ENLARGEMENT OF THE THYROID BODY AND PROMINENCE OF THE EYES.

The occurrence of enlargement of the thyroid body and prominence of the eyes, in certain cases of cardiac disease, may be conveniently noticed in the present connection, although, as will presently appear, it is by no means certain that these events necessarily involve the existence of any organic affection, and, indeed, that they depend on an abnormal state of the heart, cannot perhaps be considered as conclusively established. It is only within late years that the attention of clinical observers has been directed to these events, as connected with cardiac disease. The coincidence of enlargement of the thyroid body with affections of the heart was observed by Dr. Parry in seven cases. A few instances had previously been reported. Subsequently, Dr. Graves dwelt upon this coincidence in his Lectures on Clinical Medicine, published in 1835, giving some cases that had fallen under his observation. Still more recently, the coexistence of prominence of the eyes, together with enlargement of the thyroid body, has attracted attention. Cases have been reported by Dr. McDonnell and Sir Henry Marsh, of Dublin, and by Dr. Stokes. The latter, in his late work on the Diseases of the Heart and the Aorta, devotes considerable space to the consideration of the subject. In our own country, Dr. Isaac E. Taylor has contributed an elaborate paper, containing an account of two cases which he has himself observed." Dr. Begbie, of Edinburgh, and Robert Taylor, Esq., of London, have also reported cases. The latter gives the details of four cases which have fallen under his own observation, and an analysis, with regard to certain points, of twenty cases collected from various sources.3

The enlargement of the thyroid body is variable in degree, being considerable in some instances, but never so great as is often seen

"Collections from the unpublished Medical Writings of the late Caleb Hilliard Parry, M. D.," London, 1825.

2 New York Medical Times, vol. ii., No. 3, December, 1852. Accounts of two cases, with remarks, and references to the literature of the subject, by Prof. H. J. Bigelow, Dr. Morland, and Dr. John S. Flint, are contained in an article which has appeared, since the printing of this work has been commenced, in the Boston Med. and Surg. Journal, vol. lxi. No. 2, August 11, 1859.

London Medical Times and Gazette, May 24, 1856, and the American Journal of Medical Sciences, July, 1856, page 258.

in the ordinary form of bronchocele or goitre. According to Dr. Graves, the limited extent of the enlargement is a point distinctive of its connection with an abnormal condition of the heart. Both lobes of the thyroid body may be affected equally, or the size of one lobe may be disproportionately increased. Having attained to a certain bulk, the enlargement ceases to be progressive, and the swelling remains, temporarily or permanently, in a stationary condition. Its size has been observed, however, to fluctuate between certain limits, varying with the action of the heart. A strong arterial pulsation is felt when the hand is placed over the tumor, and frequently a tremor or thrill resembling that communicated by an aneurismal varix. Dr. Stokes cites an instance in which it was mistaken for aneurism. An arterial bellows murmur is produced within the tumor, and, in some instances, also a continuous venous hum. The latter is sometimes musical, and has been known to be sufficiently loud to attract the attention of the patient. Unusual pulsation of the arteries of the neck coexists with arterial murmur. The inferior thyroid arteries have been found to become much enlarged. The cervical veins are notably dilated, and yield a continuous murmur or hum.

These phenomena pertaining to the thyroid body in the great majority of cases have been observed in females. They have not been observed to occur before puberty. Hysterical symptoms have been present in some instances. Neuralgia is an occasional concomitant. Anæmia coexists generally. As regards the heart, the cases have been characterized by long-continued, excessive action of the organ, or frequently recurring palpitation. The physical evidence of organic disease has in some instances been present and sometimes wanting. The amount of information obtained by examinations after death is, as yet, meagre. In a fatal case reported by Dr. Marsh with the autopsical appearances, the heart was enlarged, especially the auricles, and the auriculo-ventricular valves on both sides, more especially on the right side, were thickened by morbid deposit. In another instance, communicated to Dr. Stokes by Professor Smith, of Dublin, slight aortic lesions existed, and the left ventricle was largely hypertrophied and dilated. In a third case, detailed by Dr. Begbie, the heart was large, soft, and flaccid; all the cavities, but especially the ventricles, were dilated, and the valves were sound.

My own experience furnishes but little with regard to this subject. It is not improbable that examples may have fallen under

