sleading, as in some cases the enlargement of the
thyreoid, and in others the eye symptoms, are scarcely appreciable,
while the general symptoms are well marked. The term toxic goitre or
_hyperthyreoidism_, suggested by C. H. Mayo, is preferable, as the
manifestations of the disease depend upon excessive or abnormal action
of the thyreoid tissue.

[Illustration: FIG. 282.--Exophthalmic Goitre.]

The condition is chiefly met with in young adult women, and may
develop suddenly after a shock to the nervous system. The intoxication
affects the higher cerebral functions and causes nervousness,
irritability, and tremor; the cardiac and vaso-motor centres, causing
tachycardia and pallor of the skin; the sympathetic fibres to the eye,
causing protrusion of the eyeballs, staring of the eyes without
winking, narrowing of the palpebral fissure, dilatation of the pupil,
and lagging behind of the upper lid, and sometimes also of the lower
lid--von Graefe's symptom. There may be diarrhoea and vomiting, loss
of weight, and in the worst cases there is delirium at night. In
course of time there develops cardiac insufficiency with fibroid
degeneration of the myocardium. Coagulation of the blood is retarded,
and there is a marked diminution in the number of leucocytes,
especially the neutrophils, and an increase in the lymphocytes
(Kocher).

In the early stages the thyreoid is enlarged and pulsatile, and bruits
may be heard over it; later, these vascular symptoms disappear, and
only a firm, diffuse, uniform swelling implicating all parts of the
gland remains.

_Prognosis._--The tenure of life is uncertain as the patient offers
little resistance to intercurrent affections such as influenza and
pneumonia. If the average course of the disease is represented by a
curve, the greatest height is reached during the second half of the
first year and then descends. For the next two to four years it
fluctuates with occasional exacerbations of symptoms due to fright or
worry.

_Treatment._--Medical measures, along with the external application of
radium, the strict observance of rest in bed with the exclusion of all
forms of excitement and worry, the administration of bromides, heroin
or other sedatives, and of digitalis or other cardiac tonics, are to
be prescribed in the first instance, and in any case, as a desirable
preparation for operation.

_Operative measures_ consist in the _ligation_ of the vessels and
nerves at one or other pole o