MEDICINE.

IN CHARGE OF W. H. B. AIKINS, H. J. HAMILTON, C. J. COPP, F. A. CLARKSON AND BREFNEY O'REILLY.

Minor Signs of Thyroid Insufficiency.

In an article in the Gazette Des Hopitaux, Leopold Levi and Henry de Rothchild discuss the minor signs of thyroid insufficiency, pointing out that it is as necessary to endeavor to diagnose the lighter degrees of the malady as to recognize the complete forms. These milder forms they have named paroxysmal hypothyrea and hypothyrea minima. For more than two years they have been working on this subject, and have seen the benefit of the treatment in more than four hundred cases. They state that Hertoghe has preceded them in this view, and further say they will have occasion to recall important ideas made clear by their learned confrere of Antwerp.

The Minor Permanent Signs.-It is necessary to know, first of all, that all the signs which will be discussed are not necessarily found in the one individual. Inversely one must be careful as to the making of a diagnosis on a single sign. The combination only of a great number of minor signs will allow one to suspect or to justify a diagnosis of thyroid insufficiency. The proof of treatment confirming these suspicions will render a diagnosis easier. The following signs are to be relied on:

Transitory Edemas.-In the absence of all albuminuria hypothyrea is made manifest by white sluggish edemas of firm enough consistence, which are situated at the level of the eyelids in the frontal and malar regions. Occasionally there is a passing puffiness of the feet, the patient complaining that his boots cramp him, or that the fingers are so swollen that he is scarcely able to remove his ring. These edemas repeat themselves more or less often, may or may not be periodical. Side by side with edemas of the skin may be placed swelling of the vocal cords, oftentimes coming on at the menstrual periods and explaining the huskiness of the voice. Obstruction of the nasal fosse is another noteworthy sign.

We have here some signs which by their repetition acquire some value as an aid to diagnosis:

The Sign of the Eyebrow.-Coincident with the edema of

the eyelid, or independent of it, one sees a thinning of the eyebrows at their outer margins. This is due to a keratosis pilaris or to a developmental error. This sign, easy of recognition, is extremely common in those suffering from thyroid insufficiency. It is often hereditary and seen in entire families. By its presence one should be led to look for other signs of hypothyrea. Variations of Heat Production.-The thyroid body has a thermogenic function, and a whole series of symptoms are produced by its functioning poorly. Before counting this of value, from the point of view of hypothyrea, it is necessary to examine the urine, for a certain number of these signs do not appear except where there is also renal insufficiency, this latter calling attention to a latent thyroid insufficiency, and in these cases the kidney becomes the principal object of treatment. These ailments are the following: The mildest form shows itself by giving rise to a chilliness of the extremities, especially of the feet. Of these the patient is often unconscious, especially in the case of children, or is subconscious. The chilliness, in fact, is not great, and the patient so accustomed to his symptom that he does not describe it to his physician unless questioned. A second state is evidenced by cold, confined to either one or more extremities. It may be located in the back, in the thigh, or it may be general. The sensation is usually a conscious one, and the patient complains of it. They suffer almost constantly from the cold, especially in the winter, clothing themselves heavily during the day and at night using extra coverings.

There exists often at the same time vaso-motor disturbances, these patients having often pale extremities associated with numbness of the hands or fingers. Again, their hands may be bluish in color and chilblains frequent.

A third degree is signalled by chills, as shown by Hertoghe. These are general, being most severe in the dorsal region, and occur about 4 or 5 o'clock in the afternoon, or they may occur immediately after meals or in the morning. Their duration may be momentary or prolonged, and are accompanied sometimes by "goose skin," chattering of the teeth, or a general trembling. More often they are but a momentary shudder. In a certain number of cases the body temperature is lower than normal during the day and is elevated at night. These patients with subnormal temperatures occasionally present an exquisite hyperesthesia to cold and are subject to autoinfections, such as coryza, etc.

Constipation.-Evidenced by the infrequency of stools and

hard fecal matter, often accompanied with intestinal mucus and sometimes colic.

Fatigue. These patients suffer greatly from fatigue, which comes on after slight effort and is usually seen in the mornings. This fatigue is similar to that induced by neurasthenia, and like the apathy of those suffering from myxedema.

Anorexia. An example of thyroid extract in these cases is cited: A man suffering also with chronic rheumatism, showed after the eighth day of treatment a marked appetite; ate between meals, and with heavy doses ate so much that his friends believed him to be the host of a tape-worm.

Headache. Of this there are seen two forms: a frontal headache similar to that experienced at the outset of coryza, and occipital headache with a tender point at the level of the occipital nerve. This is more intense in the morning and disappears towards evening after a heavy meal. The least fatigue, draught of air, etc., causes its return.

Muscular Pains and Painful Joints.-Those with hypothyrea complain of a varied type of muscular pains, setting them down to neuralgia, lumbago, rheumatism, etc. These pains are attributable to colds and fatigue, with diminished thyroid secretion. With the articular pains a similar condi

tion exists.

