CLINICAL SYNDROMES 357 



tachycardia and epinephrin-glycosuria on the one hand, and sweating, 

 diarrhea, pigmentation, lymphocytosis, eosinophilia on the other may occur 

 in the entire absence of thyropathy." "Unless there is struma and in- 

 creased vascularization of the thyroid gland (bruits) one should be cau- 

 tious in assuming that the symptoms are due to hyperthyroidism." May- 

 baum objects, also, to the loose application of the term rudimentary or 

 larval, since tachycardia alone may occur in hysteria, in disease of the 

 medulla, in tabes dorsalis, etc., in conjunction with other suggestive 

 symptoms ; he, accordingly, would require that at least two of the cardinal 

 symptoms be present in addition to suggestive minor phenomena before 

 making a diagnosis of "forme fruste" of exophthalmic goiter. The French 

 school also speaks of "la forme maigre," or lean type, and "la forme 

 grasse" or fat type. The former are always more severe, while the latter 

 usually do well. Some have suggested the term "latent Graves' disease" 

 for cases without the exophthalmos or goiter. Thomson very properly 

 objects to this nomenclature because such cases often present clinically 

 just as severe a set of symptoms .and often end fatally; they are much 

 rather to be classed as "unrecognized" than "latent." 



Finally, Plummer and Wilson, from their combined clinical and patho- 

 logical studies of the rich material at the Mayo Clinic, have divided all 

 goiters into (1) the non-hyperplastic atoxic, (2) the non-hyperplastic toxic, 

 (3) the hyperplastic atoxic, and (4) the hyperplastic toxic varieties. Plum- 

 mer (a) (b) admits that a considerable proportion of simple goiters, in 

 fact 23 per cent, were grouped by him under the non-hyperplastic toxic be- 

 cause they had constitutional symptoms and that whether these were classed 

 as simple or exophthalmic goiter depended upon how closely the clinical 

 complex approached Graves' disease. He further states that he was the 

 first to call attention to the fact "that an individual 22 years of age with 

 an adenoma of the thyroid has a definite chance of developing a train of 

 symptoms during the 36th year so similar to the symptom-complex associ- 

 ated with hyperplastic thyroid that the best trained diagnosticians are 

 constantly confusing the two conditions." Some clinicians are in the 

 habit of speaking of this group as "Plummer's disease." However, we 

 believe that while Plummer has certainly very emphatically called 

 attention to this group, a careful perusal of Buschan's excellent mono- 

 graph will reveal the fact that the latter also described a similar group in 

 1894. 



Under the term atoxic hyperplastic goiter Plummer includes cases with 

 a goiter that reveals on histological examination thyroid hyperplasia but 

 no clinical evidence of Graves' disease, and under the toxic hyperplastic 

 goiter he groups those cases with a definite clinical syndrome of Graves' 

 disease and a histological thyroid hyperplasia. We believe that this 

 classification of Plummer's is excellent and one that might be adopted by 

 all clinicians and pathologists, at least for the present. 



