CLINICAL SYNDEOMES 317 



double exophthalmos, in another unilateral and occasional exophthalmos, 

 while in five cases some palpitation or other cardiac nervous symptom 

 was manifest. 



Very recently Leiner reported a case of Graves' disease in which at 

 one time there was a palpable struma and all the classical symptoms, 

 but three years later there was found no cervical goiter but an area of 

 retrosternal dullness, a positive radiogram of an intrathoracic tumor, and 

 symptoms of slight hyperthyroidism. To make a diagnosis of Graves' 

 disease with an intrathoracic struma one must have, in addition to the 

 other symptoms of hyperthyroidism, clinical evidence of substernal pres- 

 sure, a definite area of retrosternal dullness on percussion, and a well 

 defined shadow in the rontgenogram. An enlarged thymus can give the 

 two latter phenomena, hence the diagnosis is at best risky. Of course 

 we would not accept as an intrathoracic struma a mere extension of the 

 cervical thyroid into the thorax, as was reported by Samuel West (a) in 

 two of his thirty-eight cases. The probable explanation of the rarity of 

 true hyperthyroidism in the intrathoracic struma is the well known clinical 

 fact that this type together with "les goiters plongeants" belong to the 

 atoxic non-hyperplastic group and not to the so-called toxic hyperplastic 

 goiter which is characteristic of Graves' disease. 



Disturbances of the Autonomic System 



Under this heading we would include all the symptoms due to an ab- 

 normal stimulation of smooth muscle, heart muscle and the secretory 

 glands : possibly one should also include some of the metabolic disturbances, 

 but for convenience's sake these will be discussed under a separate head- 

 ing. The "abnormal autonomic innervations," following Barker's ex- 

 ample, will be considered regionally as: (1) ocular, (2) cardiovascular, 

 (3) cutaneous, (4) digestive, (5) respiratory, and (6) urogenital. 



In both simple hyperthyroidism and in the Graves' syndrome, the sym- 

 pathetic as well as the craniosacral or vagal systems are involved. When 

 the symptoms referable to the 'sympathetic system predominate Eppinger, 

 Falta and Hess speak of the picture as "sympathicotonic," while in the 

 event of the craniosacral autonomic (parasympathetic) symptoms pre- 

 dominating, the syndrome is termed "vagotonic." Again when the vago- 

 tonic and the sympathicotonic symptoms are equally present, the picture 

 is described as "mixed." 



The Major Ocular Signs. Description of the Major Ocular Signs. 

 While only a protrusion of the eyeballs was noted in the first cases de- 

 scribed, there are now no fewer than fifteen more or less important ocular 

 signs or symptoms. Most of these are of autonomic origin, though it 



