350 C. P. HOWAKD 



paresis/ 7 oy the sudden giving way of the legs like that seen in inter- 

 mittent claudication. It was noted by Mackenzie in twelve cases and 

 considered by him as functional in origin though without other symptoms 

 of hysteria. On the other hand, weakness of the legs in climbing stairs 

 or even in walking is quite frequent. It may go on to a paraplegia with 

 loss of skin and patellar reflexes, but, of course, without bladder symptoms, 

 loss of sensation or marked atrophy. The myasthenia may be cerebral in 

 origin or possibly like myasthenia gravis be associated with the thymus 

 hyperplasia, which, as has already been stated, is so common in Graves' 

 disease. 



Muscle Atrophy. Ballet was the first to note the atrophy of the 

 muscles of the legs in a case of exophthalmic goiter. Miesowicz examined 

 nine hundred articles in the literature on exophthalmic goiter and found 

 only fourteen cases reported, including his own case. In the latter there 

 was an extensive muscular atrophy of the upper extremities associated 

 with a severe form of Graves' disease. In a case reported by Silva the 

 atrophy was especially noticeable in the muscles of the hand. Askanazy 

 noted in his four cases a marked and widespread fatty infiltration and 

 fatty degeneration of the voluntary muscles, characterized macroscopically 

 by the small size and pallor of the muscle bundles and microscopically by 

 nuclear changes and fatty degeneration of the protoplasm. Askanazy 

 considered these changes a result of the toxic action of the thyroid secre- 

 tion on the muscle bundle itself. Miesowicz believes that such cases, 

 exceptional though they be, point to a central origin. 



Other Motor Manifestations. The tendon reflexes are usually 

 slightly exaggerated and true spastic phenomena have been reported. 

 Monoplegia and hemiplegia have been described. Choreiform movements 

 also occur occasionally. Tetany, epileptiform convulsions, ascending paral- 

 ysis, and multiple neuritis are also reported but are probably best con- 

 sidered as complications and not as symptoms of the disease. 



Symptoms in the Hematopoietic System 



The Blood. Hemoglobin and Red Cells. The older writers were 

 in the habit of emphasizing the presence of an anemia as part of the 

 clinical syndrome. Indeed, Begbie thought it was primary and wrote on 

 "Anemia and Its Consequences Enlargement of the Thyroid Gland and 

 Eyeballs," whilst Wilks cautioned the inexperienced clinician to beware of 

 mistaking Graves' disease for ordinary anemia. This erroneous belief can 

 only Lo explained by the frequent existence of pallor in the patient, 

 which, in the absence of a blood count, was thought to be a symptom of 

 anemia. For many years it was stated in text books and magazine 

 articles that a chlorotic anemia is present in the disease. Neither Albert 



