310 0. P. HOWAED 







(1) The tontrast presented by exophthalmic goiter (hyperthyroidism) 

 and myxedema (hypothyroidism). (2) The results of grafting or of 

 feeding with thyroid gland or, better still, by the exhibition of thyroid 

 preparations. (3) The result of thyroidectomy in relieving the symp- 

 toms of Graves' disease. (4) The occasional recovery from exophthal- 

 mic goiter and the sequence of myxedema. (5) The microscopic evi- 

 dence of pathological changes in the gland. (6) The coincidence of 

 the first clinical symptoms with the swelling of the gland. 



This theory is strongly supported by Murray (&) who, however, admits 

 that "it is quite possible and indeed probable that the secretion is not 

 only increased in quantity but also altered in character. 77 Dysthyroidism 

 or intoxication by an altered secretion had been previously suggested by 

 Oswald and Minnich. This, Murray admits, can only be proven when 

 more is known of the normal secretion of the thyroid and its physiological 

 action. 



However, to return to the hyperthyroid theory proper, if we consider 

 that the exhibition of thyroid extract never produces all the symptoms in 

 fact, not even the cardinal ones of Graves' disease, and that the anatomical 

 changes in the thyroid of Graves' disease render hyperplasia of the 

 tissues probable only after the onset of the disease, and are followed 

 later by a qualitatively altered activity of the gland, the assumption of a 

 simple quantitative hyperfunctiori of the thyroid gland as the cause of 

 the symptom-complex of Graves' disease cannot be upheld. Therefore, 

 von Lcube thinks of a toxin which is developed by a qualitative activity 

 of the gland and which, introduced into the blood stream from the thyroid, 

 would cause an intoxication, especially of the nervous system. However, 

 so long as we have no positive knowledge regarding the physiological 

 significance of the activity of tfie thyroid gland and are not able experi- 

 mentally to obtain any insight into the action of the toxin of Graves' 

 disc-use, nothing remains for the present but to abandon a positive opinion 

 regarding the pathoo'enesis of exophthalmic goiter. 



Janney (b) believes that a survey of the evidence that exophthalmic 

 goiter is due to In/ perf unction of the thyroid gland renders the acceptance 

 of this view very difficult. He advances the following objections: (1) 

 There is no apparent need for the increased activity as is usually the case 

 wlicn an increase in functional activity occurs. (2) There were present a 

 considerable number of toxic non-hyperplastic cases in the large series re- 

 ported by Wilson and Plumrner from the Mayo Clinic. (3) Even the 

 typical exophthalmic goiter contains but one-fiftieth to one-twentieth of 

 the total active x-iodin present in normal thyroids, according to Kendall 

 and Wilson. (4) Exophthalmic goiter is not infrequently found in 

 families having hyperthyroid members and the combination of the two 

 has been frequently observed in the same person. (5) Cases of exoph- 

 thalmic goiter without tumor are not so very uncommon. (6) It seems 



