316 C. P. HOWAED 



times the yeins over the goiter show marked pulsation or the whole goiter 

 yields an expansile pulsation, a condition termed the "struma vasculosa." 

 In many cases there is a more or less distinct thrill over the enlarged 

 lateral lobe but more usually at its upper pole. On auscultation over the 

 four poles of the gland there is invariably a systolic bruit, sometimes both a 

 systolic and a diastolic bruit; less frequently in the soft vascular struma 

 one can detect a continuous murmur with a systolic intensification re- 

 sembling the "bruit du diable" or even the humming top murmur of an 

 arteriovenous aneurism. The best method of bringing out these murmurs, 

 according to Guttmann (quoted by Moebius), is to draw the head to one 

 direction and to listen over the convex side of the neck. The systolic 

 murmur varies in character from a soft blowing to a musical twang or 

 squeak, fancifully named by Fuller the "sleigh-runner murmur." Gutt- 

 mann believes this systolic murmur is of arterial origin, due to the 

 hypertrophy of the left ventricle and the uneven dilatation of the arteries 

 in the gland. 



The diastolic bruit has partly a venous and partly an anemic origin. 

 These murmurs may be absent from the thyroid for varying periods but 

 never depend upon the propagation of the heart murmurs which are so 

 frequent in this clinical syndrome. 



Pressure Symptoms. The hyperthyroid goiter rarely if ever causes 

 pressure symptoms, except of course when a hyperthyroidism becomes 

 engrafted on an old goiter, in which case there may be pressure on the 

 trachea or nerves, varying in degree with the size of the goiter. 



The adjacent cervical lymphatic glands are often slightly hyper- 

 trophied and may suggest an inflammatory or even a malignant process. 

 The true explanation, however, is usually that this adenopathy is a local 

 expression of the tendency to a generalized lymphatic hyperplasia which 

 occurs in this disease. 



Intrathoracic Struma. This condition deserves a brief consideration. 

 According to Woelfler it occurs in 6.7 per cent, and to Kocher in 9.7 per 

 cent of cases of simple goiter. C. H. Mayo states that an intrathoracic or 

 substernal goiter is found in his clinic once in forty operations for simple 

 goiter. The question that is naturally of more importance is: How often 

 does an intrathoracic struma develop hyperthyroid symptoms? "Intra- 

 thoracic struma" is a diagnosis frequently made by the general practitioner 

 in cases which, however, more correctly belong to the small almost im- 

 perceptible cervical struma. In a clinical experience of twenty years we 

 have never seen a case in which this question has been raised. A careful 

 search of the Surgeon General's Catalogue revealed some ' fourteen papers 

 dealing with intrathoracic struma: of these the article by Wuhrmann 

 was the most complete and dealt with ninety cases collected from the 

 literature up to the year 1896: in none of these is a reference made to 

 the clinical syndrome of Graves' disease, though in one case there was a 



