CLINICAL SYNDROMES 355 



bulbar origin, though not necessarily from organic disease. Heuer, on 

 the other hand, assigns the cerebral nerve palsies to the toxic effect of the 

 hyperthyroidism upon the nuclei of the nerves. 



Tuberculosis. This has already been discussed under "etiology." 

 Levy and others have noted the frequency of hyperthyroidism in the 

 tuberculous patient; Levy reports thirteen cases of frank exophthalmic 

 goiter and fourteen cases of definite hyperthyroidism among one hun- 

 dred and seventy patients with tuberculosis. As has been said, there is a 

 divergency of opinion as to the frequency of the association of the two 

 diseases; thus Greenfield found tuberculosis often as a complication of 

 myxedema but never in exophthalmic goiter. 



Clinical Types of Exophthalmic Goiter 



There are many and various classifications of the clinical types of 

 exophthalmic goiter, but all have their faults and limitations. 



Primary cases are those in which the goiter develops coincident with 

 or shortly after some other cardinal symptom of the disease. 



Secondary cases are those in which the symptoms of hyperthyroidism 

 occur in the subject of a previous goiter. It must be confessed that in the 

 so-called primary cases a goiter has often existed prior to the symptoms 

 without the knowledge of either patient or even his physician, which 

 greater care in the physical examination might have revealed. Surgeons 

 are frequently struck with the frequency with which operation reveals a 

 distinct enlargement of the gland, which could only have been recognized 

 preoperatively by the discovery of a thrill or murmur over the gland. 



According to Kocher's (d) well known classification there are three dis- 

 tinct types: (1) The struma vasculosa or vascular goiter which occurs 

 in the early stage of exophthalmic goiter, when the symptoms are mainly 

 local. (2) Struma basedowificata, or Basedowized goiter, is a milder form 

 of hyperthyroidism developing in a patient with a preexisting simple 

 goiter. (3) Struma basedowiana, or Basedowian goiter, which is the 

 typical form of the disease. 



Again, the duration of the symptoms may form the basis of the classifi- 

 cation, when one speaks of the peracute or fulminant, the acute and the 

 chronic forms. The peracute cases are those in which the symptoms come 

 on in a few hours and develop rapidly, and in which the course is short 

 and stormy and the issue is usually fatal. 



The acute type is distinguished from the chronic by the duration of 

 the symptoms which in the former may be present for a few weeks or 

 months or even a full year, according to some writers. Many of the acute 

 cases in the opinion of Arneill, if the history had been more critically 

 obtained and the physical examination more carefully performed, would 



