CLINICAL SYOT5EOMES 311 



unreasonable that the depressant condition of acute thyroiditis, acute 

 infectious fevers and shock could produce increased functional activity 

 of the thyroid. (7) Similar metabolic disturbances are present in both 

 hyperthyroid and hypothyroid conditions. (8) The blood picture of 

 exophthalmic goiter is practically identical with that of myxedema and 

 cretinism. 



Janney therefore advances the "hormone hypothesis" of thyroid tox- 

 emia and exophthalmic goiter. "If we then discard the hyperthyroid 

 theory we have but one remaining explanation 'dysfunction' of the 

 thyroid as the cause of exophthalmic goiter. " He considers that the 

 symptoms of the disease can be divided into two groups: (1) the toxic 

 symptoms; (2) the symptoms of thyroid deficiency. Under the former 

 he includes psychic stimulation, tremor, tachycardia, lability of the 

 sympathetic nervous system, loss of weight and nitrogen, increased basal 

 metabolism and tendency to rise in temperature. Under the symptoms of 

 thyroid deficiency Janney includes the goiter, the atrophy and pigmenta- 

 tion of the skin, scleroderma, brittleness and loss of hair, trophic nail 

 changes, abnormal deposition of the subcutaneous fat, imperfect ossifica- 

 tion and epiphyseal union, fatty degeneration of the heart and body 

 musculature, mononucleosis, delayed glucose assimilation, creatinuria, and 

 growth disturbances in youthful cases. 



The toxic symptoms are traced to the thyroid hormone itself and are 

 probably due to the development of toxic products of its metabolism. All 

 evidence tends to indicate that the thyroid hormone is a synthetic product 

 inorganic iodin and other substances possibly related to the indol- 

 containing amino-acid tryptophane. It is possible that one or more of 

 these intermediate substances is toxic and. even identical with the products 

 arising in the breakdown of the hormone in the body. 



According to this hypothesis there is, therefore, a toxic substance 

 present in the thyroid and blood of exophthalmic goiter patients, Janney 

 admits that, while it seems adequately to explain most of the facts in 

 view of our present knowledge, it too is lacking in proof. 



We also feel that the dysthyroidism hypothesis has come to stay and 

 that it is much the most rational explanation yet advanced of all the phe- 

 nomena of exophthalmic goiter. Yet it is not one generally accepted 

 by the medical profession and we have restricted the term to a group 

 of cases in which a disturbed function of the thyroid secretion is more in 

 evidence than symptoms of a purely hyperthyroid nature. 



The Neurogenic Theory. Long before the thyroid or the sympathetic 

 nervous system were emphasized, Geigel, according to Fitzgerald, assumed 

 lesions in the oculopupillary and vasomotor centers of the cervical cord 

 the former in a state of irritation and the latter in a state of paralysis. 

 Sattler, however, assumed a lesion of a circumscribed portion of the 

 vasomotor center or possibly a still more central portion of the brain, 



