The Bryson Symptom 
in Exophthalmic Goitre. 
BY 
HUGH T. PATRICK, M.D., 
Professor of Neurology in the Chicago Polyclinic. 
REPRINTED FROM THE 
Neto ¥orfc journal 
for February 9, 1895. Reprinted from the New York Medical Journal 
for February 9, 1895. 
THE BRYSON SYMPTOM 
IN EXOPHTHALMIC GOITRE * 
WITH A REPORT 0F\ J'ORTY CASES. 
By HUGH T. PATRICK, M.D., 
PROFESSOR OF NEUROLOGY-UL .JW»«TrTC AGO POLYCLINIC. 
Five years ago Dr. Louise Fiske Bryson f first called 
attention to a condition in Graves's disease that has since 
been called the Bryson symptom-viz., diminished chest 
expansion or vital capacity. She cites it as one of the 
"distinctive, fixed conditions" prevailing in this disease 
which " afford the only rational basis for prognosis." 
Other fixed conditions are not specified and no measure- 
ments or cases are given. Dr. Graeme M. Hammond J con- 
siders it " of the greatest importance in regard to the 
prognosis " and " also of assistance in locating the seat of 
the lesion." He says further: " Dr. Bryson states that 
where the expansion is found to be reduced to half an inch 
or less the termination of the case is invariably fatal." He 
found the symptom present in the eight cases reported in 
* Read before the Chicago Medical Society, October 1, 1894. 
f A Preliminary Note on the Study of Exophthalmic Goitre. N. Y. 
Med. Jour., December 14, 1889. 
J A Contribution to the Study of Exophthalmic Goitre. N. Y. Med. 
Jour., January 25, 1890. 
Copyright, 1895, by D. Applbton and Company.  THE BRYSON SYMPTOM IN EXOPHTHALMIC GOtTRE. 
2 
his paper, and as recovery took place the expansion in- 
creased. Dr. A. B. Pope * has reported a case of exoph- 
thalmic goitre in a man with chest expansion of an inch 
and a half, and in the discussion Dr. E. Le Fevre said the 
symptom was "owing to some nervous influence similar to 
that which gave rise to the rapid heart action." 
Three years after her first paper Dr. Bryson f resumes 
the theme, giving particular prominence to the respiratory 
svmptoms, and emphasizing especially diminished chest ex- 
pansion, but she seems to have receded somewhat from her 
former positive position as to its pathognomonic impor- 
tance, as of twenty cases the Bryson symptom was present 
in only thirteen. She considers the disease, however, to be 
"a disorder of nutrition respiratory in its first manifesta- 
tions, J and even makes this assumption the foundation of 
a therapy consisting of a series of respiratory gymnastics 
executed by means of Taylor's respirator. These views 
have been quoted at home and abroad,* and the Bryson 
symptom would seem to be about to take its placje among 
the important signs of Graves's disease as bearing upon the 
diagnosis, prognosis, pathology, and treatment. Ham- 
* W. K Med. Jour., April 19, 1890. 
f Exophthalmic Goitre: A View of Thirty Cases. The Post-gradu- 
ate, July, 189'2. 
| Italics mine. 
* Frank S. Johnson, Trans. III. State Med. Soo., 1893, p. 193 ; J. 
Madison Taylor, Med. News, 1893, pp. 673, 711 ; William Oliver Moore, 
Internal. Clinics, 1893, i, p. 92; Edmund Lee Tompkins, Amer. Jour, 
of Obstet., November, 1893 ; W. H. Thomson, N. Y. Med. Jour., June 
3, 1893; William A. Hammond, Dis. of the Nerv. Syst., 1891, p. 790; 
Landon Carter Gray, Treat, on Nerv. and Ment. Dis., p. 551; Mann- 
heim, Der Morbus Gravesii, Berlin, 1894, p. 33 ; Oppenheim, Lehrb. der 
Nervenk., Berlin, 1894, p. 829; Grasset et Rauzier, Mai. du syst. nerv., 
Montpellier and Paris, 1894, ii, p. 309; Debove et Achard, Manuel de 
med., Paris, 1894, a?t. by Letienne, vol. iv, p. 397; Blocq, fitudes sur 
les mol. nerv., Paris, 1894, p. 173. THE BRYSON SYMPTOM IN EXOPHTHALMIC GOtTRE. 
3 
mond,* indeed, distinctly calls it the fourth cardinal symp- 
tom, a distinction, by the way, which belongs to Marie's 
symptom-tremor. 
