CLINICAL SYNDROMES 333 



splitting from a disturbed pancreatic function. Schmidt and Salomon, as 

 well as Falta have, on the contrary, described cases of fatty diarrhea 

 and a lowered carbohydrate tolerance, which they have assigned to inhi- 

 bition of the internal secretion of the pancreas. 



Icterus. According to Crotti "in a few cases of very severe thyro- 

 toxicosis icterus may be observed. This icterus is rare, though it is 

 not uncommon to observe a yellowish tint of the sclerotics in severe thyro- 

 toxic-intestinal disturbances." The prognosis of this icterus is always bad. 

 It indicates some degeneration of the liver and when marked is usually 

 associated with general edema and ascites. It is not due to obstruction 

 in the bile ducts but is of toxic origin. 



Respiratory Symptoms. While these are not frequent or important, 

 they are of considerable interest. They depend upon a stimulation of 

 the visceral nerves and probably are of toxic origin. 



Cough. Cough of an irritative dry ringing character may be quite 

 troublesome. It may or may not be associated with hoarseness or even 

 aphonia. It may sometimes depend upon local pressure of the struma on 

 the trachea or recurrent laryngeal nerve, though this is not as common 

 as in colloid goiter. The usual explanation is a stimulation of the vagus; 

 it was considered by Germain See as a form of laryngeal crisis. 



Dyspnea. First we must note that subjective feelings of dyspnea are 

 often complained of by the patient without any manifest increase in the 

 rate or the depth of the respiration. Tachypnea or rapid breathing is 

 also reported and occurs apart from exertion. Asthmatic attacks are 

 not infrequent. Hoffbauer and Sharp both report crises of dyspnea, asso- 

 ciated with aggravation of all the hyperthyroid symptoms, a swelling of 

 the vessels of the neck, cyanosis and impending asphyxia. Such attacks, 

 according to Mackenzie, have proved fatal. Sharp was struck with the 

 resemblance of the picture to that of atropin poisoning, which was further 

 suggested by the remarkable response to opium. It has been supposed 

 that they arise from a sudden increase of direct pressure of the goiter 

 on the trachea, but Mackenzie believes it is improbable that they depend 

 upon mechanical causes. 



Hoffbauer, whose paper should be read by all, states that the respira- 

 tory disturbances cannot be explained by cardiac disease, hysteria, bron- 

 chitis, bronchial asthma or pressure upon the trachea, Hie believes that 

 the experimental work with thyroid extract as well as clinical observa- 

 tions suggest a toxic origin in many cases, though by no means in all, 

 when the above-mentioned factors may be considered. He took graphic 

 records in three patients with exophthalmic goiter by means of a Knolls 

 cardiopneumograph and a Marey drum and made the following classi- 

 fication of respiratory disturbances: (A) Continuous disturbances char- 

 acterized by (1) leveling of the respiratory curve, (2) a simultaneous 

 prolongation of both inspiration and expiration, and (3) irregularity of 



