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the idea that all the symptoms of exophthalmic goitre are caused by the excessive formation of the thyroid secretion and its absorption by the blood.

According to this theory, involvement of the thyroid is the first phenomenon of the disease, and all the other symptoms are secondary to it. This is remarkable from the fact that there is hardly a dissenting voice among the authorities that the heart disturbance is the first clinical symptom of this condition. In the majority of cases, the thyroid involvement is noticed weeks or months after the development of the rapid pulse.

A few words concerning the physiology and minute anatomy of the thyroid will serve the further purpose of this paper. In the absence of an excretory duct, the physiologist calls the thyroid a gland of internal secretion. Revelation has been denied the scientist interested in this field, or, at most, has been so grudgingly given that the nature and importance of internal secretions are matters in dispute.

As is well known, the thyroid consists of numerous tubular alveoli, united into lobules and these, in turn, forming the two lobes. The alveoli are lined with a single layer of epithelium and the spaces contain the peculiar secretion of the thyroid, known as the colloid substance. Most authorities look upon the colloid material as a secretion of the alveolar cells. The colloid escapes into the lymph spaces and through the lymphatics reaches the blood.

Rotch says true goitre consists in the enlargement of old and the formation of new alveoli. The study of many microscopical sections has demonstrated to my satisfaction the correctness of his view. This definition excludes, properly so I believe, cases of ordinary inflammation which, instead of being called goitre, are more correctly named thyroiditis. Most sections I have seen indicate a great increase of the colloid substance in the enlarged alveolar spaces. Indeed, in true goitre we expect to see the spaces packed so full of the colloid material as to seem distorted and distended from the very abundance of it. With these conditions, certainly an abnormal amount of the secretion must be taken into the circulation.

Now then, if Murray is correct in his Carlisle theory, that the symptoms of exophthalmic goitre are due to the excessive formation of the thyroid secretion, why do we not observe the heart and eye symptoms of Graves' disease not only in exophthalmic goitre, but also in every case of bronchocele ?

On the other hand, Hutchison of Edinburgh insists, and morbid anatomists are practically agreed, that there is no increase of the colloid matter to be observed in the thyroid in cases of exophthalmic goitre, and there is no reason to believe that the secretion is more rapidly removed from the sacs in that disease than in the normal condition.

To make good Murray's theory, too, it is necessary to find exophthalmos following the use of thyroid extract. While the heart and nervous symptoms of exophthalmic goitre may be produced by the injection of large quantities of thyroid extracts into monkeys, the exophthalmos is conspicuous for its absence. The failure to produce this symptom cannot be due to any peculiarity of the monkey tribe, for exophthalmos invariably follows injections of some substances into the circulation of these animals. If then all the symptoms of exophthalmic goitre must be accounted for by the excessive secretion or absorption of the colloid substance, the failure to produce exophthalmos is as fatal to the truth of the theory as in Hamlet the play is a failure without Hamlet the hero.

The truth is, bronchocele is a condition frequently met, while exophthalmic goitre is a disease of comparatively rare occurrence. As has been said, the clinical history of exophthalmic goitre shows the thyroid involvement to be secondary, at least not primary. These facts considered together are sufficient, it seems to me to disprove the theory that over-activity of the thyroid gland is the cause for exophthalmic goitre.

It is easy enough to overthrow theories which, after all, are of little comfort to the patient suffering with one of the conditions under consideration. It is of more value to throw light on its remedial treatment. As a recompense for the patient hearing given the early portion of this paper, I propose to offer a symposium of good things.

Hoping to add something of permanent value to the treatment of

goitre and exophthalmic goitre, I was led to write the following letter:

“Will you kindly tell me what remedies you have found of positive value in these conditions? Also favor me with the special indication leading you to prescribe the remedy or remedies mentioned.”

Copies were mailed to several of the older men of the Michigan profession. Men were selected who for long years have been looked upon as splendid prescribers. Not all replied, but several letters give in detail the desired information. It means much to review the testimony of expert observers who have personally witnessed the permanence of the cures related. As I have studied their

replies my own faith has been strengthened, as I trust yours

may be.

Without comment I quote their letters:

First.—“In simple goitre, I have attained more positive results from calc. iod. 3x., than from other remedies.

"While not wishing to say the enlargement is caused by uterine troubles, I do know that in all my cases such conditions exist, and by treating them the goitre readily yields.

"Exophthalmic goitre is entirely another affair. Of all remedies employed, lycopin has by far proved the most valuable. Its marked indications are the peculiarly rapid and uncertain pulse, sometimes going up to 150 or more beats per minute. The chest symptoms, especially the persistent, annoying cough, with glairy expectoration more or less tinged with blood, are also characteristic of this drug. I am mindful, of course, of the fact that the last-named symptom. together with a full, stuffed feeling in the lungs, are in a manner due to the abnormal working of the heart—not always, however, as the neurotic origin of the disease often causes them.”

Second.—“In simple goitre I have had some small successes with 'the indicated remedy,' when the local and constitutional symptoms were well marked. For instance, one recent case of small goitre tumor was promptly cured by calc.; another with one dose of lachesis; another with spongia. I think all cases have been benefitted in which I tried fucus tincture.”

