesity. Eighth. Thyroid extract increases the unpleasant symptoms in exophthalmic goitre, and is a reliable test also in the masked form of this disease. Note. In the NORTHWESTERN LANCET of November 15, 1885, is a report by Dr. D. W. Hand, of St. Paul, of an epidemic of goitre occurring at the State Reform School, at that time situated in the outskirts of St. Paul. Dr. Hand visited the school on July 3, 1885, and found that during the past two weeks a considerable number of the boys had become afflicted with a swelling of the neck, which upon examination proved to be enlargement of the thyroid gland, both lobes and the isthmus being involved in most cases. The enlargement in different cases varied from a slight tumor to a protuberant deformity. There was no prominence of the eyes and in but few cases any acceleration of the pulse. The Superintendent stated that he had a few boys with swelled necks every year, but that the number at this time was extraordinary. The boys all claimed to be in good health. Of the 140 boys in the institution 44 had the goitre. There were 19 girls in a separate building a quarter of a mile away, and of these but one had goitre, and she gave a history of the disease on entrance. Both boys and girls used the same water supply, from a bored well, 156 feet deep, The only change made recently in the food was in the brand of flour. No local cause for the epidemic could be discovered. The treatment adopted was the administration of Lugol's solution of iodine. The cases improved rapidly and were nearly all well by the end of August. An examination on the first day of October showed but five boys with any traces of the old enlargement. HOW TO SUBSCRIBE FOR THE NEW BONDSThe war loan which is now being offered will be sold to subscribers at par during the period of subscription, which ends July 14, 1898. The method of subscription has been made as simple as possible. Blank forms may be obtained at every money-order post-office, and at most of the banks and express offices, and on these forms is clearly indicated all that it is necessary for the subscriber to fill out. The subscriber may himself mail to the Treasury Department at Washington the blank form filled out, together with his remittance covering the par value of the amount of bonds for which he wishes to subscribe. That remittance may be in whatever form best suits the subscriber's convenience in currency, bank draft, check, post-office money order. The day the currency is received, or the day the proceeds are received from the checks, drafts, or money orders, the subscription will be entered and will immediately begin drawing interest. When the bonds are delivered, a check will accompany each delivery covering the interest at 3 per cent. from the day the subscription is entered to the 1st of August, the date of the bonds, and from which date the bonds will carry their own in terest. SHAMPOOING The word "shampoo" is of East-Indian origin, and signified originally "to press." In Hindoostan it was applied to the practice of rubbing, pressing, and kneading the limbs of one taking a hot bath. A similar custom prevailed among the Greeks and Romans. At the present day the word is generally restricted to manipulations of the scalp as performed by the barber. The shampoo of this functionary is of two varieties, the dry and the wet. The wet shampoo consists in rubbing the scalp while it is covered with a soap lather. The operator goes thoroughly over every portion of the scalp with his finger-tips and finishes by washing away the lather with an abundance of warm water poured over the head while the subject of the operation bends over a basin. A hot towel is used to dry the hair, dandruff or other accumulation is bursed away, and finally an oil is rubbed into the scalp. It will be seen that the shampoo is, in effect, a species of massage, and that, therefore, properly performed, it must have a beneficial influence upon the nutrition of the scalp and promote healthy growth of the hair. Its action, as far as it goes, has a tendency to prevent the development of premature baldness. Considered in this relation, it is a procedure of much importance. |