CLINICAL SYNDROMES 309 



lodin and Thyroid Extract. The prolonged use of iodin as well as of 

 thyroid extract has called forth the symptoms of hyperthyroidism in 

 some cases. Theodore Kocher (ft), in a long article entitled "lodbasedow," 

 states that Rilliet in 1860 first described exophthalmic goiter under the 

 name of "lodisme constitutionel." Kocher reports the case of a young 

 woman with a small goiter of years' duration, who developed symptoms 

 of hyperthyroidism following the use of iodin ointment. He believes it 

 is a common cause of the disease. There are many reports in the litera- 

 ture of cases of acute thyroid poisoning following the prolonged or ex- 

 cessive use of thyroid tablets for obesity or some other malady. These 

 cases have shown palpitation, tachycardia, tremor, nervousness, sweating 

 and a gastro-intestinal irritation, but never the exophthalmos or goiter. 



Pathogenesis. Pierre Marie (a.) has rightly said apropos of exoph- 

 thalmic goiter : "There are in pathogenesis as in therapy many theories 

 but little truth." 



Four theories have been advanced to explain the method of production 

 of the disease. The first two tne toxic and the infectious will receive 

 but scant consideration. 



The Toxic Theory presupposes a chemical alteration of the water 

 supply, as has been advanced by Marine and others before him for epi- 

 demic goiter. We have already pointed out the divergence of opinion 

 as to the relative geographical distribution of the epidemic or endemic 

 form of goiter and exophthalmic goiter. 



The Infectious Theory emphasizes an infection of the water supply 

 by Bacillus coli communis or even an auto-infection of the patient by the 

 normal or abnormal bacterial flora of the intestinal tract. McCarrison (e) 

 has made out a rather good case for this method of production of epidemic 

 goiter, but makes no direct suggestion as to its applicability to exophthal- 

 mic goiter. Neither theory is universally accepted, as the observations 

 forming the basis of both theories up to the present time lack confirmation. 

 In any event, as Williams asks, does the provocative agent act through the 

 medium of the sympathetic system or directly by a chemical action on the 

 thyroid gland ? 



The two main theories are the thyrogenic and the neurogenic, each of 

 which will be discussed at length. 



Thyrogenic Theory. This theory, though first outlined by Rehn in 

 1883, was elaborated by Moebius in 1886 into its present form. It was 

 soon accepted by Stewart and Gibson, Murray, and Mackenzie in Great 

 Britain, and by Mueller (a.) and Kocher on the Continent. 



It supposes an intoxication from a morbid or excessive p(roduc- 

 tion of the thyroid secretion, or, in Moebius' (&) own words, "Graves' 

 disease is an intoxication of the body by a morbid activity of the 

 thyroid gland." It has substantial support in many of the well estab- 

 lished clinical and experimental facts, among which are the following: 



