ACUTE ENLARGEMENT OF THE THYROID GLAND; 
ANGIO-NEUROTIC OEDEMA. 
(Reprinted from the International Medical Magazine, April, 1892.) 
BY ty 
WILLIAM A. EDWARDS, M. D. 
San Diego, California. 
Fellow of the College of Physicians of Philadelphia, American Pediatric and 
Philadelphia Pathological Societies; formerly Instructor in Clinical Medicine 
and Physician to the Medical Dispensary in the University of 
Pennsylvania; Physician to St, Joseph’s Hospital; Associate 
Pathologist to the Philadelphia Hospital, and Membep'J 
Advisory Council for the Section on Diseases 
of Children of the Pan-American 
Medical Congress. 
Kate H., a large-framed Irish servant girl, early in Sep- 
tember, 1888, had an attack of nephritic dropsy with an albu- 
minous urine, from which she apparently entirely recovered, as 
the dropsy disappeared, and the urine was free from albumin. 
The treatment at this time had consisted of Rochelle salt, 
Basham’s mixture, and compound jalap powder. In October 
of the same year she consulted Dr. Walter F. Atlee,* of Phila- 
delphia, on account of a great swelling in front of her throat, 
which moved up and down to some extent in swallowing, as if 
connected with the thyroid gland. Compound iodine oint- 
ment was applied and pil. ferri iod. given internally. By 
November 16, the enlargement was much greater, and by De- 
cember 5 the swelling had extended all over the front of the 
neck, even to the shoulder-blades. On the 8th there was much 
expectoration of tough phlegm tinged with blood, great diffi- 
culty in swallowing, and pronounced apnoea. On the 9th she 
became moribund and died on the nth. The enlargement of 
* Through whose courtesy I am enabled, to report the case. the thyroid was great and rapid, so that the neighboring parts 
did not have time to accommodate themselves to its increased 
size; consequently the pressure exercised ou the larynx, the 
upper part of the trachea, the carotid arteries, and the internal 
jugular veins produced a fatal result. Her voice was hoarse, 
feeble, and finally absent entirely; dysphagia existed to a 
marked degree, and the respiration also was so much interfered 
with that she perished by slow suffocation and starvation. 
The swelling was painful only to palpation, and at such times 
the pain extended to the shoulder and the back of the neck. 
The arteries of the neck beat violently, and the veins were 
greatly swollen; there was much fever, sleeplessness and rest- 
lessness. The expectoration was bloody and muco-purulent, 
as if the trachea had been opened. 
This case is one of extreme rarity; indeed the paucity of like 
cases in medical literature renders it difficult to make any 
deductions upon its relative frequency of occurrence. A some- 
what extended search, as careful as the means at my disposal 
would permit, has failed to show its counterpart. Of course 
we recognize the fact that in cases of chronic parenchymatous 
nephritis of which this was an example, effusions are the rule 
rather than the exception, but it is usually the serous cavities 
that are the selected sites and not the parenchyma of organs. 
We are unable to account for the unusual condition present in 
our case, the more so from the fact that the dropsy was so local 
and at the time of its fatal occurrence was the only effusion 
present. As far as could be ascertained all the serous cavities 
were free from serum. It was this sudden outpouring in the 
vital structures at the base of the ueek which caused such a 
rapidly fatal termination. 
This acute swelling of the thyroid gland in Bright’s disease 
does not seem to have attracted much attention from observers, 
Barlowf has reported an illustration of acute enlargement of 
the gland in a child just recovering from an attack of erythema 
nodosum, in whom slight and gradually-increasing enlarge- 
ment of the thyroid gland occurred, accompanied by pain, dys- 
phagia and fever, which yielded at the end of two weeks to 
leeching. Notwithstanding the association in this case with 
erythema nodosum, which, according to some, would place the 
case in a rheumatic light, Barlow is inclined to agree with 
Tucke that it had an idiopathic origin; a slight nasal catarrh 
and exposure to cold when in an anaemic condition might have 
f Annual Universal Medical Science, 1889. been factors in its production. In the discussion of Barlow’s 
paper, Berry referred to several fatal cases of acute enlargement 
of the thyroid, which usually occurred at or about the period of 
puberty. Access to the original paper has been denied me, 
and I am not aware whether the pathology of these cases of 
Berry’s was considered or not. This case in many respects 
resembles those somewhat odd cases described as acute local, 
acute circumscribed, or angio-neurotic oedema, a disease, as 
Osier! remarks characterized by the sudden onset in various 
regions of oedematous swellings, more or less limited in extent, 
and of transient duration. This writer briefly states the follow- 
ing characteristics in the cases that he has studied, the occur- 
rence of local swelling in various parts of the body—face, hands, 
arms, legs, genitals, buttocks and throat. In one instance, 
possibly in two, death resulted from a sudden oedema glottidis. 
One of the eases in this report died, aged sixty, of Bright’s dis- 
ease, who had had from the age of twenty many very serious 
attacks of local oedematous swellings. 
We are inclined to regard our case as a vaso-motor neurosis 
in association with Bright’s disease, a grouping that is not at 
all unusual, and under whose influence the permeability of the 
vessels is so altered that leaking occurs. Unfortunately, how- 
ever, at present our knowledge of the process of transudation 
is not at all complete, and as these forms of oedematous swell- 
ings come under this heading we can but agree with Cohu- 
heim, 11 “that we have to do here with clinical facts and obser- 
vations which urgently call for scientific investigation, and 
that we possess at present but extremely scanty material for 
an adequate explanation of neurotic oedema.” 
% Allgemeine Pathologie. Bd. i. p. 500; Osier, ibid. 
|| American Journal of the Medical Sciences.