can be no doubt of the fact that interference with the various functions of the body, as indiscretions in diet, irregular hours, or other habits of life, lower the resistant vitality of the system and are important etiological factors in their production. Overheated houses, imperfect ventilation, insufficient exercise, improper clothing, lack of care of the skin and excessively hot baths, the inordinate use of tobacco and alcohol, all have an influence in lowering the resisting power of the body and rendering the nasal mucosa more exquisitely sensitive. Anxiety, overwork and mental strain act in the same manner and are possible causes that should not be overlooked. The healthier the organism and the more perfect the condition in which the nasal mucosa is maintained the more effectually can the various deleterious influences be resisted. Septal deflections or spurs alter the conformation of the nasal chambers, and the column of inspired air is caused to impinge with too great force on certain areas and produces irritation of its lining membrane. The membrane also suffers when the air taken in is charged with dust, smoke, or the fumes of irritant chemicals.

The toxic action on the vascular system observed in constitutional disorders, especially lithemia, and disturbances in the gastro-intestinal tract is a frequent influence in the production of catarrhs, as is abundantly evidenced by the fact that numbers of cases can not be relieved until these conditions receive appropriate treatment.

It is in the initial stage of coryza that treatment attains its highest efficiency, and it is a matter of regret that but few cases reach us during the earliest stages, for after each attack there are left more or less inflammatory products that permanently thicken the nasal structures and impair its function. A cold is not the trivial ailment that the slight consideration. given it by some would lead us to believe, and to so conduct an attack as to restore the tissues to their normal condition and function is an undertaking that is worthy of our best endeavor. Each case should have careful attention and the patient be impressed with the importance of prompt and efficient measures. It is necessary to give due attention to the cause producing the disorder that further hurtful influence from that source may be eliminated and the disease process be

brought under proper control. The importance of hygienic surroundings should be insisted upon, the patient fully instructed in this regard and the observance of these precautions should be persisted in until the disturbance has entirely disappeared. The treatment would be much facilitated if we would consider it an acute infection and give more attention to a study of the conditions of lowered resistance under which it develops. If there is much elevation of temperature the patient should be kept in the house, which should be maintained at an equable temperature, well ventilated and free from irritant dust and vapors. The congestion of the turbinal tissues and the feeling of fullness it produces respond very readily to the administration of the "coryza" tablet of Bishop. Quinin seems to have but little effect in this condition, except to act as a stimulant. Inhalations of menthol exercise a good influence at this stage and can be used in an inhaler, in a nebulizer in a 20 per cent. solution with albolene, or in a 3 per cent. solution with an atomizer. A weak solution of adrenalin mopped or sprayed over the swollen membrane constringes the tissues, restoring the respiratory channel, permitting ventilation of the accessory sinuses and relieving the necessity for oral breathing. Cocain solution locally applied acts in a similar manner, but its exhibition should be limited to the production of anesthesia on account of the ease with which some patients can become habituated to its use. Very weak antiseptic astringents will aid materially in maintaining the opening of the nasal passages, and their use is indicated in an infectious process. In lithemic subjects the diet should be carefully regulated and the functions of the bowels, skin and kidneys stimulated by the use of cholagogues, baths and the administration of bicarbonate of soda. In the more advanced stages of coryza, if the nasal hydrorrhea be troublesome it may be very effectually checked by local applications of adrenalin of 1 to 5000 strength in normal salt solution, or if the discharge is purulent in character the passages should be cleansed with a non-irritating douche. Indiscriminate douching is responsible for much mischief, and when it is deemed necessary to order a douche great care should be taken to have its density the same as that of the blood serum in order

to prevent undue osmotic action, and it should be used at a temperature near that of the body.

Greater care in the treatment of colds would prevent a great amount of discomfort and suffering and would remove the necessity for much special treatment in later years. Randolph Building.

EXOPHTHALMIC GOITRE.

RÉSUMÉ OF CASES AND THEIR TREATMENT.*

HENRY POSERT, M.D.

MEMPHIS.

