CLINICAL SYNDROMES 32? 



and (4) a blunt ap"ex so that the transverse diameter may not exceed 

 the normal and is often less than normal. 



The Arteries. The carotids and brachials may pulsate violently and 

 the radial pulse may have the characters of the "pulsus celer" to as marked 

 a degree as in aortic insufficiency. Folley has noted the marked pulsation 

 and even dilatation of the abdominal aorta, as well as of that of the 

 ascending portion of the arch, which can be well seen in the fluoroscope and 

 which has been called by him the "see-saw sign." This pulsation of the 

 abdominal aorta is especially annoying to some patients. 



Further as a rule in these cases a well marked "capillary pulse" can 

 be seen in the nail bed, the mucous membrane of the lips, the retinal ves- 

 sels, especially of the optic disc and at the margin of the red line which 

 appears upon stroking the skin of the forehead. The venous pulse in 

 the veins of the hand may be seen with great distinctness. The sphygmo- 

 graph, or better still the polygraph, will reveal in addition to the pulsus 

 celer a "pulsus irregular is respirator ius." Arhythmia is not uncommon 

 but is usually of the ventricular extrasystole variety. In other cases 

 there are more marked arhythmias, as the nodal or even the pulsus al- 

 ternans. In some cases there is irregularity of force and rhythm leading 

 to a slow pulse count at the wrist. 



The electrocardiogram shows a tracing exactly similar to that ob- 

 tained following physical exertion. Barker and Richardson report a 

 case of hyperthyroidism or perhaps dysthyroidism in a patient with focal 

 infections and thyroid adenomata, whose electrocarcfiographic study re- 

 vealed at one time or another (1) a physiological rhythm, (2) a dis- 

 location of the pacemaker from the sino-atrial node to points elsewhere 

 in the atrium, (3) alternate atrial extrasystoles, paroxysmal tachycardia 

 and atrial flutter. 



White and Aub noted in a routine electrocardiographic study of 47 

 cases of hyperthyroidism, auricular fibrillation in 6 patients (13 per 

 cent) and paroxysmal auricular flutter in one. While some patients have 

 been observed to have an irregular pulse for years without evidence of 

 cardiac decompensation, the severe arhythmias are usually of serious prog- 

 nosis. Occasionally a venous pulse has been noted in the liver and 

 spleen in acute cases of Graves' disease. 



The Blood Pressure. The blood pressure is said by Barker (&) to be 

 usually too low, though he admits that "the Graves' syndrome may occur 

 also in patients with arterial hypertension." Such a statement is quite 

 contrary to the experience of the writer, who has for years been struck 

 with the constancy with which a slight increase in the systolic pressure 

 (130-150 mm.) is present even in moderate cases of hyperthyroidism 

 when first coming under observation. Our observations are in accord with 

 those of Dock, Plummer and Swan in this country and such continental 

 clinicians as Pierre Marie (&), Kraus, and A. Kocher (&). Dock (a-) 



