CLINICAL SYNDKOMES 349 



do not vibrate independently but the hand moves as a whole. It was 

 observed by Murray to be unilateral when the goiter and exophthalmos- 

 were also confined to one side. A large percentage of the cases, though 

 by no means all, present a tremor. Thus Murray noted it in one hundred 

 and eleven of his first series of one hundred and twenty patients or in 92.5 

 per cent. It is fine or of small amplitude and rapid with seven to ten 

 oscillations per second; it is especially troublesome to the patient when 

 performing such movements as sewing or drawing a straight line. It is 

 best induced in the fingers when the arm is held out rigidly with the fingers 

 wide apart. It can often be brought out by placing a thin card or a 

 heavy piece of writing paper upon the upturned fingers. - The tremor 

 affects the whole extremity and not the fingers only ; it may be observed 

 in the leg as well as in the arm and is sometimes present in the toes. In 

 some cases, as we have said, it is limited to, or more intense in, one limb. 

 Attacks of trembling may affect the whole body and, according to Mac- 

 kenzie, a such attacks bear the same relation to the tremor that palpita- 

 tion does to the rapid cardiac action." The tremor was first recorded by 

 Pierre Marie (b) (1883), who found a characteristic tracing in exophthal- 

 mic goiter. Peterson also made very careful kymographic tracings of the 

 tremor and found that the individual vibrations numbered 8.7 to 12 per 

 second in Graves' disease, 8.5 to 12 per second in chronic alcoholism, 5.4 

 in multiple sclerosis and 3.7 to 5.6 per second in paralysis agitans. The 

 earlier measurements of Marie (5 per second), Charcot (4.5 per second), 

 and Graves (4.8 to 7 per second), were by a sphygmograph an instru- 

 ment not as suitable for the estimation of tremor as was the kymograph 

 used by Peterson. 



Muscular Weakness. This is another very characteristic symptom and 

 is well brought out clinically by the difficulty in climbing stairs from an 

 involvement of the quadriceps extensor muscles and in the hurried and 

 shallow breathing from an alteration in the intercostal muscles and dia- 

 phragm. According to Balfour "the weakness is often most striking in 

 the ham-string group of muscles and the patient's difficulty or inability 

 to step onto the foot-rest of an examining table is very characteristic." 

 Wilson (d) believes it is probable also that one of the large factors in the 

 production of exophthalmos itself is the weakness and relaxation of the 

 recti oculorum. The weakness may be associated with muscular atrophy 

 and degeneration according to Askanazy, who states that the muscles 

 most affected are those of the thorax, abdomen, pelvis, eyes and tongue. 

 Mueller gave some careful measurements of the degree of weakness esti- 

 mated in kilograms; he found, for example, that the power of flexion 

 in the right finger of a normal woman was twenty whereas that in a case 

 of Graves' disease was only six and one-half kilograms. The various 

 muscle groups of the shoulders, elbows, hips and knee joints showed 

 the same marked discrepancy. Charcot (b) has noted a rare sign in "para- 



