A still more important object of treatment than relief in the paroxysms is their prevention. During the intervals this object claims assiduous attention. First in importance is the avoidance of all exciting causes. Bodily exercise is to be kept within the limits required in order to incur no risk of a paroxysm being produced. The same precaution applies to mental excitement. Unhappily, this is not as easy as the avoidance of muscular exertion. John Hunter's saying, that his life was at the mercy of any scoundrel who chose to insult him, proved a prediction. He fell dead on receiving an insult from one of his colleagues at St. George's Hospital. Sexual intercourse I have known to prove an exciting cause. Excesses in eating and drinking are in this category. The diet, however, is not to be reduced below the full requirements for nutrition, and wine or spirits, as conducive to digestion, are in some cases serviceable. The use of tobacco is to be interdicted.
Coexisting affections which have no special pathological connection with the angina may act as auxiliary causes, and therefore claim attention. Gout is to receive appropriate treatment. Anæmia especially is to be removed. This condition strongly conduces to the development and the continuance of neuralgic affections. Chalybeate remedies and the dietetic treatment are called for if this condition coexist. It is a rational indication to supply the heart with good blood if it be true that angina depends on an ischæmic condition of this organ.
Associated cardiac lesions are to be treated according to symptomatic indications, as in cases in which angina does not occur. Digitalis may be used under the proper restrictions. I have known this remedy to prove highly useful in preventing the recurrence of paroxysms. Nux vomica is sometimes useful as a cardiac tonic.
Various drugs have had repute as empirical remedies. Of these may be mentioned the preparations of zinc, arsenic, the nitrate of silver, phosphorus, the bromine salts, the iodide of potassium, and quinine. There is no proof that these remedies have any special therapeutical effect in this affection, but that they are sometimes useful there is abundant testimony. Trial should be made of them, with proper care in their administration. Electricity in the form of the induced and of the constant current has been advocated as not only serviceable, but as effecting in some instances a permanent cure.6 Beard and Rockwell have found general faradization useful in a few cases.7
6 Vide Eulenburg in Ziemssen's Cyclopædia, vol. xlv. p. 54.
7 Vide Medical and Surgical Electricity.
Exophthalmic Goitre (Graves' Disease; Basedow's Disease).
This affection is characterized by three striking symptomatic events—namely, persistent increase of the frequency of the heart's action, enlargement of the thyroid body, and protuberance of the eyeballs. The name exophthalmic goitre relates to the last two of these three events. It is defective, inasmuch as it does not include the increased frequency of the heart's action, which is the primary one of the three events, and the only one which is never wanting. As an individual affection it was first described by Graves in 1835, although cases in which these events were associated had been previously reported. Parry collected 7 cases in which the affection of the heart was associated with thyroid enlargement, and in 1 of these cases exophthalmia existed. An account of these cases was published in 1825. The name Graves' disease, proposed by Trousseau, has been adopted by French, English, and American writers. Basedow's disease is the name given to the affection by German writers. The affection was described by Basedow in 1840 under the name Glotz augenkrankheit.
There are cases in which one of the events in this symptomatic triad is wanting, the cases in other respects corresponding to the affection. The exophthalmia is the event oftenest wanting, the goitre, the functional disorder of the heart, and the associated phenomena being the same as if protuberance of the eyeballs coexisted. In some instances the goitre alone is wanting. The name exophthalmic goitre is not strictly applicable to these cases, but that the affection is essentially the same as when the three events are present cannot be doubted. It is a chronic affection, being in the great majority of cases of long duration. Exceptionally, it is developed suddenly and disappears after a few days. In these cases the affection has been distinguished as acute, but its claim to be so called rests exclusively on the shortness of its duration.
SYMPTOMATOLOGY.—Of the three cardinal events, the increased frequency of the heart's action is the first in the order of time. This precedes the other events usually for several weeks or even months. The frequency varies in different cases within wide limits—namely, from 90 or 100 to 150 beats, and even more, per minute. There is notable variation at different times in the same case. Generally, the frequency is greatly increased by exercise and mental emotions. In other words, irritability of the heart is in most cases a marked feature. As a rule, there are none of the disturbances of action, in other respects than frequency, which are found in cases of functional disorder not associated with exophthalmic goitre. The action may be intermittent or in other respects irregular, but in most cases the rhythm is not disturbed. The patient is conscious of the heart's action, and is annoyed by it, especially under any excitement; but there is not that distressing sense of the disorder which is felt in the paroxysms of palpitation with irregularity of action considered in the first division of this article. At the outset and for a considerable period there are no signs of any organic disease of the heart, or if the latter be present the association is accidental; the disordered action, as far as it relates to the affection under consideration, is purely functional. At a later period there may be enlargement of the heart as a result of long-continued increased activity of function. From the first cardiac murmurs are generally present at the base and over the body of the heart. These are blood-murmurs due to coexisting anæmia.