CLINICAL SYNDROMES 361 



of all the clinical and laboratory findings." He considers that there are 

 certain symptoms distinctive of each condition and again some symptoms 

 common to both : the latter are fatiguability, tachycardia, pyrexia, cough 

 and dyspnea, and derangement of digestion and metabolism. He, how- 

 ever, can offer no very great assistance in the differentiation of the two 

 diseases. We may have to depend very largely upon the basal metabolism 

 and Goetsch's epinephrin test for light in certain obscure cases. 



Chlorosis. Thyreotoxic Pseudochlorosis. These conditions may pre- 

 sent a problem in differential diagnosis. Wunderlich observed protrusion 

 of the eyeballs in anemic-looking girls, which was often associated with 

 pallor, fatiguability, emaciation and tachycardia. This clinical picture 

 was supposed to be due to chlorosis; indeed, many of the earlier writers, 

 notably James Begbie and J. W. Begbie, spoke of the "struma chloro- 

 ticum." A blood examination reveals, however, a normal or even an 

 excessive amount of hemoglobin and a normal number of red cells. Such 

 patients in Mueller's opinion are no doubt the subjects of exophthalmic 

 goiter. 



Thompson calls attention to the possibility of mistaking the highly 

 toxic clinical picture in which fever, acute dilatation of the heart, cardiac 

 murmurs, dyspnea, precordial pain, delirium, sweating, edema, and an 

 erythematous rash are present, for such acute conditions as malignant 

 endocarditis or other forms of acute general septicemia. This is especially 

 true when exophthalmos is absent or when the thyroid enlargement is 

 not prominent. He quotes from his own experience two cases illustrating 

 this point, and we must confess it would require a long continued critical 

 observation of either case to make the differential diagnosis. However, 

 the presence of embolic phenomena or the finding of one of the well known 

 varieties of bacteria in the blood cultures should help to establish the 

 presence of an ulcerative endocarditis. 



Great assistance in the differential diagnosis of mild grades of hyper- 

 thyroidism from obscure cases of other nature can no doubt be obtained 

 by certain laboratory tests as the determination of alimentary hypergly- 

 cemia and glycosuria, the basal metabolism, the epinephrin test of Goetsch, 

 the acetonitril test of Hunt and the iodin test : these will be discussed at 

 length in another chapter by an authority on this subject. Suffice it here 

 to remind the reader that the white cell count invariably shows a relative 

 and usually an actual increase in the mononuclear cells, especially of the so- 

 called lymphocytes, but also at times of the large mononuclear cell of 

 Ehrlich. We have learned to place a good deal of reliance on such a 

 mononucleosis and regard it as at least suspicious evidence of hyperthy- 

 roidism and one calling for a careful revision of the clinical history and 

 physical examination from a hyperthyroid angle. 





