CLINICAL SYNDROMES 315 



and one-half inches. It must be borne in mind that careful and repeated 

 measurements of the circumference of the neck will reveal spontaneous 

 alterations in the size of the gland. In some cases no enlargement can be 

 made out in spite of the most careful palpation of the neck at the time of 

 the first visit. Thus Murray (&) (1896) notes a complete absence of the 

 struma in 29 of 283 cases collected from the literature: he pointed out in 

 this article that a closer examination would have revealed a struma in 

 all: nevertheless in his own personal series of 120 cases published six 

 years later the thyroid enlargement was present in only 117 cases a 

 much higher proportion, it is true, but still not a perfect one. Repeated 

 examination throughout the course of the disease would probably still 

 further reduce these figures. Barker points out that "when symptoms of 

 Graves' disease are present and the thyroid does not seem to be enlarged, 

 the explanation may lie in (1) a struma not recognizable before operation, 

 (2) an insular change in the gland, or (3) an intrathoracic struma." The 

 thyroid enlargement may be so slight as to be masked clinically by the 

 subcutaneous fat of the neck but sufficient to be readily recognized when 

 the gland is freed from its bed by the operative procedures. By an "in- 

 sular change" in the gland is meant the occasional restriction of the 

 hyperplasia to islands scattered throughout the normal gland substance. 

 It must further be borne in mind that there is no necessary relation be- 

 tween the intensity of the symptoms and the size of the gland and that in 

 some of the most severe forms of the disease thyroid enlargement is 

 inconspicuous. 



Shape. The struma of Graves' disease may involve uniformly the 

 whole gland and so give rise to a horseshoe shaped goiter or to the 

 so-called "butterfly gland." Again one lobe may be more enlarged than 

 the other, and this is especially true of the right. 



Consistency. The surface of the gland feels granular. There may 

 be tenderness at the onset of the thyroid enlargement or during a tempo- 

 rary increase in size. Lian has recently called attention to a well defined 

 hyperesthesia and hyperalgesia which are present over the thyroid gland 

 in the early stage of exophthalmic goiter ; indeed, he considers it pathogno- 

 monic in the larval forms. The consistency of the gland is rarely hard; 

 more often it is firm and elastic, soft and elastic or soft. Sometimes it 

 is so soft as to resemble a varicocele. Before we leave the physical con- 

 sideration of the struma, it must be recalled that the subjects of old 

 simple goiter may develop the clinical syndrome of Graves' disease, in 

 which case the size, shape, and consistency of the gland differ considerably 

 from the pure hyperthyroid goiter ; thus the gland may be of a large size 

 and is usually asymmetrical : it may be hard or soft, cystic, adenomatous 

 or fibrous. 



Vascular Phenomena. In many cases there is a visible pulsation in 

 the lateral lobes, sometimes transmitted from the carotid arteries. Some- 



