EXOPHTHALMIC GOITER AND THE ADRENALS. 161 



both disorders traceable to suprarenal inadequacy. "The pa- 

 tient developed slowly, both mentally and physically. She did 

 not walk until nearly three years old. She was frail and 

 excitable as a growing child. When six years old she had a 

 severe attack of measles. During the six years that intervened 

 she enjoyed fair health. She made slow progress at school." 

 Not only was there evidence of infantile myxcedema, there- 

 fore, but the general vulnerability of the adrenals had been 

 increased by severe measles. That the cellular protoplasm of 

 this child should be correspondingly vulnerable to disturb- 

 ances, chemical or physical, as a result of the suboxidation to 

 which her organism had been submitted since her birth, seems 

 reasonable. When twelve years old, "a blow on the right side 

 of the neck, from behind, which caused intense fright and hys- 

 teria," served as starting-point of the exophthalmic goiter. A 

 feature to be emphasized here is that "the pulse was small and 

 soft": evidence that the adrenals were unable to respond above 

 a certain limit to the excess of thyroidal secretion poured into 

 the circulation, or that the case had promptly lapsed into that 

 of suprarenal insufficiency. Five months' treatment with thy- 

 roid yielded a satisfactory result. 



Two cases reported by H. L. Winter 25 may also be included 

 in this class. The patients were sisters, 22 and 17 years of 

 age, respectively, of Swiss birth. The former was "stout and 

 anemic," in the latter there was "no marked anaemia" evi- 

 dence that some degree of anaemia pallor was present. The 

 flushing was not of the continuous kind, but of the kind 

 brought on suddenly, and characterized by the author as 

 "flushes," just as the muscular signs are termed "startings" 

 sudden expressions of equally sudden contractions or spasm of 

 the central vascular trunks, arising from weak adrenals, as 

 flashes of flame arise from stirred embers. "In Cases I and II" 

 (the cases referred to), says the author, "exception might be 

 taken to the diagnosis. The rapid heart-beat, usually the first 

 symptom of a typical case of exophthalmic goiter, was not 

 present; the pulse was high only during an attack of palpita- 

 tion." In the light of our views no exception could with 



26 H. L. Winter: Loc. cit. 