At the time when Dr. Bryson's first article appeared I 
had under observation a case of exophthalmic goitre which 
T measured several times, finding the chest expansion not 
materially diminished. After this I measured a number of 
cases, finding the expansion sometimes diminished and 
sometimes about normal, and I presently noticed that di- 
minished expansion seemed to go with a diminution in 
general vitality and muscular strength. I finally, then, 
began comparing the chest expansion with the hand grasp 
as recorded by the dynamometer, this affording the most 
convenient, if only approximately accurate, index of the 
general muscular condition. It is the result of these meas- 
urements that I wish to present. I may premise that only 
well-developed, in a measure typical, cases are comprised 
in this report, no formes frustes being included, and that 
the diagnosis was in every instance confirmed by some well- 
known neurologist. I have therefore deemed it unneces- 
sary to lengthen my paper by giving the symptoms of each 
case in detail. With the exception just noted, the cases 
have not been selected, but embrace all that I was able to 
measure from November 1, 1892, to May 1, 1894. 
The patients were all women, and it may be worthy of 
note that of some sixty cases seen since 1891 only two 
were in men. 
It is a matter of common remark that no two observers 
take the chest expansion exactly alike, so that figures ob- 
tained by different persons can not be compared with con- 
fidence. To form a safe basis for compaiison, therefore, I 
took the chest expansion and dynamometric measurement 
* Graeme M. Hammond, loc, cit. 4 
THE BRYSON SYMPTOM IN EXOPHTHALMIC GO1TRE. 
of twenty-eight women who came to the dispensary for 
various ailments, selecting those whose troubles would not, 
in my opinion, affect the result. These are presented in 
Table IL 
Table II.-For Comparison. 
No. 
Age. 
Affection. 
General 
condition. 
Chest 
expan- 
sion. 
DYNAMOMETER. 
R. 
L. 
Aver- 
age. 
1 
52 
Tabes. 
Fair. 
Ctm. 
4 
30 
25 
27'5 
2 
24 
Hysteria. 
Very good. 
7 
80 
70 
75 
3 
31 
u 
Good. 
5 
45 
45 
45 
4 
51 
Chronic rheumatism. 
Fair. 
4 
40 
25 
'32-5 
5 
41 
Incipient tabes. 
Good. 
52 
55 
55 
55 
6 
29 
Cerebro-spinal syphi- 
Good ; very 
5 
100 
75 
87-5 
1 
30 
lis; dement, paral. (?) 
Epilepsy. 
muscular. 
Good. 
50 
50 
50 
8 
46 
Ophthalmoplegia. 
a 
7 
47 
47 
47 
9 
23 
Brach, neuralgia. 
Very good. 
80 
70 
75 
10 
43 
u u 
Fair. 
6 
72 
70 
71 
11 
39 
Chronic rheumatism. 
Very fair. 
5j 
60 
40 
50 
12 
18 
Sciatica. 
Fair. 
4 
55 
50 
52-5 
13 
26 
Neurasthenia. 
Very fair. 
3f 
65 
50 
57'5 
14 
38 
Hysteria and 
Fair. 
4 
58 
42 
50 
15 
17 
neuralgic pains. 
Hystero-epilepsy. 
Good. 
5 
55 
47 
51 
16 
28 
Lumbago. 
Very good. 
6 
95 
95 
95 
17 
36 
Hysteria. 
Fair. 
4 
30 
30 
30 
18 
22 
u 
Good. 
4| 
46 
46 
46 
19 
34 
Hysteria and neu- 
a 
6 
75 
70 
72-5 
20 
22 
ralgia. 
Hysteria and organic 
Fair. 
37 
50 
43-5 
21 
30 
heart disease. 
Headache. 
Anaemic. 
4 
75 
70 
72-5 
22 
30 
Tabes. 
Very good. 
80 
67 
73-5 
23 
15 
Hysteria. 
Good; well 
4 
45 
35 
40 
24 
19 
Valvular heart 
developed. 
Anaemic. 
4J 
51 
55 
53 
25 
27 
disease. 
Headache. 
♦i 
50 
40 
45 
26 
41 
Hysteria. 
Good. 
4| 
61 
54 
57 5 
27 
23 
Hysteria and lumbago. 
Very good. 
4 
47 
47 
47 
28 
26 
Sciatica. 
Good. 
6 
77 
75 
76 
4-8 
56'36 THE BRYSON SYMPTOM IN EXOPHTHALMIC GOtTRE. 
5 
I am well aware also of the varying results given by the 
dynamometer, and I do not allege absolute accuracy for 
my figures or wish to make too sweeping deductions from 
them, but all measurements were taken by myself in as 
nearly a uniform manner as possible, and sources of error 
excluded as well as might be. 