my observation without having been noted, inasmuch as my attention has been directed to the subject only for the last four or five years. Within this period I have met with three instances of an enlarged and pulsating thyroid body in connection with a notable. degree of cardiac disorder. In all these instances the patients were females. In one the patient was twenty-seven years of age, had been married eleven years, and had had five children, four of which she had nursed for twelve months. At the time of my examination she was five months advanced in pregnancy, and her youngest child was two years of age. The enlargement of the thyroid body commenced shortly after the last confinement. It was considerably enlarged, and pulsated strongly. It is not noted whether murmurs and fremitus existed in the tumor. She had suffered from inordinate action of the heart for a year and a half. The action of the heart was not irregular, and the pulse numbered one hundred and twelve. Her appearance was not in a marked degree anæmic. She was affected with intercostal neuralgia. The impulse of the heart was abrupt and smart, with violent shock, but no heaving. No endocardial murmur was discovered. The sounds were normal. Owing to the large development of the mammæ, it was not easy to determine the size of the heart. The patient was from a distance, and the subsequent history of the case is unknown. In the second case the age of the patient was fifty-seven. She was the wife of a farmer, and had been accustomed to hard work in the management of a dairy. Menstruation had ceased three years before. Thirteen years prior to my examination she had acute articular rheumatism. For more than a year she had been troubled with palpitation, occurring especially at night, and produced by any excitement. It was unattended by dyspnoea. Considerable enlargement of the thyroid body had existed for about a year. On my first examination no murmur was discovered. The situation of the apex-beat was normal; the force of the impulse was not increased, and no abnormal modifications of the heart-sounds were observed. A year afterward a soft systolic bellows murmur over the apex was discovered, without any other signs of organic disease. The palpitations still continued. The subsequent history is not known. The third case came under observation quite recently. The patient is a young girl aged nineteen, presenting a healthy aspect, the countenance not denoting anæmia. She had been conscious of increased action of the heart for a year. The pulse was one hundred and twenty, and had been even more frequent. The enlargement was

moderate, the body on the right side being more affected than that on the left. There existed strong pulsation and a bellows murmur on both sides over the tumors; also arterial bellows murmur and venous hum over the carotids and jugular veins. The heart-sounds in this case were intensified, but otherwise not abnormal. No endocardial murmur was discovered, and the heart did not appear to be enlarged. Prominence of the eyeball existed in this case.

The view taken by Drs. Graves and Stokes of the pathological connection supposed to exist between enlargement of the thyroid body and an abnormal condition of the heart is, that the former may occur in consequence of undue rapidity, irregularity, and force of cardiac action, persisting for a sufficiently long period. Agreeably to this view, the heart may or may not be affected with organic disease. Prolonged functional excitement appears to be regarded as the essential abnormal condition, and this condition may be associated with different lesions, or the organ may be structurally sound. In the majority of the cases which have been reported, physical signs have been present denoting either enlargement or some organic change. It is evident that the subject claims farther clinical study, and that the data are at present insufficient to warrant positive conclusions respecting the nature and extent of the relations existing between the phenomena pertaining to the thyroid body and those referable to the heart.

Prominence of the eyes has been observed as a concomitant of the affection of the thyroid body. It was noted by Dr. Parry in one of the seven cases which he recorded of the latter affection. It coexisted and was more or less marked in the cases reported by the other observers whose names have been mentioned. The appearance of the eyes is peculiar and striking. The protuberance of the globes renders visible a broader portion of the tunica albuginea surrounding the cornea than usual, and gives to the countenance a wild, staring expression, which, as Dr. Taylor remarks, when once seen, will never be forgotten. The conjunctiva and other coats may remain clear and transparent, and sometimes the eyes acquire an unusual brilliancy. The pupil is not affected. Vision is unimpaired. The condition is unattended by pain. In some instances the projection of the eyeballs is so great that the lids are unable to cover them, and the patient sleeps with the eyes partially open; yet Dr. Stokes states that under these circumstances the sense of sight did not suffer, and ophthalmia was not developed in a case which remained under his observation for more than a year. The

affection is sometimes developed suddenly. In a case referred to by Dr. Stokes it became apparent after a long-continued fit of coughing and retching. An instance in which it occurred during a single night is related by Robert Taylor.

The rationale of this remarkable appearance of the eyes is not fully understood. Dr. Stokes attributes it to enlargement of the eyeballs from an increase in the vitreous and aqueous humors, and considers it therefore as denoting a form of hydrophthalmia, or general dropsy of the eye. This explanation is hardly consistent with the absence of pain, of defect of vision, etc. It is, moreover, disproved by a fact stated by Robert Taylor, viz., the balls can be readily replaced by gentle pressure. The hypothesis of Mr. Dalrymple is more plausible. He attributes it to "an absence of the proper tonicity of the muscles by which the eyes are retained in their natural positions in the orbit, and some amount of venous congestion of the tissues forming the cushion behind the globes." From the cases which have been reported it would appear that it is almost invariably associated with enlargement of the thyroid body, and that the latter first occurs. Hence there is room for the conjecture that it is incidental to enlargement of the thyroid body, and if dependent on an abnormal condition of the heart, it is so indirectly. Another conjecture is, that enlargement of the thyroid body and prominence of the eyes are different effects of a common pathological condition, whatever it may be, the latter effect being less frequent, and rarely occurring without the former.

With regard to this subject, I can contribute from my own experience even less than with regard to the subject just considered. I have met with a single example only, and, by a curious coincidence, it has occurred since I commenced this chapter. The case has been already referred to, being the third of the three cases of which an account was given in connection with the subject of enlargement of the thyroid body. Abnormal rapidity of the heart's action preceded the prominence of the eyes for seven or eight months. The projection was noticed all at once, and the patient states that it followed violent fits of coughing. Both eyes were affected, but the right much more than the left. The thyroid body was also more enlarged on the right side than on the left. The general health of the patient has been, and is now apparently good. She is 19 years of age, and presents a healthy aspect. The countenance does not denote anæmia, but a loud venous hum, as well

Quoted from article by Dr. Taylor.