356 C. P. HOWAKD 



have shown, distinct signs of the disease months or years before the sudden 

 appearance of the more striking symptoms of struma and exophthalmos. 

 In these acute cases circulatory symptoms of tachycardia, irregularity of 

 the pulse and the dyspnea are usually marked; in addition, vomiting, 

 diarrhea, fever, sweating, pigmentation and vasomotor cutaneous disturb- 

 ances are frequent. 



The chronic type includes the vast majority of cases of exophthalmic 

 goiter. In this group after months or years of vague neurasthenic symp- 

 toms the cardinal clinical features gradually make their appearance and 

 persist for years, sometimes throughout the lifetime of the patient, in 

 spite of all remedial measures. 



According to the number of the symptoms, cases are spoken of as 

 complete, incomplete, abortive, rudimentary or larval. 



In the complete or typical cases the four cardinal symptoms of tachy- 

 cardia, struma, protrusio bulborum and tremor are present. 



In the incomplete forms only one or two of the main symptoms are 

 manifest. However, as Dock (&) points out, "in a disease with so many 

 symptoms the question of completeness must depend largely upon the accu- 

 racy of the observations and the care in noting them." Some further quali- 

 fying term would be of assistance in such cases, since without it we do not 

 know whether the "incomplete case" lacks exophthalmos or goiter or even 

 whether it has none of the classical symptoms except tachycardia, emacia- 

 tion and nervousness. To such cases we are in the habit of applying the 

 term "simple hyperthyroidism." 



In the abortive cases the onset is usually abrupt but is soon followed 

 by a rapid improvement; in the great majority of these, however, as in the 

 acute cases, a careful inquiry will reveal a long history of some slight 

 symptoms. Some mental shock, physical exertion or infection will light 

 up the latent stage into a more or less complete syndrome. This acute 

 stage will then be followed by a period of relative improvement. So true 

 is this to a greater or lesser degree of the majority of cases that Eenaut 

 lias suggested the recognition of a latent stage, a stage of tolerance and a 

 stage of intolerance. Exacerbations tend to develop rapidly but to subside 

 gradually and to recur at longer or shorter intervals, sometimes without 

 hii t usually with a discoverable cause. 



In the rudimentary or larval cases, termed by the French "les formes 

 frnstes," the four cardinal symptoms are absent but there is, notwith- 

 standing a long array of symptoms of hyperthyroidism. However, Bark- 

 er's- (?;) word of warning is timely when he states that in our present knowl- 

 edge of the autonomic nervous system "we must be more cautious than for- 

 merly in deciding that a given case with incomplete symptoms is really due 

 to hyperthyroidism, for we now know that many of the symptoms met with 

 in Graves' disease may be due to disturbances in other endocrin glands 

 <;r to an irritation in local domains of the autonomic system." "Thus 



