[Reprinted from The Medical News, September 7, 1895.] EXOPHTHALMOS {GRAVES' D ISE A S E) WI TH - OUT THYROID ENLARGEMENT. By P. S. DONNELLAN, M.D., OF PHILADELPHIA'; VISITING PHYSICIAN TO ST. MARY'S HOSPITAL ; LECTURER ON PHYSICAL DIAGNOSIS, MEDICO-CHIRURGICAL COLLEGE. M. H., a married woman, aged forty years, a weaver by occupation, was admitted to my care at St. Mary's Hospital on May 4, 1895. She presented the following history, for which I am indebted to Dr. Joseph H. Ross, one of the resident physicians at the hospital. Her father had died at the age of forty-five years from chronic nephritis; her mother at the age of thirty-two years of puerperal fever. All of her brothers and sisters had died in infancy. In the families of the parents there was no history of nervous disease or of any disease similar to that from which the patient was suffering. The patient herself was born in Scotland, and came to this country when fourteen years of age. She had always enjoyed good health until twelve years ago, when she was treated at this hospital for typhoid fever, from which she recovered without complication or sequel. She remained in good health until three years ago, when her present illness began-the result, she states, of a fright from a beating she received from her husband. There was no history of rheumatism or of alcohol, and specific infection was denied. Since her present illness began, the woman complains of constant and severe cardiac palpitation, with shortness of breath, vertigo, and insomnia. For three months 2 previous to admission there has been swelling of the feet, particularly after standing or walking for any length of time; and the quantity of urine was much dimin- ished. The patient has also noticed that her eyeballs have become very prominent, and they feel, as she ex- presses it, as if they would bulge out of her head. She suffers from occasional attacks of bilious vomiting ; her appetite is poor; her bowels are constipated, and her tongue is coated. The patient is a feebly nourished anemic-looking woman. Her eyeballs are very prominent. In looking downward the upper eyelids do not follow the descent of the eyeballs (von Graefe's symptom), and, while the voluntary movements of the lids are unimpared, the complete absence of involuntary winking (Stellwag's symptom) is noted. Dr. Louis F. Love, ophthalmolo- gist to the hospital, kindly made an examination of the eyes for me and confirmed these observations. He re- ported in addition : " Pupils, 2% mm., about equal; active to light, but sluggish in accommodation and convergence. Ophthalmoscopic examination-cornea? maculated, rest of media apparently clear; discs oval, axis 1800; veins well filled, with dilatation; marked astigmatism in each eye." Dr. G. Hudson Makuen, laryngologist to thehospital, kindly examined the patient for me, and reported that there was no enlargement of the thyroid gland. There was visible pulsation in each carotid artery noticeable at a distance of six feet from the patient. The pulse varied between 160 and 190 beats per min- ute, except when the patient had been taking two ounces of infusion of digitalis in the twenty-four hours for several days, when it dropped to 68 beats per minute, only to rise again when the digitalis was suspended. The vascular tension was much below normal. In examining the chest, increased frequency of respi- ration (from twenty-five to thirty per minute) was noticed, 3 but otherwise the respiratory functions were normal. The heart was hypertrophied, as shown by increased area of cardiac dulness downward and to the left. The impulse was felt in the sixth interspace to the left of the nipple- line. Auscultation revealed violent and irregular cardiac action, with increased frequency of the number of beats and synchronous with the radial pulse. A well-marked mitral systolic murmur was heard at the apex, trans- mitted to the axilla and to the angle of the scapula. The urine was negative chemically and microscopically, and upon admission measured only two ounces in the twenty- four hours, but rest in bed, and the use of the infusion of digitalis with strychnin, rapidly brought the quantity up to the normal. The principal points of clinical interest in this case are the absence of enlargement of the thyroid gland and the visible pulsation in the carotid arteries. Most observers with whose studies 1 am acquainted regard these phe- nomena as unusual. Trousseau called cases of this kind formes frustes (abortive forms), and considered them important types of the disease. An elaborate study of cases in which either the goiter or the exophthalmos may be wanting was made by Marie, who found that in such cases tachycardia was frequently present, and often accompanied by tremor. Hirt quotes the observations made in his wards by Ernst Cramer, who was able to con- firm the results of Marie. The consensus of opinion seems to be that the excited and accelerated heart-action is the first characteristic symptom of Graves' disease; then follows symmetric enlargement of the thyroid gland, the exophthalmos being, as a rule, of later development. Whether in this case the natural order of things has been reversed, and the enlargement of the thyroid gland may yet take place, only subsequent observation can determine. 4 Broadbent: The Pulse, Philadelphia, 1891, p. 89. Fagge: The Principles and Practice of Medicine, London, 1886, vol. ii, p. 87. Fuchs: A Text-book of Ophthalmology (translation), New York, 1893, p. 589. Hirt: The Diseases of the Nervous System (translation), New York, 1893, p. 131. Marie: Contribution & 1'etude et au diagnostic des formes frustes de la Maladie de Basedow, Paris, 1886. Meyer; Diseases of the Eye (translation), Philadelphia, 1887, p. 623. Osler: Practice of Medicine, New York, 1892, p. 712. Trousseau : Du Goitre Exophthalmic. Gazette des Hopitaux, Paris, i860, No. 139, 142. Strumpell: A Text-book of Medicine (translation), New York 1893, p. 56o- Literature.