CLINICAL SYNDROMES 331 



Morrow has reported a unique case in which the solid edema was sym- 

 metrical and did not yield to thyroid extract, while the skin over it pre- 

 sented the characteristic changes of elephantiasis. Nevertheless some of 

 the cases of Graves' disease with symmetrical solid edema are caused by 

 a secondary hypothyroidism or possibly dysthyroidism and will yield 

 promptly to thyroid extract as rapidly as does true myxedema. 



Dermatopathies. Erythema, probably of a toxic nature, is very com- 

 mon, while urticaria^ pruritus, furunculosis and eczema are not rare. Mul- 

 tiple gangrene will be considered under the complication of the Graves' 

 syndrome. 



Canities. Early graying of the hair is said to occur, and has been 

 seen by me in one female patient, 



The nails are long and tapering, and occasionally show trophic dis- 

 turbances, being thin, weak and brittle sometimes, indeed, being repre- 

 sented by a soft paper-like film, comparable to a micaceous transformation. 

 These trophic disturbances sometimes vary in the two hands and even 

 in the individual fingers. They have been well described by Kohn, Uphoff, 

 Kocher (&), Riedel, Landstroem and Stewart and Gibson. 



Gastro-Intestinal Symptoms. The teeth show rapid decay and 

 marked fragility, according to Koeppen, Buschan, Mannheim and Kocher. 



The Appetite. Appetite is variable, though anorexia is uncommon 

 except when the disease is running an unfavorable course. There is 

 more often bulimia or a voracious appetite with an especial craving 

 for carbohydrate food. Again the appetite may be capricious and the 

 patient as in pregnancy have longings for unusual kinds of food. The 

 bulimia is said to occur in two forms : in one the craving occurs "at long 

 intervals in paroxysms extending over several days ; in the other the hunger 

 occurs almost daily, usually several times a day for periods of an hour 

 or so, though the bulimia in this variety is not as intense as in the former 

 variety. Both types may accompany the diarrhea and vomiting, but 

 not necessarily so. Thirst, too, may be increased owing to the excessive 

 sweating. 



The Saliva. This may be profuse in the vagotonic cases or scanty 

 in the sympatheticotonic. It may be paroxysmal in occurrence but is 

 usually more or less continuous. Diminished salivation with a resulting 

 xerostomia is rare. 



The Gastric Secretion. Miesowicz reports a case of complete absence 

 of the hydrochloric acid from the fasting gastric contents, from the ma- 

 terial removed after a test meal and from the vomitus. This observation 

 was confirmed by him in four out of seven patients with Graves' disease 

 that were later examined by him. Considerable amounts of mucus were 

 found in the gastric contents of his first case. There is also reduction 

 in the amount of pepsin. The motor function may also be affected, and 

 premature emptying of the gastric contents as shown by the motor test 



