was sick for two days. Afterward the headache disappeared for a short time. In September, this was again the subject of complaint, and was described by the patient as attended by a peculiar frying sensation in the top of the head.

This continued till January, 1869, when patient had an attack similar to the one in August. He took a furlough of a week, and then reported for duty much improved.

The next symptom which attracted attention was excessive palpitation of the heart under excitement or unusual exertion. Patient complained of these symp toms, headache and palpitation, continuously, till July. He was then prostrated by an attack resembling ma larial poisoning; was treated with quinia, followed by tonics. He soon resumed labor, though in no condition to do so. He had lost much in flesh and strength, and was greatly changed in appearance. In August, 1869, he had a severe attack of illness, marked by profuse perspiration, nervous anxiety, and depression. Respirations were 35 to the minute and difficult; pulse 120. The sphygmographic pulse traces taken at this time, from both the right and left arms varies from the normal

Trace from right arm.

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Trace from left arm.

pulse, in that each curve is surmounted by a horizontal or flat top, and assumes the form described by Marey as the senile pulse. Eyes were prominent, there was a choking sensation in the throat, and patient could only lie on the left side.

Everything ingested was vomited. A more critical examination revealed an extensive swelling of the thyroid gland, occupying the space between the sterno-cleidomastoid muscles, and extending from the clavicles to the prominence of the larynx.

This had not been noticed by the patient or his wife; upon applying the hands over it, the peculiar thrill of an aneurism was detected; the bruit was also conveyed to the ear.

Aneurism was at first suspected, but was excluded from the diagnosis, as both sides of the neck were equally prominent, the circulation in both carotids equally disturbed, and finally the swelling was located in the thyroid gland.

Exophthalmic goitre was diagnosticated. At this time the size of the neck over the swelling was 16 inches, the patient usually wearing a 14 inch collar. Ophthalmoscopic examination revealed a highly colored fundus, arteries enlarged, and the pulsations markedly visible. The veins seemed to be about double the normal size. The border of the optic nerve was well defined and the nerve substance paler than usual.

As he had no appreciation of his condition, and would not believe his disease was other than ordinary goitre, he was not placed under treatment. He took a leave of absence, and went to Canada, where he consulted an "Indian doctor," who agreed with the patient in the diag nosis of the case, furnished him an ointment composed, apparently, to a great extent, of iodine, and promised him a speedy cure. After some ten days he returned,

confident that out of door exercise and the use of the wonderful "Indian ointment," would result in recovery. For a few days he picked hops, and was comfortable in health; he then had attacks of profuse perspiration, which reduced him rapidly; his eyes became more prominent,

and on the 20th of September the size of the neck was increased to 17 inches. The patient became fearful, gave up the use of the ointment, and applied for treat

ment.

One of Chapman's ice bags was applied over the tumor, and ordered worn constantly. Fluid extract digitalis, to control the action of the heart; was given in two drop doses, increased afterward. Pulse 120. September 22d, pulse 108; 23rd, 104; 25th, patient has been vomiting, is reduced in strength; pulse again 120. September 29th, pulse 114; temperature 101 degrees. The sphygmographic traces of the two arms differ remarkably from each other, the right presents a dicrotic trace, with

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Trace from right arm.

a normal acute apex, while the left retains the characteristics noticed in the traces taken the month before.

Trace from left arm.

September 30, vomiting continues; nothing is retained on the stomach: digitalis discontinued. Patient is in bed, restless, complains of heat, sleeps little. October 8, has retained nothing for eight days; is much emaciated; temperature 102; is very irritable, impatient, fault-finding. Given injections of beef extract. Pulse is very rapid and irregular, at times reaching 150. Murmurs, indicative of mitral insufficiency are heard over the heart, and the pulse beats of the abdominal aorta are painfully strong and distinct. The eyes are very prominent and staring, and the aspect of the pa tient is anxious and fearful. October 12, temperature

99; very restless and sleepless, and at times delirious; enemata discontinued, as they promote diarrhoea; retains a little buttermilk. October 15, temperature 100, pulse 104; takes an egg and drinks a little ale; still delirious. October 20, is thin and emaciated; vomits. October 22, sensation of thirst and heat very strong; patient more delirious, got up in the night, and was about to throw himself over the banister, saying there was a stream of water flowing below. Tongue red and glazed, throat and fauces dry; requires constant watching. October 27, walks out a little daily; very weak and feeble; deglutition difficult; voice changed; size of neck 163 inches. November 8, since the first of the month has steadily improved; eaten well, gained in flesh and strength. November 9, severe paroxysm of cough and dyspnoea, with bloody sputa; very dizzy; emotional; cries and worries without cause; temperature 102; size of neck, 16 inches; pulse 120; carotids beat forcibly; respiration prevents auscultation or percussion being of avail. November 12, severity of paroxysm allayed by sedatives; no further indication of inflammatory action. November 18, size of neck reduced to 15 inches. Has profuse night sweats, some cough, and is restless. Heat of skin normal; pulse 96; given quinia and phosphoric acid to control action of skin. November 22, gaining in flesh and strength, and free from night sweats. December 15, performed some light labor in the ward. Improved in general appearance; eyes less prominent; size of neck 15 inches; pulse about 100; is eating and sleeping well. He continues thus, though face was tumid and congested, till about the middle of January, when his extremities began to swell and become painful on standing or walking. The swelling steadily increased till February, when he left the institution. He was then irritable

fault-finding and unreasonable, and his mind much enfeebled. For a few days his stomach rejected food; he was restless, sleepless, and losing flesh rapidly. Palpitation was again a troublesome symptom.

After going to the home of his friends, all the phys ical and psychical symptoms mentioned as existing in October were aggravated. The patient became very troublesome from his irritability and helplessness. His insanity was fully marked, and continued during the few weeks of his illness. He died late in April.

The treatment adopted in this case was that recommended by Trousseau—the free use of digitalis and the local application of the ice-bag. The results are briefly stated: the digitalis quiets palpitation and diminishes the frequency of the cardiac and arterial pulsations; the application of the ice offers the twofold advantage of causing a violent revulsion to the skin, and of rendering innervation and nutrition more perfect.

Trousseau says iodine was used both internally and externally in this form of goitre before it was recognized as a distinct variety. Its use was abandoned by nearly every one, as the symptoms were aggravated. He expresses himself strongly in this regard: "When in a case of goitre you find palpitation, protrusion of the eyeballs, and a strange look of the eyes, never give iodine. You have to deal with exophthalmic goitre, and iodine will only increase all the symptoms of the disease."*

In many cases the anemia present would seem to indicate the use of iron, but when the pulse exceeds 100,

*Dr. W. B. Cheadle has recently reported to the Harveian Society eight cases of this disease, in six of which iodine was given continuously for many weeks, and in only one case was it deemed necessary to discontinue it on account of increased palpitation following its administration.-Jour. Med. Science, October, 1869.