CLINICAL SYNDROMES 303 



tion." "The factors producing this condition might be the well known 

 causes of exophthalmic goiter." "The result of the premature discharge 

 of the hypothetical toxic intermediary product would be an impoverish- 

 ment of the gland of the thyroid hormone, which would explain the fact 

 that Graves' disease goiters are poor in iodin and especially in the active 

 alpha-iodin proteins." "Kendall (g) and Wilson report that the typical 

 goiter of Graves' disease contains but one-fiftieth to one-twentieth of the 

 total active iodin present in the normal thyroid gland; if the hyper- 

 thyroid theory were correct, more iodin, not less, should be present in 

 such hyperfunctioning glands." "The decreased production of the normal 

 hormone due to the causes mentioned would be accompanied or followed 

 by signs of thyroid insufficiency." On these grounds Janney accounts for 

 the occurrence in Graves' disease of such symptoms as goiter, the various 

 cutaneous changes (as atrophy, pigmentation, scleroderma, brittleness and 

 loss of hair, the rare abnormal deposits of fat), imperfect ossification and 

 epiphyseal union', fatty degeneration of the heart and skeletal muscles, 

 the mononucleosis, the metabolic disturbances of delayed glucose assimila- 

 tion, creatinuria and growth disturbances in the youthful case. Cer- 

 tain symptoms as weakness, loss of weight and creatinuria may properly 

 be assigned to either the presence in the blood of the hypothetical toxin 

 or to a deficiency of the normal hormone. The evidence as to whether, 

 there is actually a toxic substance present in the blood stream in Graves' 

 disease is very meager and as yet unconvincing. Janney's paper should 

 at least stimulate further research along these lines. It is of interest, if 

 not of actual significance that Caro as well as Klose have demonstrated 

 the toxicity of the urine in exophthalmic goiter, while recently Blackford 

 and Sandford found a depressor substance in the thyroid gland and in 

 the serum of patients with Graves' disease. 



Hyperthyroidism 



C. P. HOWAKD 



IOWA CITY 



INTRODUCTION 



Synonomy. This is a term of comparatively recent date used to in- 

 dicate a hyperfunction of the thyroid gland. Until quite recently the 

 fully developed state of hyperthyroidism was considered to be illustrated 

 by the symptom-complex, commonly called exophthalmic goiter, just as 

 the fully developed stage of hypothyroidism was exemplified by the disease 

 myxedema. 



Whether this is the absolutely correct view or whether Graves' disease 

 is more rightly to be regarded as dysthyroidism, will not be discussed at 



