CLINICAL SYNDROMES 359 



the vascular phenomena previously described in detail, namely the visible 

 pulsation, the palpable systolic expansion, palpable thrill and audible 

 bruits. Barker (a) points out that not every acutely developing goiter is 

 an exophthalmic goiter : further, that the symptoms of Graves' disease may 

 become superimposed on an ordinary colloid struma, termed by Marie 

 "goitre Basedowifie" and by Kocher a struma basedowificata." 



The goiter heart of exophthalmic goiter is a thyreotoxic phenomenon 

 and can usually be distinguished from the three types of heart which 

 may arise from the mechanical effect of a simple goiter, viz. : (1) disturb- 

 ances of the heart due to a struma extending through the superior aperture 

 of the thorax (Kocher), (2) the goiter-heart due to a mechanical injury 

 of the venous circulation (Kose's goiter heart), and (3) that due to inter- 

 ference with respiration (the dyspneic goiter heart of Kocher). 



Exophthalmos of the characteristic kind with the protrusio bulbi and 

 the various other ocular phenomena can be assigned only to the Graves' 

 syndrome. It is unfortunately true, however, that cases of orbital tumor 

 (especially chloromata), aneurism of the orbital artery and sinus throm- 

 bosis are too often mistaken for exophthalmic goiter because of the pres- 

 ence of a unilateral or even rarely of a bilateral protrusio bulbi. In- 

 creased intracranial pressure from hydrocephalus may also cause some 

 exophthalmos. A careful examination of the eyes and of the pressure 

 phenomena in these cases will lead to a correct diagnosis. Finally 

 Barker and Hanes have reported exophthalmos with one or more of the 

 allied ocular signs (anisocoria, von Graefe, Stellwag or Moebius) in six- 

 teen out of thirty-three cases (48 per cent) of chronic nephritis without 

 apparent involvement of the thyroid gland. It is true that twelve of 

 these sixteen showed arterial hypertension (above 160 mm. Hg), but this 

 was not, in Barker's opinion, the cause of the exophthalmos, 



Differential Diagnosis. There are two diseases that from their gen- 

 eral symptomatology are sometimes mistaken for Graves' disease, namely 

 neurasthenia and pulmonary tuberculosis. 



Neurasthenia can usually be readily differentiated from mild Graves' 

 disease by complete and repeated physical examinations. However, we 

 must admit that the underlying factor in a considerable proportion of 

 so-called neurasthenia can only be brought out by more or less elaborate 

 laboratory tests. Harlow Brooks noted among the American troops at 

 Camp Upton a high incidence of patients suffering from tachycardia with 

 arhythmia increased by exercise and by the administration of epinephrin ; 

 next to the tachycardia emotional instability was the commonest symptom, 

 while enlargement of the thyroid gland to some degree was present in 66 per 

 cent of the cases. Further, there was frequently a family history of goiter, 



Iisually on the maternal side : lastly, he noted exophthalmos in some of the 

 ong standing cases. Brooks' s observation could not be confirmed by Addis 

 .nd Kerr, who divided the examined recruits into two groups the first 



