332 C. P. HOWAKD 



meals and barium X-ray examination. Miesowicz has observed at autopsy 

 atrophy 01 the gastric mucosa. 



Vomiting. This is sometimes very troublesome in the severe cases, 

 and may apparently be unrelated to the ingestion of food. It may be 

 quite exhausting though is rarely if ever painful, but of course results 

 in a more or less profound acidosis with a fruity odor to the breath, 

 acetonuria, air hunger and restlessness. Hematemesis of a mild degree 

 may accompany these crises. Vomiting was noted by Murray in only 

 eleven of his 180 patients. 



Diarrhea. Diarrhea of a watery, painless character may be present, 

 and was noted by Marie (a) in 12 out of 15 patients, by West (a) in 7 out 

 of 38, by Mackenzie in 8 out of 38, and by Maude (b) in 4 out of 9 pa- 

 tients. These small series no doubt exaggerate its true frequency, as it was 

 observed by Murray in only 20 out of his large series of 180 cases an 

 incidence of just over 11 per cent. The number of stools varies from 

 four to thirty in the twenty-four hours. One of the writer's recent 

 cases of hyperthyroidism was complaining chiefly of a profuse diarrhea, 

 with ten to twenty-four stools per diem, which had led to a diagnosis of 

 parasitic diarrhea by her previous physician and to very frequent ex- 

 aminations of the stools for amebge or other intestinal parasites. It is 

 a true "intestinal crisis" and has been aptly termed "bowel hurry" by 

 Kingston Fox. It is often paroxysmal and has been likened by Charcot 

 to the gastric crises of tabes dorsalis. The bowels may be quite regular 

 for some weeks and then suddenly, usually in the early morning and 

 without apparent cause, the patient has without pain or colic large, liquid, 

 light-colored stools varying greatly in number. The feces resemble at 

 times the "rice-water" stools of cholera from the small flakes of mucus 

 present: rarely are they definitely bloody: they may show good digestion 

 or none at all : bile is often deficient. In one of Maude's cases the 

 attacks of diarrhea were accompanied by a rise in temperature the first 

 attack of which was mistakenly diagnosed typhoid fever. The diarrhea 

 may be very intractable and lead to rapid and profound cachexia. The 

 crises often alternate with periods of constipation of the spastic type. It 

 may or may not be associated with vomiting. A slight melena with 

 bright red blood may accompany the severer crises. Sometimes the diar- 

 rhea is dietetic in origin and in others it is due to a gastric hyposecretion 

 with hypermotility : rarely it has the features of a toxic process associated 

 with abdominal pain. Eppinger and Hess and more recently Pottenger 

 arid Crotti have assigned -the diarrhea to an excessive stimulation of the 

 intestinal glands and longitudinal muscles of the bowel by the vagus nerve 

 secondary to some toxic influence of the thyroid in other words a 

 vagotonic symptom: the same is true of the vomiting. 



Sieatorrhea. Fatty diarrhea independent of the mucous diarrhea 

 may occur, due to a disturbance of fat-absorption and not to faulty fafc 



