334 C. P. HOWAKD 



the size and form of single elevations with periods of complete or almost 

 complete respiratory pauses. (B) Periodic attacks of (1) deepening of 

 the respiration, (2) more rapid inspiration and expiration, and (3) re- 

 spiratory pauses. 



Pulmonary Hemorrhages. Hemorrhages from the lungs have been 

 observed, and Murray has described crises of bronchorrhea. 



Bryson s Sign, Bryson in 1889 first noted a diminished chest ex- 

 pansion in every case of Graves' disease examined by her: this amounted 

 in severe cases to a restriction of the chest measurements to half an inch. 

 She believed that an expansion of one inch or more was of favorable 

 prognosis. This phenomenon was confirmed by Hammond and named 

 by him Bryson's sign. Patrick, some years later, reported its presence in 

 only 10.5 per cent of forty cases and considered it in no wise pathog- 

 nomonic, nor indeed an important sign. He further states that it has no 

 significance in prognosis and should be relegated to the comparative ob- 

 scurity of an individual in a large community of manifestations all of 

 which depend alike upon the general state. 



Bryson also noted in one patient a peculiar catching of the breath 

 when reading aloud. 



A disturbance of Littens phenomenon often suggests imperfect con- 

 traction of the diaphragm. This as well as the diminished chest expansion 

 may be explained by the muscular weakness which is often a marked symp- 

 tom of the disease. 



Laryngeal Paralysis. Matthews concluded from a study of the vocal 

 cords in one thousand cases of goiter that the nerve fibers supplying the 

 abductor impulse of the posterior crico-arytenoid muscle are most readily 

 affected by pressure of the enlarged thyroid. Thus there occurred a par- 

 tial or a complete paralysis of one or both cords in 272 cases an inci- 

 dence for all types of goiter of 27 per cent. He further states that: 

 "Exophthalmic goiter does not differ materially from other forms of 

 goiter in its effects on the vocal cords except in cases of extreme hyper- 

 thyroidism in which the effects are evidently increased as a direct result 

 of general muscular wasting." This paresis of the cords often occurs 

 without hoarseness or other symptom of laryngeal involvement, and on 

 this account Matthews emphasizes the importance of a careful laryngo- 

 scopic examination before operation. C. H. Mayo also makes a similar 

 plea. 



Urogenital Symptoms. The intimate relation of the thyroid gland 

 to the female genitalia has long been appreciated on account of the 

 swelling of the thyroid at puberty and during pregnancy. Further, 

 Graves' disease is more frequent in women than in men. 



Menstrual Disturbances. Menstrual disturbances are frequent ac- 

 cording to some observers, while others comment on their comparative 

 rarity. Murray noted disturbance of menstruation in 45 out of 170 cases, 



