[304 C. P. HOWAKD 



this juncture. We will content ourselves with following the usual custom 

 of including under the term of "Hyperthyroidism," both the fully de- 

 veloped picture of "exophthalmic goiter/ 7 and the "larval forms" or "les 

 formes frustes" of the French. The only distinction to be made between 

 simple hyperthyroidism and exophthalmic goiter is that in the former 

 both the exophthalmos and the goiter may be absent at the time of 

 observation; subsequently the goiter and exophthalmos may develop but 

 this is neither invariable nor inevitable. 



The following designations of the malady under discussion are to be 

 found in the literature: 



Exophthalmic Goiter. Parry's disease, Graves' disease, exophthalmic 

 bronchocele (Lay cock), cardiothyroid exophthalmos (Walshe), exoph- 

 thalmos anemicus (Mackenzie), anemic protrusion of the eyeballs (Tay- 

 lor) in Great Britain; Basedow's disease, hyperplastic toxic goiter 

 (Plummer) in America; Glotz-augenkachexie (Basedow), Glotzaugen- 

 krankheit, die Basedowsche Krankheit, Struma exophthalmica in Ger- 

 many; Maladie de Graves (Trousseau), cachexie exophthalmique, dys- 

 crasie exophthalmique, exophthalmie cachectique, tachycardia strumosa 

 (Lebert) in France; Morbo di Flajani, struma seu gozzo esoftalmico in 

 Italy; bocio exoftalmico in Spain; Thyrotoxicosis (Kocher) in Switz- 

 erland. 



Of these twenty-one synonyms for the clinical syndrome of exoph- 

 thalmic goiter, those in most common use are Graves' and Basedow's dis- 

 ease. To whom belongs the right of priority has no doubt been made clear 

 by the writer of the section on the history of diseases of the thyroid gland. 



Definition. Exophthalmic goiter is tersely denned by Osier in his 

 well known text-book, as "a disease characterized by goiter, exophthalmos, 

 tachycardia and tremor, associated with a perverted or hyperactive state of 

 the thyroid gland." After looking over a score or more definitions of the 

 disease we decided that this was possibly the safest one to adopt. We 

 however believe we can accept Plummer's (&) proviso, namely that the 

 term exophthalmic goiter should be reserved for cases running a certain 

 definite course, associated with parenchymatous hyperplasia of the thyroid 

 gland. This would include all cases with the cardinal symptoms of ex- 

 ophthalmos, tachycardia and tremor together with macroscopical or micro- 

 scopical hyperplasia of the thyroid without necessary evidence of an actual 

 st m in a. 



Incidence. AIL exact, idea of the true incidence of the disease is dif- 

 ficult to obtain. Many cases were overlooked in the various clinics of 

 the metropolitan hospitals of Europe and America in the latter half of 

 the nineteenth century and now statistical studies have been largely 

 abandoned. However Samuel West (a.) in 1886 noted three cases among 

 'U7!> out-patients at the Chest Hospital, Victoria Park, London, an 

 incidence of about 1 in 1,000. George Dock (&), formerly of Ann Arbor, 



