41S CASES OF EXOPHTHALMIC GOiTRE. 



further off only since she came into hospital, but the presbyopia 

 may have come on some weeks before, as she had no work, and 

 therefore no opportunity of observing it. The vision of the left 

 eye is ^-f of Snellen's types. That of the right eye is- -^-J, with 

 a —48 lens it becomes -ff. Her eyes ache if she looks long at 

 any object. They did not use to do so. She is often troubled 

 with muscse volitantes. She has some subjective visions w^hen 

 filer eyes are closed. These are in the form of stars flying 

 .about ; they are usually of a red colour. On ophthalmoscopic 

 examination, the media are found to be a little hazy. ISTo thing 

 abnormal in the discs, except that the right disc seems a 

 little smaller than the left. The fundus of both eyes is fairly 

 natural.] 



Circulatory Sijstem. — The heart's apex beats two inches below 

 .and half an inch outside of the left nipple. There is a systolic 

 murmur. The abdomen is retracted, and there is strongly- 

 marked epigastric pulsation. The veins on the arms, legs, and 

 neck are very large, full, and light blue, not dark blue, in colour. 

 When emptied, they fill very rapidly from behind. The face is 

 not flushed, nor are the ears red. The temporal arteries are 

 prominent and tortuous. The pulse is 120, full and regular. 

 The sphygmographic tracing show^s a flat plateau and mode- 

 rately slow descent. This seems to indicate that the arteries 

 have undergone senile degenerati*a, and that they do not empty 

 with any very great rapidity. There is no marked pulsation in 

 the thyroid gland, nor is there any very obvious increase in the 

 pulsations of the carotid arteries. 



Respiratory System. — The voice is soft and pleasant. (She 

 has lately noticed it change, and become weaker and more 

 " clinky." She has only noticed this since she began to recover 

 in hospital. She sometimes has a little pain in her throat when 

 she speaks.) The lungs are normal. 



Muscular and Nervous Systems. — The muscles are very small. 

 The thumbs are drawn in upon the palms. She finds difficulty 

 in rising from a sitting posture. She is very neat in her habits, 

 is not quick-tempered, but the contrary. She is very emotional, 

 and is in either very high or very low spirits. When well, she 

 is high-spirited and full of fun ; but for three weeks before 



