EXOPHTHALMIC GOITER AND THE ADRENALS. 153 



metabolism and consequent muscular fatigue, also due to 

 excessive oxidation, as manifested by the fibrillary tremor 

 similar to that of excitement and to be distinguished from the 

 paretic tremor, the painful cramps in the extremities, the 

 reduced chest-expansion, the tetanic spasms of the hands, and 

 general emaciation. 3. The contraction of central and other 

 muscular vessels and centrifugal dilation of the capillaries, 

 as manifested in the brain by the signs just referred to; in 

 the peripheral tissues by cutaneous flushing and superficial 

 heat, urticaria, erythema, purpura, localized and general, 

 oedema; and in the deeper organs by dyspnoea, dry cough, 

 epistaxis, and haemoptysis as to the respiratory organs; saliva- 

 tion, vomiting, intense thirst, capricious and often ravenous 

 appetite to compensate for the excessive oxidation, as to the 

 stomach; and the earlier retro-ocular vascular, sometimes 

 varicose, turgescence with slight exophthalmos, flashes, sensa- 

 tion of pressure, and brow-ache as to the visual apparatus. 4. 

 The increased cardiac stimulation, as shown by the rapid and 

 violent action, due to cramped heart, a condition that prevails 

 when, as will be shown, the continued presence of poisons in 

 the blood causes the suprarenal secretion to continuously flow 

 in excess, the violent action being transmitted to the carotid 

 and other large vessels, and to the liver and spleen, which may 

 also be felt to pulsate (cardiac hypertrophy is often found post- 

 mortem in such cases). 5. And, finally, by the exaggerated 

 tendon-reflex, due to excessive muscular and spinal oxidation. 

 Adrenal insufficiency, though not encountered in all cases, 

 is fully as well exemplified: 1. By the cerebral suboxidation 

 and nutrition, as manifested by the mental impotence and low 

 spiritedness; melancholia. 2. By the reduced muscular me- 

 tabolism, as suggested by the loss of strength, stumbling, 

 paretic tremors, paralysis agitans, and finally hemiplegia and 

 other forms of motor paralysis. 3. By the dilation of the cen- 

 tral and other muscular vessels and passive contraction of the 

 capillaries, as illustrated by the cerebral and muscular symp- 

 toms just referred to, the pallor and general marasmus; sweat- 

 ing due to relaxation of the sweat-gland muscles; alopecia; 

 dental caries; vitiligo, leucoderma, scleroderma, and in ad- 

 vanced cases bronzing; and also by the colliquative diarrhoea 



