324 C. P. HOWAKD 



patients of ^Troell's (a) series of 164 cases, but has been observed also by 

 Claiborne. The latter in addition calls attention to the dilatation of 

 both pupils in advanced exophthalmic goiter and particularly in the 

 blonde subject ; following thyroidectomy the pupils become smaller. 



Jellinek's Sign. Pigmentation of the eyelids is due in all probability 

 to an associated disturbance in the chromaphil system. It is generally 

 part of a widespread pigmentation ; it is an early symptom and diminishes 

 usually during the course of the disease. 



"Riesmaris Sign. A loud bruit audible over the eyeball has been 

 noted by Riesman in two cases of Graves' disease with especially marked 

 vascular phenomena. A search through the literature revealed the fact 

 that it had been previously described by Bonders, Schoenfeld and Car- 

 r ing*ton and Drummond. 



Roseribdctis Sign. This consists of tremor of the closed eyelids and 

 is of course part of the generalized muscular tremor. 



Paresthesias. Subjective feelings of heat or pain in the eyeballs 

 are not uncommonly complained of, just as in other parts of the body. 

 Paralysis of the various ocular muscles, nystagmus, etc., will be con- 

 sidered under the nervous symptoms and the complications of the disease. 



Cardiovascular Symptoms. The circulatory system suffers more 

 than any other system in exophthalmic goiter. Its condition determines 

 very largely the course and the prognosis of the disease. The "Kropf- 

 herz" of Kraus and the "cardiopathia thyreogenes" of His are terms used 

 to designate the cardiac symptomatology of Graves' disease and simple 

 hyper thy roidism. 



Tachycardia. Tachycardia, which is also known as pycnocardia, poly- 

 cardia and syncosphyxia, is the most constant sign of Graves' disease, 

 occurring, as it does, in practically 100 per cent of all cases, according 

 to Murray and many other authorities. In well marked cases the pulse 

 rate may range between 100 and 180 or even 200 beats per minute. In 

 one of Dock's cases it reached 225 beats and continued at this rate for 

 many hours. According to Mackenzie (&) the rate in mild cases varies 

 from 00 to 110, in moderate cases from 110 to 130, and in severe types of 

 the disease from 130 to 160 beats per minute. According to Kocher the 

 pulse falls to 80 beats per minute only after a long rest. While physical 

 exertion increases the tachycardia, an emotional stimulus does this to 

 a still more marked degree. It is often the first symptom of the disease; 

 in fact, all pulse rates that remain persistently above 80 to 85 beats per 

 minute should be regarded as a suspicious symptom of Graves' disease in 

 the absence of an acute or chronic infection. Barker states that it is 

 not unusual to see a "rest-cure" patient with an initial bradycardia of 60 

 to 05 beats, develop, after bed-rest and overfeeding, a, tachycardia of 

 80 to 100 beats through the unmasking of a thyropathy, often responsi- 

 ble, in part at least, for the so-called nervous breakdown. Mueller be- 



