306 0. P. HOWAKD 



further explanation of this discrepancy, that on account of their com- 

 parative rarity, male cases are more frequently reported than the female. 

 None of these objections can be offered to the figures from the Mayo 

 clinic, which show that among 2,928 cases of exophthalmic goiter, 85 per 

 cent were women and 15 per cent were men a ratio among hospital cases 

 of about 5.6 to 1 a proportion which should stand for the United States, 

 at least, as approximately correct. 



Age. Most are agreed that the age of greatest susceptibility lies be- 

 tween the sixteenth and fortieth years that is to say, between puberty and 

 the menopause. Cases in childhood have been reported, even as early as 

 two and a half years. Lewis reported in a series of 1,512 cases from the 

 Mayo clinic, five cases under ten years of age, all of the patients being 

 girls. In Buschan's series of 495 cases, 15 were under ten years and 31 

 over fifty years of age. Charcot (fr) saw a case at sixty years. At all 

 events it is very rare after the fiftieth year, and when reported it has 

 usually been in the male sex, though Barker (6) speaks of having seen it 

 in a woman over sixty. 



Heredity. A predisposition seems to exist in certain families, and 

 one can speak of a thyroid diathesis. Buschan reports a large series of 

 cases with this familial tendency. Mackenzie (c), too, elicited a history of 

 familial predisposition in 44 of his series of 438 cases. Oesterreicher 

 reports a remarkable family; the mother, who was hysterical, had ten 

 children, eight of whom were the subject of exophthalmic goiter, and one 

 of these had three children with the same disease. In Kosenberg's series 

 there were a grandmother, father, two aunts, and two sisters affected. 

 Moss also reports a patient with Graves' disease whose mother and sister 

 were similarly affected. Thus the disease sometimes affects several mem- 

 bers of the same family or it may occur in successive generations. But 

 what even better still illustrates the "thyroid diathesis" is the occasional 

 incidence of exophthalmic goiter and myxedema in the same family: 

 thus Arthur Maude reports the case of a myxedematous woman with a 

 son and a daughter affected with Graves' disease, and Oppenheimer the 

 cases of two sisters, one with myxedema and the other with Graves'. 



Obesity and the various neuroses are thought by the French clinicians 

 to ho more frequent in the families of patients with exophthalmic goiter 

 than is normal. 



Swan (a ) was struck with the frequency in the history of his fifty cases 

 of exophthalmic goiter, of heart disease, nephritis, tuberculosis and carci- 

 noma ; he suggests that the children of such parents are started in life 

 with a constitution holow par and with the passing of the years various 

 disturbances arc followed by the devolopnient of exophthalmic goiter. 



llabiis nnd Occupation. The excessive use of tea, coffee, tobacco or 

 alcohol plays no role in the predisposition to the disease, according to Swan 

 and others who have studied this question. While occupation is no 





