The paraplegia at times associated with Graves's disease is clue to a lumbar myelitis, and trembling to a mild in flammatory process extending to the cervical and dorsal cord. These are the result of a toxic substance in the blood from disturbance of the thyroid func tion. The influence of a neuropathic constitution is not excluded by this as sumption. Angiolella (Boletiuo de Med. Naval, Madrid, Ease. I, '93).
One might expect that the muscles which are most prone to show weakness would be the ones most likely to become paralyzed, but this is apparently not borne out by experience. The movement of the eyes which is most often defective in Graves's disease is convergence, but paralysis may affect the external recti as well as the internal. The explanation for this discrepancy lies partly in the fact that the disorders of movement such as underlie the impairment of converg ence and change of voice, which some times show themselves as impairing the consensual lateral movements of the two eyes, are due, partly at least, not to local ized lesions, but to central disorders of co-ordination (Sattler).
IIemiplegia may occur in a curable form, not due to haemorrhage and per haps analogous to hysterical hemiplegia.
Muscular atrophy, of the spinal type, rarely reaching a high degree, affecting pre-eminently the intrinsic hand-mus cles, with quantitative electrical changes, and susceptible of cure, may occur. Only one typical case of this sort has come within my personal observation. This case was in all respects severe, but ended in almost complete recovery. This patient found great difficulty in rising from a chair and mounting the stairs, and the gait was a high degree of wad dling character.
I have, however, seen several patients who exhibited great difficulty in rising from the chair or mounting stairs, and perhaps careful search would have re vealed diffuse or localized atrophy as a cause.
Cardiac signs: tachycardia, not easily controlled by digitalis, excitability, often irregularity, and palpitation are the com mon signs. Secondary dilatation is fre quent, and with it loud systolic murmurs. True endocarditis is not characteristic, and even conditions which seem serious may disappear if the progress of the case is otherwise favorable. The pulse-rate
frequently reaches 150, occasionally 200 or more, especially during attacks of pal pitation. These attacks can occur with out apparent cause often at night, and be of alarming severity and cause terri ble distress, though in fact death rarely occurs in them. 31Obius suggests that the apparently-causeless occurrence of these seizures marks them as probably of toxic origin; but if this is sound reason ing it must be extended to embrace many cases of tachycardia in neurasthenia and hysteria.
Vasomotor system. Flushing and high vascularity of the skin, "derma tography," and pulsation of the larger arteries, especially the carotids are very common. Less often noted, but calling for further study, are pulsation of the abdominal organs and vascular dilata tion confined to localized areas.
Attention called to the pulsation of the spleen and liver, which has been ob served in a number of cases: a phe nomenon of importance in distinguish ing between mitral insufficiency and Basedow's disease. C. Gerhardt (Mit theilungen ails den Grenzgebeiten der Med. and Chir., B. 1, H. 2).
Attention called to the distended con dition of the arteries of the body gener ally in this disease, especially the aortic branches; similar conditions found in the arteries of the extremities as in the pal/liar arches and crurals. Capillary pulsation noted and pulsation of the spleen, liver, and even of the kidneys. Gerhardt (Centralb. f. Chir., Sept. 5, '96).
A fatal ease of exophthalmic goitre in a girl 11 years old. She was large and well formed, but infantile. Menstrua tion had not yet appeared. Exophthal mos was marked. The thyroid gland was slightly, but perceptibly, enlarged. There was no thrill, but a systolic bruit was heard on auscultation over the goitre. The heart was rapid, 132 in the minute. There were general tremors. The treatment consisted of rest in bed, and tincture of belladonna, 3 minims; potassium bromide, 10 grains, thrice daily. Nausea and vomiting set in, a little blood a.nd some coffee-ground ma terial being eradiated on several occa sions. The condition of the patient grew gradually worse, and death resulted from exhaustion. An autopsy could not be secured. Armstrong (Liverpool Medico Chin Jour., Feb., 1900).