368 C. P. HOWAKD 



ulants necessary except when there is evidence of cardiac decompensation, 

 which occurs only late in the disease or in very acute cases. Digitalis in 

 Graves' disease is very apt to produce cardiac arhythmia and troublesome 

 gastric irritation, and on this account even when indicated because of a 

 dilated heart should be given in small doses every other day, and prefer- 

 ably in the form of the powdered leaves, digitalin or digipuratum. In 

 mild cases of cardiac weakness five to ten drops of the tincture of strophan- 

 thus are well borne and fairly efficacious. Strychnia may also be tried. 

 For the nervous phenomena rest, fresh air and a comfortable bed do more 

 for the patient than drugs. A warm bath at 95 F. given just before 

 retiring for the night is very quieting, particularly when followed by a 

 hot drink or a hot water bottle to the feet. If in spite of these measures 

 insomnia persists a full dose of bromid or better still of veronal may be 

 given at bedtime. Pure hypnotics as chloral and opiates should be 

 avoided. 



For the gastrointestinal irritation regulation of the diet usually 

 suffices. Nux vomica or strychnia are useful for improving the appetite 

 and stimulating the gastric juice. Constipation should be met by diet, 

 water-drinking and regular habits, and when these do not suffice a mild 

 laxative as cascara sagrada or sodium phosphate. Traczewski and Kocher 

 formerly thought that sodium phosphate was almost a specific in the 

 treatment of exophthalmic goiter. This view is no longer tenable. 



For the gastro-intestinal crises lavage, catharsis and enemata are indi- 

 cated. A simple diet of albumin water and peptonized or boiled milk 

 should be used for a few days. Bismuth and salol may be tried in appro- 

 priate doses, but opiates and astringents should be avoided. 



The anemia is rarely severe enough to require iron and arsenic. 

 Fever, when marked, can be treated by sponging with tepid water or in 

 selected cases by tepid full baths or even cold full baths. 



For the conjunctival and corneal irritation a boracic acid solution 

 usually suffices except in very severe cases when special treatment with 

 other drugs may be necessary. 



Organotherapy. Some of those who believe in the theory of an 

 altered secretion (dysthyroidism) rather than an increase of the normal 

 secretion ( hyper thy roidism) as playing the dominant etiologic role highly 

 recommend the administration of the fresh or desiccated thyroid gland. 

 Dock (a) tried it in nine cases with a certain amount of success in some. 

 Mackenzie suggests that thyroid extract may be useful in old cases with 

 signs of hypothyroidism. It is nevertheless true that freshly made and 

 active preparations of thyroid gland will produce in the great majority 

 of exophthalmic goiter patients an increase in their symptoms and some- 

 times to an alarming degree. Accordingly, in light of our present knowl- 

 edge and experience, the use of thyroid preparations in uncomplicated 

 Graves 7 disease should be discouraged. 



