346 C. P. HOWAKD 



than normal while there was a definite atrophy of the medulla; in a 

 second cas'e there was almost complete atrophy of the medulla of both 

 adrenals. He is inclined to emphasize the importance of the chromaphil 

 system in certain combination cases both from clinical observation and 

 from experimental investigation. Further, he believes that the hyper- 

 trophy of the suprarenal medulla results from the loss of the theoretical 

 thymic function. 



11 Pancreas, Disorders in Function of. Cohn and Peiser have called 

 attention to the presence in five cases of disease of the pancreas (three 

 hemorrhagic, one suppurative and one chronic interstitial pancreatitis) 

 of the ocular symptoms which are commonly associated with hyper- 

 thyroidism: thus they found slight exophthalmos in four, a positive von 

 Graefe sign in four, positive Moebius and Stellwag signs, tremor, der- 

 matographia and tenderness of the thyroid gland in five, while a lymphocy- 

 tosis of from 22 to 40 per cent was present in four cases. Their observa- 

 tions have been confirmed in one case by Garrod (&), who writes that 

 "where thyroidal and pancreatic symptoms are seen in association, the thy- 

 roid appears to be the organ primarily at fault and the observations of Cohn 

 and Peiser, for which the converse holds good, are of all the greater 

 interest on that account." If, in pancreatitis, the eye symptoms are 

 due to an excessive thyroid secretion, it is really the sympathetic nervous 

 system which is stimulating the gland to overactivity and it is not won- 

 derful that the sympathetic should be disturbed when the pancreas is the 

 seat of the disease, when one considers how near a neighbor it is of the 

 great abdominal ganglia and plexuses. 



Neuromuscular Symptoms 



Cerebral Symptoms. A change in the mental condition of the patient 

 is often one of the earliest symptoms of exophthalmic goiter, although occa- 

 sionally one meets with a case in which the patient remains placid, good 

 tempered and amiable throughout the course of the disease. Mental 

 irritability, excitability and restlessness are among the early manifesta- 

 tions. The subjects long for continual changes and must constantly be 

 seeing or doing something new. At times the patient is low spirited and 

 tearful ; at others cheerful and smiling but always resents being thwarted 

 or contradicted. Apprehension and anxiety are especially common. 



There is often insomnia, or at least the sleep is disturbed and restless 

 because of disagreeable dreams, from which the patient awakes in a 

 fright. Sometimes somnambulism occurs. 



The moral nature may be so perverted that the patient becomes spite- 

 ful, untruthful, suspicious and generally discontented. The intellectual 

 powers may remain unimpaired, but various phobias and obsessions are also 



