CLINICAL SYNDROMES 305 



Michigan, reports 52 typical cases among 5,000 admissions to the Medical 

 Clinic of the University of Michigan or about 1 in 100 a very much 

 higher incidence than that of West. Paessler, of Jena, which is in a 

 goitrous district of Germany, noted 58 cases among 2,800 patients, or an 

 incidence of about 1 in 50. In our own medical clinic in Iowa City, 

 which corresponds very closely to that of Dock both in its geographical 

 position and its consulting character (by which I mean both draw material 

 from a large rural community of about two millions of people) there 

 were eighty-eight cases among 7,907 medical admissions, or, in other 

 words, an incidence of 1 in 90. 



Etiological and Predisposing Factors. Climate, Race and Country. 

 It seems to be as prevalent in one country as another. The question has 

 naturally arisen : Does the distribution of Graves' disease run parallel to 

 that of goiter ? According to George Murray (fr) it is not more frequent in 

 the so-called goitrous districts of England, viz., Kent, Surrey, Wiltshire 

 and the Thames Valley. Dock (a), on the other hand, noted that in Michi- 

 gan, not only was simple goiter very common, occurring as it did in 10 per 

 cent of all young women, but exophthalmic goiter itself was very common 

 (32 cases among 4,000 admissions). Moffitt of California has noted that 

 it is more common on the shores of San Francisco Bay than in the other 

 counties of the state, but gives no comparative figures regarding simple 

 goiter. Albert Kocher (b) writes of his experience in Switzerland as fol- 

 lows : "It is just as frequent in goiter regions as elsewhere, with the differ- 

 ence, however, that many cases in the goiter-regions run a milder course, 

 partly because they come under observation earlier on account of the pres- 

 ence of ordinary goiter, and partly because goiter formation, inasmuch as 

 it reduces the quantity of functionating tissue and impairs the vascularity, 

 is antagonistic to thyrotoxicosis." 



Sex. Women are much more frequently affected than men : the ratio 

 is variously stated as 13, 8, 5 or 2 to 1 by the different authorities. The 

 higher incidence in the female is true in childhood as well as in later life 

 a contrast to cretinism which affects nearly as many males as females. To 

 account for the variation between the figures of 13 to 1 and 2 to 1, Mac- 

 kenzie (c) admits of a possible variation in the proportion of the disease 

 in the two sexes in different countries: thus according to Charcot the 

 disease in France was only a little less frequent in the male, and Eulen- 

 burg in Germany found the proportion of female to male as two to one: 

 in England, on the other hand, the proportion was much higher as illus- 

 trated by Mackenzie's own series in which there were only 45 males in a 

 series of 438 cases, and that of George Murray (e), whose series of 180 

 cases included only 10 males. Further it would seem that relatively more 

 male cases are seen in private practice than in hospital: Thus Buschan, 

 in a series of 980 cases collected from various sources, found 805 females 

 and 175 males a proportion of nine to two. Mackenzie also offers as a 



