330 C. P. HOWAKD 



"it is not unlikely that the reason of this diminished resistance in 

 Graves' disease is to be found in the vasomotor dilatation of the skin 

 capillaries, which thus render the skin saturated with fluid and prac- 

 tically reduce the thickness of the ill-conducting epidermis to a mini- 

 mum." Cardew, while reporting a diminished electrical resistance in 15 

 out of 20 cases of Graves' disease, denies its diagnostic value and assigns 

 it to the increased sweating which may not always be perceptible to the 

 patient or even to the examiner's hand. With this latter explanation 

 von Leube and Barker are fully in accord. 



Pigmentation of the skin has been frequently observed. Thus Murray 

 noted it in 16.6 per cent of his first 120 cases, and in 23.3 per cent in his 

 series of 180 cases. It may be generalized over the surface of the body 

 but is more often localized to the eyelids, face, nipples, axillae, genitalia 

 and regions where pressure is caused by the clothing. The mucous mem- 

 branes of the mouth and lips is rarely if ever affected. The pigmentation 

 often fades as the other symptoms improve. Patches of leukoderma or 

 vitiligo and multiple telangiectases may appear alongside of the pigmented 

 areas. It is generally thought that this pigmentation is due to an associ- 

 ated disturbance of the chromaphil system. 



According to du Castel there are many other trophic cutaneous troubles 

 apart from the pigmentation and vitiligo, namely scleroderma, diffuse or 

 localized alopecia, telangiectases, multiple gangrene, etc. 



Scleroderma has been reported in patients with Graves' disease by 

 Jeanselme, Dupre and Thibierge, according to du Castel. This is of 

 interest because of the occasional response of scleroderma and morphea to 

 the administration of thyroid extract. 



Purpura, while not common, has been noted by du Castel, Maude (c), 

 Dore and Burney Yeo. It is usually discrete and rarely in itself of great 

 severity, though the hyperthyroidism is usually of a severe type. 



Edema. Millard collected nine cases from the literature up to the 

 year 1888 and added two cases of his own. Maude (a) states that a slight 

 edema of the ankles occurred in one-third of his cases. He considers 

 three varieties of edema as of possible occurrence in exophthalmic goiter : 

 (a) edema of cardiac insufficiency, (b) edema of nervous origin and 

 (c) transitory edema. The transitory edema is the rarest, and is irregular, 

 fugitive and asymmetrical in its distribution. Its favorite sites are the 

 neck, arms, hands, cheeks and eyelids and, rarely, the supraclavicular 

 fossae. It may last only a few hours, does not pit on pressure, does not 

 exude fluid to a needle prick and when present in the eyelids does not 

 cause closure of the palpebral fissures; indeed, it may be present with 

 retracted ejelicls. This type does not yield to thyroid extract. Maude 

 considers the intermittent hydrarthrosis, noted under "complications," 

 as another form of this angioneurotic edema. While patches of solid 

 edema of the skin are now well recognized as occurring in Graves' disease, 



