362 C. P. HOWAED 



Course and Duration 



In some cases all the four cardinal symptoms appear more or 

 less simultaneously, but more commonly one or two symptoms are 

 first manifest; thus tachcardia, tremor, palpitation and some of the 

 secondary symptoms may appear first to be followed later by exoph- 

 thalmos and goiter. Sometimes exophthalmos is the first symptom 

 to appear and sometimes the last. Most commonly the goiter is the first 

 sign of the disease. Murray (d), in a series of eighty-seven cases in which 

 the onset was recorded, found that the first symptom was goiter in forty- 

 three, palpitation in nineteen, and exophthalmos in four. Plummer (a) 

 found from an analysis of over one thousand cases of exophthalmic goiter 

 occurring in the Mayo Clinic up to the year 1913 that the average order of 

 onset of the most important symptoms was: (1) cerebral stimulation, (2) 

 vasomotor disturbances of the skin, (3) tremor, (4) mental irritability, 

 (5) tachycardia, (6) loss of strength, (7) cardiac insufficiency, (8) 

 exophthalmos, (9) diarrhea, (10) vomiting, (11) mental depression, (12) 

 jaundice, (13) death. The course of the disease is essentially a chronic 

 one and varies from ten to twenty or more years. Very rarely the duration 

 may be measured by weeks or even days. Exacerbations may come on 

 suddenly, due to various causes as infection, mental shock or physical 

 exertion. 



In a large number of cases, as W. G. Thompson has so graphically 

 described, sooner or later an acute febrile toxemia develops, in which, in 

 addition to the cardinal symptoms of goiter, fever of 103 to 104 F., 

 acute dilatation of the heart with murmurs, rapid pulse, dyspnea, pre- 

 cordial or abdominal pain, gastro-mtestinal crises, edema of the legs, 

 sweating and sometimes erythema make their appearance. Such attacks 

 of acute hyperthyroidism usually follow some mild intercurrent infection 

 as tonsillitis, quinzy, influenza or bronchitis. It may subside in the course 

 of several weeks or it may result in death from the resulting cardiac 

 insufficiency. 



Relapses are not uncommon in both the medically and surgically 

 treated. 



C. II. Mayo admits that they occur in ten per cent of those cases which 

 have undergone some form of surgical treatment. 



Trousseau speaks of six relapses and Graves of three as having occurred 

 in patients before the days of surgical treatment of the disease. A relapse 

 may occur years after an apparent recovery from the disease; of course in 

 such a case the question can be raised: 



Are these true relapses or merely recrudescences of the disease which 

 has never really subsided '? 