Somnolence.-Briquet, of Armentiers, and Lorand, of Carlsbad, have pointed out that sleep is regulated by the thyroid body, whether it may or may not be influenced by the pituitary body. Patients with thyroid insufficiency have need of a great deal of sleep, and are sleepy after meals. Thyroid medication diminishes the need of sleep, and if pushed to excess causes insomnia.

Obesity. Hypothyrea is often associated with obesity, and in these cases again the extract produces excellent results.

Physical and Mental Backwardness.-Of all the glands which by their internal secretion regulate physical and mental development of the child, the thyroid gland plays the prominent part, and children with hypothyrea learn their alphabet and arithmetic with difficulty. This backwardness may be associated with incontinence of urine, voice troubles, etc.

Early Senility.-Varicose veins, hemorrhoids, cutaneous hemorrhages all are evidences of this. In these cases again the exhibition of the extract produces good results. The existence in the one patient of several of these signs should lead one to a diagnosis which the good results of medication should verify.

ACCIDENTS OF THYROID INSUFFICIENCY.

Autoinfections.-Those with hypothyrea fall an easy prey to infections of the mucous membranes; pharyngitis, tonsillitis, peritonsillar abscess, herpes, etc., are common with these subjects. Heredity appears to play a prominent part and espe cially in those who suffer from tonsillar affections, and in these there seems to be a remarkable periodicity.

Periodical Autointoxications.-Migraine should draw one's attention to the possibility of hypothyrea, for it is often of thyroid origin. It is found most frequently in females, but also in males, and may appear as early as nine years or as late as thirty-five. The migraine is paroxysmal in character, and often associated with vomiting and nausea as to force the patient to his bed. Here, again, one should search for other signs of hypothyrea. Vomiting without apparent cause is seen to occur in the mornings; this and also the periodical vomiting of infancy are often of thyroid origin, as the happy effect of the treatment has shown. Urticaria and pruritis are frequently observed in these patients. Hertoghe has shown that thyroid medication possesses an inhibitory action on the menstrual flow, and is indicated in some cases of metrorrhagia. The pain which often accompanies menstruation in these cases is greatly lessened. They give as an example a young lady of twenty-three years who had suffered for ten years and who now passes her periods without any discomfort. In those suffering from hypothyrea the medication exerts a great influence on their moral natures. Attacks of anger, sadness, enervation, nervous excitability, also vertigo, diarrhea, palpitation, disappear with treatment. Thyroid insufficiency is often a family disorder and hereditary, as are some of the symptoms which accompany it, such as constipation and the sign of the eyebrow. Sometimes it is manifested by a morbid temperament rather than by any distinct disorder.

Recognizing actual minor signs and symptoms of hypothyrea, let us endeavor to make a diagnosis in order to give proper treatment. One should always examine the urine, as a certain. number of manifestations of hypothyrea are also noted in autointoxications of a different origin. Many times in a well known case, side by side with well recognized symptoms are others which appear to conflict with the diagnosis. Thus, instead of constipation we may have diarrhea, insomnia in the place of somnolence. A third may have the eyebrows well developed. In reality this is often the case, and justifies the theory of dissociation of the thyroid functions, or they may be

simply reactional paroxysms, hypothyrea giving place to hyperthyrea through action. It is thus that it is necessary to interpret these signs that we have placed under the category of accidental. In these cases it is necessary that the medication be given with care in order not to aggravate the symptoms one seeks to combat. The object of the treatment is to re-establish thyroid equilibrium, and with experience the exact dose may be arrived at.

With the discovery of the signs of hypothyrea, giving ample evidence of an ill-functioning gland, one does not necessarily arrive at a complete diagnosis. Hypothyrea may be only an incident in the illness. There may, for instance, be an ovarian or hepatic insufficiency as well.-J. S. A. G.

Epileptoid Attacks in Bradycardia and Tachycardia.

Fred Hugh Clarke, in the British Medical Journal of Aug. 10th, 1907, discusses the above subject, and refers to four cases in which there was no demonstrable heart lesion.

Tachycardia, according to Allbutt, is "an enormous quickening of the pulses of a heart, not necessarily the seat of static disease, with sudden onset and subsequent reversion to the normal, less certain phenomena of exhaustion." These latter refer especially to symptoms connected with the nervous system. According to Clarke, in the cases presenting tachycardia, no heart lesion was demonstrable, beyond the fact that after numerous attacks signs of hypertrophy may be noted, a bruit may be temporarily present during the attack, the tachycardia may last from a few hours to several days. Finally, as exhaustion sets in irregularity occurs, stops are felt in the radial pulse and concurrently the patient suffers in mild cases from sparks before the eyes, to in severe ones epileptiform convulsions with loss of consciousness, the face becoming pale, lips livid, thumbs drawn inwards, head backward; the patient may scream and convergent squint be present. The prognosis in this class of case is more favorable than those of bradycardia, in which Clarke believes an organic lesion in the region of the bundle of His to be the direct cause; the former he considers to belong to class of neuroses.

The immediate cause of the attacks is to be found in the cerebral anemia consequent on ventricular asystole, and the severity of the case depends on its duration. In tachycardia, apparently a pure neurosis, characterized by great rapidity in the auricular contractions, after a time fatigue of the bundle of His occurs and repeated asystole of the ventricles ensues,