AMERICAN JOURNAL OF INSANITY, FOR JULY, 1870. EXOPHTHALMIC GOITRE WITH INSANITY. BY J. B. ANDREWS, M. D. This disease was first described by Graves in his treatise on "Clinical Medicine," and from this fact bears his name. It has also been called Basedow's disease, but his description was subsequent to that of Graves. Trousseau, in his recent work on "Clinical Medicine," presents very fully the symptoms and pathology of exophthalmic goitré. The disease is marked by three characteristic symptoms: prominence of the eye-balls; enlargement of the thyroid gland; palpitation of the heart. The presence of these symptoms he would deem conclusive in forming a diagnosis. There is generally no disturbance of vision. Occasionally, adaptation is difficult, and there weakness of sight; but diplopia is never present. Hypertrophy of the thyroid gland takes place gradually; both lobes may be enlarged to an equal degree, but in a majority of cases the right is the one chiefly affected. The patient complains of dizziness and palpitation of the heart, long before the exophthalmos or the goitre have been detected. The force of the heart's action at VOL. XXVII.-No. I.-A times produces a prominence of the chest walls which can be readily detected. There are secondary symptoms which should be noted. In some cases the appetite is diminished-in others voracious and always capricious. These several conditions may be found during the propress of the same case. Digestion may be good, but assimilation at the same time so defective that there is a progressive emaciation. Diarrhoea may supervene, and increase the tendency. The patient is restless and sleepless, and is often tormented with thirst. The presence of the enlarged gland renders respiration and deglutition difficult. The heart's action is increased in frequency, the pulse varying from 120 to 150. This is attended by a rise in the temperature of the body of from one to four degrees. The sensation of heat is almost unbearable, and is such as accompanies certain lesions of the sympathetic nervous system, as in diabetes mellitus. Vomiting and cough are unpleasant and, at times, dangerous complications of the disease. Other symptoms characteristic of debility, as oedema of the extremities, night sweats and nervous pains, are present. The patient's temper is greatly altered. He may become quick tempered, irritable, and at times violent. Hallucinations and sometimes insanity may occur in the course of the disease. A change in the voice takes place, which is due to disturbance of respiration from pressure upon the recurrent laryngeal nerve. Blowing murmurs are heard over the gland and vessels of the neck, and a true aneurismal thrill is imparted to the hand at each diastole of the carotids. The beating of the abdominal aorta is readily distinguished, and produces a sensation of oppression, and often of pain, which is referred to the region of the solar plexus. In all cases where the exophthalmos is not marked, there is a strange look about the eyes, and they are unusually lustrous and large. The disease runs a chronic and an acute course. In both forms it is characterized by many of the symptoms above enumerated. The condition of the patient is truly a pitiable one, and to a person unaccustomed to the disease a hopeless one. Patients rally from several of these attacks, and may die of intercurrent disease. Death in the first paroxysm is not frequent. Examination shows that the thyroid arteries increase in diameter, and become flexuous; their extremities and branches are enlarged, and their anastamoses seem to multiply. The venous system of the gland is also much developed. This exaggerated development of the arteries accounts for the blowing murmur heard over the swelling, and for the expansion felt when the hand is applied over the gland. In some autopsies organic diseases of the heart are discovered. In a majority of cases, the cardiac alterations are variable and temporary-analogous to those which are met with during pregnancy. Permanent cardiac lesions are more frequent where the neurosis has been of prolonged duration. Attempts have been made to ascertain the anatomical cause of exophthalmos. A largely increased amount of cellular tissue and an enormous hypertrophy of adipose material within the orbit have been found. When the prominence of the eye shows itself, as it often does, in paroxysms, we ascribe this condition to a violent and active congestion. Frequent repetitions of these congestions may increase the nutrition of the cellular and adipose material, till from its greatly increased hypertrophy it may push forward the eyeball and give rise to a permanent exophthalmos. Exophthalmic goitre has been called a cachectic affection: "but this cachexia," says Trousseau, "is only the last term of a morbid series which begins with multiple congestions, which are themselves due to a peculiar modification of the sympathetic nerve. To sum up, the disease is in my opinion a neurosis of the sympathetic, if not a complaint attended with material lesions of the ganglionic nervous system." This opinion he supports by post mortem appearances, and by the causation of other local congestions. The only other disease with which this is likely to be confounded is aneurism of the aorta, or of one of the arteria innominata. This mistake has been made, and may readily occur upon a superficial examination. The differential diagnosis is briefly stated. In aneurisms the swelling will occupy but one side of the thyroid gland; in this disease it may exist on both sides. By far the most marked difference is found in the peculiar combination of the three characteristic symptoms which co-exist in no other, and make this a disease “sui generis.” Graves' disease is common among women, but relatively rare in men. Of fifty cases collected by one author, but eight occurred in men. CASE. A man, 26 years of age, born in Canada, where his father is still living. His mother died nine years since of consumption. Patient enjoyed uninterrupted health till about two and one-half years ago, when he suffered from a severe attack of typhoid fever. This continued for nine weeks. He seemed to recover fully from the effects of the disease, and about two years ago was employed as an attendant in this asylum. He then weighed 187 pounds, and was in an apparently vigorous state of health. Three months thereafter he began to complain of a constant and troublesome headache, and lost appetite and flesh. In August, 1868, he was attacked with vomiting and spasms of the stomach, and |