My main object in reporting these cases is to bring about a more favorable opinion of the treatment of Graves' disease. A great many among us have their greater or less share of these cases. Each has probably tried a method to benefit his patient and probably given it up after a while as hopeless. But here, as in many things in life, perseverance is often crowned with success. Of the nine cases I have seen in the last eleven years I have lost sight of three. There remains then a group of six, five females and one male. Their ages varied from 14 to 43. Four were married; two lived in the country; four in the city; three were of foreign and three of American parentage. Their previous history revealed nothing of importance. As to heredity, I could trace in each a neurotic taint. In two the disease was found in the family. The uncle of one patient also had exophthalmos. In another I was able to trace simple goitre in the maternal aunt and father's sister. The parents of another came from Tyrol where, as you know, goitre is prevalent.

As to the immediate cause of the attack I am unable to say much. Only in one case, a widow 41 years old, I could refer it distinctly to grief and deprivation. She was of a highly sensitive nature. Her husband died after a protracted illness, leaving her penniless. A few days later the first symptom appeared.

The cardinal symptoms, exophthalmos, tachycardia and enlargement of the thyroid gland, were present in all. Five were *Read before Tri-State Med. Assn. (Miss. Ark. & Tenn.) Memphis, Nov. 18, 1903

of an aggravated form; the sixth, a woman of 26, and mother of three living children, was a mild one. The pulse varied from 130 to 146. The violent beating of the heart was a constant cause for complaint; it would prevent sleep, and again it would often wake them up. In four the right lobe was more enlarged than the left. Of the other accompanying symptoms two had exhaustive diarrhea, so as to become for a while the chief cause for alarm. Three suffered for a long time from a "giving way in the knees," as they described it. It was neither a physical weakness nor a paresis. It prevented them for various periods of time from coming to my office. Their appetite was poor, or capricious; all suffered from emaciation; it was especially marked in two, as they were very stout when first attacked. The psychic symptoms were pronounced in all. They were excitable and irritable, easily confused, with poor memories and slow mentality; one complained. of being in constant fear and had for a while hallucinations.

Apart from treating symptoms as they arose my main reliance for the cure of the disease was electricity. Faradism was applied to the thyroid gland, to the cervical sympathetic and to the orbicularis palpebrarum. To do any good it ought to be applied every day for fifteen to twenty minutes for a long period, say for nine months or a year, with intervals spent in a different climate. Change of climate effected remarkable improvement, and should be insisted upon when feasible.

DURATION OF CURE. Five recovered. The sixth male, 34 years old, died of an intercurrent disease. Of the recoveries one has continued free from attack nine years; two, seven years; one, two and one-half years; one, one year and three months.

I have not seen any beneficial result from use of drugs, not even the much-talked-of thyroid extract. Why this organic extract should be given I am at a loss to understand. Is it then proven, that the disease is brought about by a lack of secretion from the thyroid gland? It certainly is not. On the contrary, one of the theories lately discussed and to which Joffroy, Marie, Moebius and others adhere, ascribes Graves' disease to an over-activity of the thyroid gland. In fact, the entire pathology and its causation is obscure and practically

unknown. Each theory has its advocate, but none tallies with facts, nor is borne out by pathological findings. Others place the trouble to a derangement in the medulla, but this has not been shown by fact. The most plausible theory is that which ascribes it to a form of derangement of the sympathetic nervous system. This does partially explain the tachycardia, the sweating, flush, deranged secretions; the diarrhea, the abnormal vasomotor action of the vessels.

Surgical procedure, especially in the last few years, has found favor with many. I am not an advocate of it for the following reasons:

1. Statistics do not show a more favorable result than where treated medically.

2. Since we do not know which theory is correct, it is hard to decide between excision and operation on the cervical sympathetic.

3. The danger of anesthesia.

4. Under cocain, used in most operations, it is extremely painful; it is bloody, and fatal hemorrhage is always to be feared, since the gland is extremely friable.

5. Scar is left; a consideration in a disease that afflicts women in their youth.

6. Operation demands a skillful operator, who cannot so easily be procured by everybody and everywhere. Hence surgical treatment should not be resorted to except where other means have failed.

Why should Faradism be preferred for treatment? Because (a) It stimulates nerves.

(b) It effects better blood supply and thus promotes metabolism.

(c) It prevents rapid proliferation of connective tissue, which latter strangles the cells and inhibits normal function.

"THE MEDICINE MAN" is the name of a beautiful chromolithograph now being sent to physicians by the Mellier Drug Company, of St. Louis. This is a beautiful souvenir, and should be in the office of every physician.