It will be seen that the average chest expansion in the 
forty cases of exophthalmic goitre is 4-3 centimetres and 
the hand grasp 43-75 kilogrammes; in the twenty eight 
other cases, 4-8 centimetres and 56'36 kilogrammes respec- 
tively-that is, the expansion in Graves's disease is dimin- 
ished half a centimetre, or ten and a half per cent., the 
hand grasp 12'61 kilogrammes, or twenty two and two fifths 
per cent. In other words, the grasp is diminished more 
than twice as much as the expansion. It may be contended 
that the average expansion of the twenty-eight women used 
for comparison is not up to the normal, and I think this 
may possibly be true, but I also think they make a far bet- 
ter basis for comparison than statistics of measurements 
taken by some one else whose methods would doubtless 
differ in some degree from mine, and consequently whose re- 
sults, other things being equal, would differ from mine. 
Further, these measurements were made in the same dis- 
pensary which furnished the majority of the cases of 
Graves's disease,* and the subjects are fairly representa- 
tive of the class of patients furnishing the material for 
this report, and, as before mentioned, the pathological 
conditions in these women were not such as to mate- 
rially affect chest expansion or hand grasp. But even 
supposing that the expansion of the twenty-eight might be 
materially below the normal, we could not suppose in all 
these various cases a condition which would affect chest 
expansion to the exclusion of other muscular action, in- 
* Professor Mendel's Poliklinik, Berlin. 6 
THE BRYSON SYMPTOM IN EXOPHTHALMIC GOtTRE. 
eluding hand grasp, and as we find that the hand grasp in 
Graves's disease is diminished twenty-two and two fifths 
per cent, and the expansion only ten and a half per cent., 
the natural conclusion would be that if one of these two 
is pathognomonic of this malady it would be the weakened 
grasp and not the diminished chest expansion, an assump- 
tion I would not for a moment entertain. Again, we find 
of the forty cases twenty-six with an expansion below the 
average of the twenty-eight, while thirty show a diminished 
grasp. 
Could we take accurate dynamometric measurements of 
the lower extremities and of the pelvic muscles, I have no 
doubt we should find an equal falling oif. Many of these 
patients complain of a sudden " giving way of the legs," 
and placed in the recumbent posture show their muscular 
weakness in the manner of rising. 
A woman now under observation, not included in this re- 
port, is a case in point. It is not what could be called a very 
severe case; she does her own housework, gets about very 
well, hand grasp and chest expansion only slightly diminished, 
and yet she rises from the supine position much like a patient 
with idiopathic muscular atrophy; that is, she first raises the 
trunk by means of the arms till she rests on her elbows; then, 
again by help of the arms and with a peculiar wriggle or writh- 
ing movement to bring accessory muscles into play, she brings 
the trunk to the perpendicular; the erect position is then at- 
tained, with manifest effort, by turning round and pushing her- 
self up with her hands first on the floor and then on her thighs 
or adjacent objects. 
I think the diminished power of convergence often ob- 
served, as well as the occasional affection of the laryngeal 
muscles, is quite analogous to these other findings, and is 
simply a part of a general myasthenia, sometimes affecting 
one set of muscles more, sometimes another. THE BRYSON SYMPTOM IN EXOPHTHALMIC GOtrRE. 
7 
I find, further, that many of these cases show a rapid 
and marked falling-off in both chest expansion and hand 
grasp on repeated effort. Thus either may diminish one 
half after three or four trials in rapid succession, and in a 
general way the decrease affects both and is proportional 
to the debility. 
The idea that the diminished chest expansion is simply 
part of a diminished vitality or energy is borne out by the 
history of individual cases. I have generally found that 
as the patient improves in general tone the expansion in- 
creases (and vice versa), although not necessarily in the 
same ratio, and that the grasp goes with it hand in hand. 
But as the diminished hand grasp shows the larger per- 
centage in the table, so here it is apt to show the larger fluc- 
tuations, which would seem again to indicate that it is the 
more delicate index of the two. These facts are well illus- 
trated by Case III. The rule, however, is not absolute, and 
Case XXXVII is a striking exception in the first two ex- 
aminations. 
The only one of my patients (Case III) who ever showed 
an expansion as low as half an inch (P25 ctm.), indicating, 
according to Dr. Bryson, an absolutely fatal termination, 
had, four months later, gained over twenty pounds in 
weight, and was better than at any time during the six 
months she was under observation. 
