348 C. P. HOWAED 



the extremities as numbness, tingling and formication. Hyperesthesia is 

 as usual iA the sensory tracts as is tremor in the motor nervous mech- 

 anism. Thomson has called attention to the frequency of tenderness of 

 the auricle of one or both ears. Pains in the tips of fingers and toes and 

 in the heels are common. Local twitchings and cramps, especially in the 

 legs, may be troublesome at night. As a rule these cramps do not last long- 

 but occasionally Mackenzie has observed more persistent spasm in which 

 the hands assume the more characteristic form seen in tetany. 



Headache does not seem to be common in the experience of most clin- 

 icians, yet Swan (a) noted it in thirty-one of his series of fifty cases; it 

 was either general in distribution or localized to the frontal, occipital or 

 vertical regions. Neuralgias in various parts of the body are by no means 

 rare; thus a facial neuralgia is sometimes a troublesome and obstinate 

 symptom. Vertigo and globus hystericus occur in the less severe cases. 

 Dock reports a temporary paraphasia in one case. 



Special Senses. Among the ocular symptoms one must mention pain 

 in the eyes, amblyopia, diplopia, achromatopsia, narrowing of the visual 

 fields, scotoma, and transient blindness. These usually affect only one 

 eye. Paralysis of the ocular muscles will be discussed under complica- 

 tions. A pulsation of the retinal vessels was first noted by Becker in 

 1857, according to Sattler, and has been confirmed by many since then. 

 Nystagmoid movements have been noted by Moutet, Sainton et Pisante, 

 Levi et Rothschild, and more recently by Sainton. Indeed, according to 

 the latter author they were present in twenty-two out of the forty cases in 

 which they were sought for ; he admits that they were spontaneous in only 

 two cases, while in the other twenty cases they were elicited only in the 

 extreme lateral position of the eyes. In these cases the nystagmus was 

 in a more or less rapid horizontal or oblique axis. Three cases of rotatory 

 nystagmus have been reported. Two of these which were reported by 

 Bramwell and Snell (quoted by Sattler) occurred in coal miners in associa- 

 tion with Graves' disease, but must be discounted because of the well 

 known association of nystagmus with coal mining. However, Frankau 

 has described a third case of bilateral rotatory nystagmus in a^ tradesman 

 afflicted with exophthalmic goiter but with normal vision and eye grounds. 



Among the auditory symptoms are a sense of fullness or throbbing 

 in the ears, transient but sometimes persistent deafness, tinnitus and severe 

 aural vertigo. 



Anosmia occasionally occurs. 



Motor Symptoms. Tremor is. so characteristic of exophthalmic goiter' 

 that since the days of Charcot it has been classed as one of the 

 cardinal symptoms. As to whether the tremor is to be regarded as a 

 motor nervous manifestation or a muscular one is still uncertain; we 

 prefer to consider it the former. It affects the flexor and extensor muscles 

 of the wrists and not the intrinsic muscles of the hand so that the fingers 



