The treatment of exophthalmic goitre : based on forty-five consecutive cases / by A.D. Rockwell.

  • Rockwell, A. D. (Alphonso David), 1840-1925.
Date:
1893
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Credit: The treatment of exophthalmic goitre : based on forty-five consecutive cases / by A.D. Rockwell. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    Medical Record A Weekly fournal of Medicine and Surgery Vol. 44, No. 14. Whole No. 1195. New York, September 30, 1893. $5.00 Per Annum. Single Copies, ioc. Original Articles, THE TREATMENT OF EXOPHTHALMIC GOI- TRE, BASED ON FORTY-FIVE CONSECUTIVE CASES.1 By A. D. ROCKWELL, A.M., M.D., NEW YORK. In considering this strange and intractable disease I shall enter into no speculations as to its pathology, for the reason that all explanations of the phenomena that attend it are in the main conjectural. Neither shall I take time in discussing its etiology or its well- known symptoms, for these can be found in every text- book on Neurology, with little variation of detail. The evidences of pathological anatomy have thus far been so thoroughly negative that we are left to the symptoms alone for guidance in treatment. These are, however, so positive and suggestive as to afford ground for a rational therapeutics, the end of which must be to regulate and give tone to nerve force, and to equalize the circulation. In an experience including the treatment of forty-five cases of exophthalmic goitre, dating from 1876 to the pres- ent time, a period of sixteen years, I have been enabled to clinically study the disease very thoroughly, and form an opinion as to the benefits to be derived from certain methods of treatment not altogether in accord with pre- vailing opinions. In short, I hold that the prognosis in this disease is better than is generally believed, and if my results have been more satisfactory than others that have been reported, it has been due to a more rational use of the remedy which has been my main reliance, and greater thoroughness and persistency in its application. The remedy to which I refer is electricity, and while I by no means exclude the administration of drugs in the management of this disease, they are in my hands re- garded as supplementary to the chief remedy, and subject to changes according to the indications in each individ- ual case. The surprising lack of unanimity of opinion in regard to the efficiency of medicinal treatment is due to the fact that, not only have those drugs that have proved beneficial in some cases failed to do good in others, but sometimes a drug that has in one case proved palliative has in another seemed to do harm. Iron, for example, is a universal remedy that is perhaps in the majority of cases fully indicated and is well borne, but I have occasionally found it to be productive of unpleasant symptoms even when anaemia existed, and have been compelled to dis- continue its use. The statement of Von Graefe, that iron is useless in the height of the malady, but that it does good when a certain amount of improvement has occurred, is an observation of value, and founded upon an extensive experience. My own experience has not been very favorable to the use of quinine, strychnia, or arsenic, and I now rarely ad- minister them, and I believe the iodides often do more harm than good. Belladona has been highly recommended, and is un- doubtedly of value. Carbazotate of ammonia I have used in but one case, but discontinued it after ten days, on account of the gastric disturbance that it seemed to occa sion. Digitalis is by some believed to be useless in this 1 Read before the Pan-American Medical Congress, Therapeutic disease, on the theoretical ground that it directly stimu- lates the muscular fibres of the cardiac vascular system. While the value of this remedy is now well recognized, there still exists much difference of opinion as to the method of its action. It has been regarded as a tonic, a stimulant, and as a sedative. The latter view, as is well known, was taught by Trousseau long ago, who held that it occasioned contraction of the superficial blood-vessels, thus producing diuresis, very much on the same principle as the action of fright or cold. In a recent discussion1 Professor Crocq held that digitalis was not a sedative nor a cardiac tonic any more than alcohol is a tonic to the brain. It is simply a stimulant. Another view is that digitalis ac‘s on the pneumo-gastric and sympathetic nervous system, thus regulating the action of the heart. By one the remedy is believed to act only on the left heart, by another on the right heart as well, retarding the action of both. But whatever theory is accepted, obstinate experience will not wheel into line at the com- mand of any theory, however plausible. On the theory of the stimulant and tonic action of digitalis I hesitated for a long time to use it in this dis- ease, but when I finally came to put it to the test of ac- tual trial I was most agreeably disappointed in the results, especially when combined with certain other remedies to which allusion is made further on. If the heart seems abnormally strong in exophthalmic goitre, this is not by any means always the case. Very frequently there is enfeeblement of the myocardium, and digitalis is in many cases useful in slowing the rapid sys- tole associated with it. The condition of the heart thus becomes improved by the physiological rest it obtains through prolongation of the diastole. Yet, like iron, digitalis may under certain conditions prove not only useless but harmful; but like iron, and especially in combination with iron, it possesses undoubted value. In what may be termed sthenic cases, where the excitability of the heart is great without enfeeblement, digitalis is certainly contra-indicated, and one such case will be found in this report. In this case good results were obtained by substituting veratrum viride for digi- talis. Strophanthus has received high commendation, and on theoretical grounds it is recommended in preference to digitalis. While both tend to lengthen the interval be- tween the contractions of the heart, strophanthus is sup- posed to contract the calibre of the arterioles in less degree than digitalis, and is to be preferred as not increas- ing the work of the heart to the same degree as the lat- ter. In conjunction with digitalis or strophanthus, and iron, ergot and bromide of zinc seem to me to be distinctly valuable, and I have no hesitation in saying that a com- bination of these remedies will more nearly fulfil the in- dications in the majority of cases of exophthalmic goitre than any other single remedy or combination of remedies. There are probably to be found few, if any, who will not accord to electricity an important place among the remedies indicated in exophthalmic goitre, and unlike some others mentioned, it cannot, if judiciously used, do harm even in those cases where it does no good. Gowers, who does not in general accord to electricity a very high place in therapeutics, yet says that in this dis- ease it is followed in many cases by a distinct fall in the frequency of the pulse (amounting to 10 and even 20 beats per minute), and sometimes by a slight diminution