I think, then, we may conclude that the Bryson symp- 
tom, although present in many cases of exophthalmic 
goitre, is in no wise pathognomonic of this affection, or 
even an important sign; that it has no special significance 
in relation to the prognosis, pathology, seat of the lesion, 
or treatment, and should be relegated back to the compara- 
tive obscurity of an individual in a large community of 
manifestations which all depend alike upon the general 
state; a state which makes the French designation of the 8 
THE BRYSON SYMPTOM IN EXOPHTHALMIC GOtTRE. 
disease, exophthalmic cachexia, quite as appropriate as any 
other.* 
Venetian Building. 
* I wish to express my great gratitude to Professor Mendel, Pro- 
fessor Jolly, Professor Oppenheim, Professor Bernhardt, Professor Eu- 
lenburg, and Dr. Goldscheider of Berlin, Professor Brissaud of Paris, 
and Dr. J. Hughlings Jackson of London, for permission to examine 
cases entering into this report. No. 
Age. 
Duration of 
disease. 
Date of 
examination. 
Chest ex- 
pansion. 
Average. 
DYNAMOMETER. 
Remarks. 
R. 
L. 
Average. 
29 
Centimetres. 
1 
years. 
Nov. 1, 1892. 
40 
30 
Following fright. 
Dec. 8, 1892. 
47 
40 
Feb. 25, 1893. 
4 
46 
37 
Mar. 2, 1893. 
4| 
4 
31 
50 
45 
41'8 
2 
30 
2 years. 
Nov. 1, 1892. 
55 
45 
3 
Feb. 17, 1893. 
4 
4 
75 
60 
57 
54-2 
32 
4 years. 
Nov. 30, 1892. 
If 
21 
21 
At fourth examination she had been two 
Dec. 14, 1892. 
U 
12 
16 
weeks confined to bed, following mental 
Dec. 21, 1892. 
26 
16 
worry. May 17th, much better; had 
Jan. 28, 1893. 
Mav 17, 1893. 
11 
gained over twenty pounds. 
37 
2 
1 
8 
16 
16 
107 
4 
1 year. 
Nov. 9, 1892. 
3 
37 
47 
Is right-handed, but has always been stronger 
31 
Nov. 30, 1892. 
8| 
3 
25 
40 
50 
43'5 
in left. 
0 
Probably 
Oct. 15, 1892. 
7 
67 
47 
Much worse since a confinement nine weeks 
6 
4 years. 
Dee. 2, 1892. 
6 
25 
49 
48 
52-75 
ago. 
23 
1 year. 
Feb. 20, 1893. 
4i 
4 
5 
22 
15 
18-5 
7 
17 
1| year. 
Nov. 19, 1892. 
5 
5 
65 
55 
60 
8 
40 
12 years. 
Nov. 1, 1892. 
4 
30 
25 
Goitre from youth. 
9 
Jan. 5, 1893. 
31 
3 
75 
30 
18 
25-75 
55 
8 years. 
Nov. 2, 1892. 
31 
3 
5 
37 
30 
33-5 
No treatment the past year, as treatment 
35 
Nov. 3, 1892. 
the two preceding years almost cured her. 
10 
8 years. 
2 
2 
20 
10 
15 
Much worse since influenza two years ago. 
11 
30 
2 years. 
Nov. 9, 1892. 
6 
6 
67 
63 
65 
Developed after hemiplegia. Cerebral apo- 
12 
21 
plexy. 
3 years. 
Nov. 12, 1892. 
7 
7 
60 
50 
55 
13 
18 
2 years. 
Nov. 14, 1892. 
«1 
6 
5 
50 
50 
50 
14 
28 
4 months. 
Nov. 12, 1892. 
51 
5 
5 
44 
44 
44 
15 
51 
years. 
Nov. 16, 1892. 
51 
45 
55 
Locomotor ataxia for the last ten years. 
Mar. 2, 1893. 
5 
5 
25 
42 
40 
45-5 
16 
24 
1 year. 
Nov 19, 1892. 
5 
30 
45 
Stigmata of hysteria; right hand excluded 
from estimate, as low figure is due to 
Dee. 14, 1892. 
4 
4 
5 
3 
62 
45-6 
19 
psychic inhibition. 
17 
3 years. 
Nov. 22, 1892. 
34 
3 
5 
45 
45 
45 
18 
26 
9 months. 
Nov. 29, 1892. 
4 
62 
57 
Dec. 14, 1892. 
31 
62 
55 
35 
Jan. 10, 1893. 
4 
3 
83 
67 
53 
59'33 
19 
1 year. 
Dec. 7, 1892. 
