358 C. P. HOWAKD 



Diagnosis of Exophthalmic Goiter 



The diagnosis of a typical case of exophthalmic goiter is one of the 

 simplest in clinical medicine. The classical symptoms of tremor, tachy- 

 cardia, vascular struma and exophthalmos can be recognized by even a ju- 

 nior medical student, On the other hand, the atypical cases with slight 

 tachycardia and mild nervous disturbances are usually overlooked, because 

 a careful examination is not made. It would perhaps not be out of place to 

 discuss at this point what one would include under the term "exophthalmic 

 goiter." Should all toxic hyperplastic goiters be included? Plummer (a) 

 (&) answers this in the affirmative, though he admits the possible existence 

 of a small group of cases which should not. It is quite possible that exoph- 

 thalmos may occur with a non-hyper plastic toxic goiter, but if so, it is so 

 rare that it may be considered accidental. We have accepted the position of 

 Plummer, who believes exophthalmic goiter is a definite clinical complex al- 

 ways associated with hyperplasia of the thyroid and sharply distinguished 

 from the constitutional state that may develop with rion-hyperplastic goiter. 

 Both conditions are covered by the term "thyrotoxicosis" but each is usual- 

 ly distinguishable from the other. However, as mentioned before, Plum- 

 mer has also emphasized his belief that an individual of twenty-two years of 

 ago with an adenoma of the thyroid has a definite chance of developing 

 during his thirty-sixth year a train of symptoms, so similar to the 

 symptom-complex associated with the hyperplastic thyroid of exophthal- 

 mic goiter that the best trained diagnosticians are constantly confusing 

 the two conditions. Apart from the chronicity of the course this group is 

 further characterized by the relative absence of acute toxic symptoms as 

 diarrhea, tachycardia, etc., the absence of exophthalmos and the slow 

 development of symptoms of chronic cardiovascular disease. 



Barker (a) recommends that the average practitioner consider the pos- 

 sibility of hyperthyroidism in every case in which he meets (1) tachycardia, 

 (2) rapid emaciation, (3) excessive sweating, (4) persistent watery diar- 

 rhea without apparent cause, (5) the neurasthenic state, (6) outspoken 

 lymphocytosis, (7) one or more of the ocular signs, and (8) fine tremor. 



If tho tachycardia does not subside with rest, if there is no ordinary 

 heart lesion, and if there is a characteristic tremor with Stellwag's and 

 Moebius' signs, emaciation, increased perspiration, insomnia and dyspnea 

 on slight exertion, the diagnosis should be made without difficulty. That 

 astute diagnostician, Pierre Marie (7;), as long ago as 1883 wrote: "Each 

 time one finds a permanent tachycardia and tremor without notable in- 

 crease of temperature think of Basedow's disease: its existence will always 

 be confirmed by tho presence of one or several symptoms diarrhea, gen- 

 eralized or localized sweating, bulimia, etc.' 7 The goiter, especially in 

 goiter-districts, is not in itself a diagnostic sign except in the presence of 



