Maude has described fugitive puffy swellings as occurring in various parts, as the face, neck, arms, etc.
Irregular and inadequate innervation of the circulatory system undoubtedly accentuates or causes other disturbances, such as the diarrhoea, the sweating, the exophthalmos, the epistaxis, and other hemorrhages from the mucous mem branes. It must not, however, be for gotten that if it be true that a poison is circulating with the blood, the irritation attending its elimination might help to account for some of the affections of the various secreting surfaces: the skin, the bowels, and the kidneys, as well as of the organs concerned in primary metabolism. Still more must it be remembered that the real explanation of many of the con stantly recurring—so to speak—specific signs of this disease is probably far more subtle than our conceptions can now fathom.
Not only are dyspncea and a sense of suffocation present during attacks of pal pitation, but a diminished inspiratory capacity is sometimes to be noted, as an early symptom and throughout the ill ness.
Stress laid on diminished chest-ex pansion (found in all cases observed). Chest-expansion of 1 inch or more is considered sufficient ground for favor able prognosis. Louise Fiske-Bryson (N. V. Med. Jour., Dec. 14, '89).
Forty cases of exophthalmic goitre examined. There was an average dim inution of chest-expansion, but this was dependent upon, and in the individual cases more or less proportionate to, the amount of general muscular weakness. Patrick (N. Y. Med. Jour., Feb. 9, '95).
The typical paralyses of the eye-mus cles have already been referred to as among the affections of the nervous sys tem.
In two cases an involuntary flow of tears observed as the first symptom of exophthalmic goitre. E. Berger (Le Bull. Mad., Mar. 15, '93).
Besides these, the most characteristic signs are retraction of the lids (Stell wag's sign), exophthalmos, and the im pairment of the power of convergence. Graefe's sign (lagging of the upper lid when the globe moves downward) and impairment of the wink-reflex are di rectly traceable to the retraction of the upper lid.
Exophthalmos is late to appear and marks the height of the disease. Von Graefe's sign commonly appears before the exophthalmos. J. M. Taylor (Med.
and Surg. Reporter, Apr. 14, '38).
Graefe's lid-symptom found in 12 out of 613 patients of all kinds. People in health can, not infrequently, cause it by staring. As it often fails in exophthal mie goitre, its diagnostic importance is not great. Sharkey (Brit. Med. Jour., Oct. 25, '90).
The two chief abnormal variations in movements of the eyelids are von Graefe's sign — the eyelid descending not synchronously with the descending globe, but more slowly and, it may be, more jerkily—and Stellwag's sign, con sisting in retraction of lids and conse quent increase in the width of the palpe bral fissure. This retraction is most ob vious in the upper lids, and is frequently associated, as is seen when the patient's gaze is directed downward, with a cup ping of the lower lid. Both these signs are quite independent of exophthalmos, and their clinical value is difficult to estimate. They are neither constant nor pathognomonic, and are variable even in the same person. Von Graefe ascribed the deranged movement to spasm of the fibres of Miller. More recently Ferri has advanced the theory that the re traction of the lid is the result of the mechanical shortening of the levator palpebra due to the increased volume of blood-vessels distributed in its sub stance. The writer leans to the theory that these states are due to an affection of the oculornotor nucleus and a conse quent paresis of the upper facial group of muscles. A. 3laude (Edinburgh Med. Jour., July, '97).
Case of exophthalmic goitre observed with typical heart and thyroid symp toms, but with only unilateral exoph thalmos. This was the third case the author had seen. Hinshelwood (Edin burgh Med. Jour., May, '98).
Retraction of the lid may be present without exophthalmos, the staring ap pearance giving a false impression of pro trusion. The lid-signs may vary in in tensity from day to day. The protrusion itself is generally present in greater or less degree, sometimes, though very rarely, to such an extent that the eye is nearly or quite dislocated from the socket, yet the movements of the globes remain consensual and double vision is not characteristic.