4 
4 
62 
56 
59 
Was much worse eight months ago; all 
2 years. 
Dec. 20, 1892. 
symptoms were more pronounced. 
20 
48 
5 
5 
15 
10 
12-5 
21 
20 
9 months. 
Dec. 20, 1892. 
4 
4 
47 
37 
42 
22 
21 
Uncertain, 
Jan. 5, 1893. 
41 
48 
47 
Patient thinks an operation on the nose for 
1 to 4 years. 
Jan. 20, 1893. 
31 
50 
35 
catarrh aggravated the disease. 
Feb. 16, 1893 
5 
47 
37 
Mar. 2, 1893. 
5 
42 
40 
Apr. 27, 1893. 
. 41 
40 
30 
July 10, 1893. 
41 
4 
45 
35 
35 
40-5 
23 
39 
8 years. 
Jan. 10, 1893. 
31 
60 
60 
Feb. 17, 1893. 
31 
3 
5 
50 
50 
55 
24 
25 
4 years (?). 
Jan. 13, 1893. 
3 
3 
16 
16 
16 
Has had goitre ten years. 
38 
Feb. 16, 1893. 
4 
4 
37 
33 
35 
Nervous and irritable four vears. All symp- 
toms of Graves's disease five weeks, fol- 
26 
21 
Feb. 18, 1893. 
lowing failure in business. 
3 years. 
61 
6 
5 
30 
20 
25 
Complicated with hysteria. 
27 
30 
6 months. 
Feb. 22, 1893. 
41 
67 
67 
Has imperative ideas. March 2d, feels much 
29 
Mar. 2, 1893. 
41 
4- 
5 
85 
85 
76 
better. 
28 
4 years. 
Feb. 24, 1893. 
5 
5 
71 
59 
65 
Symptoms aggravated by operation on uterus 
29 
37 
7 months (?). 
Mar. 1, 1893. 
51 
5 
5 
65 
60 
62-5 
two years ago. 
Difficult labor seven months ago, since 
which time is nervous and anaemic; is 
now two months pregnant; all symptoms 
30 
of Graves's disease six weeks. 
2 years. 
Mar. 3, 1893. 
3 
3 
60 
57 
58'5 
31 
34 
11 months. 
Mar. 9, 1893. 
41 
60 
57 
Following confinement eleven months ago. 
Mar. 20, 1893. 
51 
5 
50 
50 
56'75 
32 
23 
2 months. 
Mar. 15, 1893. 
4 
37 
30 
June 13, 1893. 
31 
3- 
75 
32 
30 
32-25 
33 
38 
4 years. 
May 17, 1893. 
31 
3- 
5 
45 
45 
45 
Following a fright; sister has same disease, 
34 
38 
May 12, 1893. 
and is much worse. 
3 years. 
51 
43 
43 
Following influenza; thyreoidectomy thirteen 
35 
29 
4 to 5 years. 
May 22, 1893. 
41 
5 
42 
45 
43-25 
months ago, with great improvement. 
Mav 12, 1893. 
41 
57 
63 
Julv 10, 1893. 
5 
4 
75 
55 
65 
60 
36 
46 
2 years. 
Apr. 23, 1893. 
Nov. 17, 1893. 
Jan. 18, 1894. 
41 
4 
5 
50 
47 
48-5 
37 
18 
2 years. 
4 
2 
50 
66 
40 
45 
Following fright. 
Jan. 30, 1894. 
31 
3 
16 
32 
37 
45 
38 
26 
2 years. 
Dec. 5, 1893. 
2 
55 
50 
Jan. 19, 1894. 
21 
55 
55 
39 
Jan. 30, 1894. 
2 
2 
16 
40 
45 
50 
39 
3 years. 
Jan. 1, 1894. 
Jan. 18, 1894. 
Jan. 30, 1894. 
3 
3 
3 
3 
50 
40 
32 
45 
38 
27 
38 • 66 
Epilepsy; much worse the last three years. 
40 
29 
2 years (?). 
Feb. 12, 1894. 
Feb. 24, 1894. 
4 
4 
30 
28 
25 
12 
After inception cured (?) by rest, etc.; re- 
currence one year ago. 
Mar. 6, 1894. 
41 
35 
23 
Mar. 31, 1894. 
41 
40 
32 
Apr. 13, 1894. 
4 
4 
4 
2 
3 
35 
25 
28-5 
43-75 
Diminution 
Diminution, per cent.. . . 
0-5 
101 
12-61 
224 
- 
Table I.-GRAVES'S DISEASE. The New York Medical Journal. 
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