Third.—“I can give you but few remedies, but the few in my hands have been so nearly specifically curative, that I have not sought after other remedial treatment.

“Spongia, from the ix to 3x, is my sheet-anchor. Secondly, spongia and calcarea phos, 3x or 4x, in alternation, in a moderately soft gland, and, of later years, in stone-like hardness, give spongia and calcarea fluorica, 3x to 4x, in alternation.

“When the goitre is apparently cured, to prevent its return, I give natrum phos. 3x four doses daily, for three or four months.

"I use no external applications except the indicated remedy. This is dissolved in water, a cloth pad saturated with it, and applied to the goitre every night, until the last vestige of the disease has disappeared."

Fourth.--"In goitre I have used iodine and its compounds, phytolacca, corydallis, stillingia, and various other apparently indicated remedies. I prescribe sticta if the patient's breathing has a dry, wheezing sound. If the sound is moist, I always give spongia c.c. I have had no reason to vary these remedies, except in dyscrasia, when the indicated psoric remedy must be prescribed. In these cases I most frequently use mercury, sulphur, psorinum, calc. carb., thuja and lycopodium.

"In exophthalmic goitre, each case must be studied by itself, and the treatment directed to the special indications met. When clear of ‘entangling alliances,' I gave fucus vesiculosis in five to ten or thirty drop doses of the tincture before each meal. So far, in the seventeen years I have been using it, I have not had a failure. I first prescribed it as an anti-fat in a patient who had exophthalmic goitre, and have since used it in every case, where fat predominates in the patient. In lean people, I rely upon the psorica and the usual objective and subjective symptomatic indications.”

Fifth.—“I have so long relied upon galvanism in these conditions, that I have little of value to offer you along the lines you seek knowledge.”

Sixth.—“For simple goitre I have used podophyllum, both externally and internally, with satisfaction. This remedy is of special value in young girls, when the condition of the gland seems to depend largely upon the menstrual condition.

“Also, I have prescribed, both externally and internally, iodinethe use of this remedy is, of course, very familiar to you.

"Electricity and electrolysis, to promote disintegration and absorption, are measures that I have used with good results."

I confess considerable disappointment that in these letters more prominence is not given another remedy. In all modesty, I desire to call attention to sulphur as a most useful agent in the treatment of simple goitre or exophthalmic goitre. I look upon this as a remedy much abused, too much prescribed and, after all, too little used by our profession. In the condition we are now studying, it certainly seems to me to be of inestimable value. Not only in the treatment of simple goitre, but also in exophthalmic goitre, even if Murray's etiological theory is eventually accepted, sulphur will continue to demand recognition.

A study of this drug shows its action on the glands, increasing their activity. Palpitation and irritability of the heart are characteristic, and the constitutional symptoms, so common in exophthalmic goitre, call frequent attention to this remedy.

Hirt mentions diarrhæa and copious vomiting of watery bile, as symptoms of the disease. Naturally they suggest sulphur with its bilious vomiting and diarrhæa.

The same authority calls attention to the falling out of the hair. Sulphur has that symptom.

Free perspiration is always mentioned in enumerating the symptoms of exophthalmic goitre, and usually accompanies the disease. Sulphur must be thought of here.

The reports of sulphur provings do not mention prominence of the eyes, but this omission does not necessarily disprove the homeopathicity of the remedy to exophthalmic goitre. It is considered unscientific to prescribe upon a single symptom, and it seems to me that the remedies which are credited with exophthalmos lack the other essential symptoms so commonly met in this condition. Therefore, upon the totality of symptoms, in my experience at least, sulphur has frequently seemed the similimum.

As a remedy is simple goitre, I believe its homeopathicity has never been denied.

As is very evident, there has been no effort on my part to exhaust the subject of this paper. If there had been by neglecting to mention the many remedies in common use, I should be guilty of criminal neglect. However, I cannot close without a reference to Dewey's splendid article on sapir albus, in the treatment of simple goitre, to Linnell's exhaustive article on "Remedies in Exophthalmic Goitre," and O'Conner's recent recommendation of sparteine sulph. in the latter disease.

WHEN SHALL WE CALL OUR BRIGHTIC PATIENTS

WELL?*

By GEORGE FREDERICK LAIDLAW, M.D.

New York.

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N this paper, I shall discuss the prognosis of that form of

chronic albuminuria which goes by the name of chronic Bright's disease. In so doing, I do not include the kidney complications of gout, syphilis, heart disease and lead poisoning. These latter conditions resemble true Bright's disease in that each ends in a nephritis with the resulting damage to the renal tissue and the inevitable dropsy or uremia; but, in cause and in development, they differ from true Bright's disease. True Bright's disease is not so much the result of a specific poison as a remote effect of external influences acting upon the skin.

Of the general symptoms of chronic Bright's disease, the condition of anemia is the best guide in prognosis. Conditions of

*Read before the Homeopathic Medical Society of the State of New York at Syracuse, 1898.

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