The Thyroid Gland in Relation to “Toxic Goiter”

Abstract

THE term “toxic goiter” is used to include those clinical conditions variously classified as Graves' disease, Basedow's disease, thyrotoxicosis, hyper-thyroidism, dysthyroidism, exophthalmic goiter, toxic adenoma, etc. The prevailing tendency seems to be to recognize two presumably distinct and independent types of toxic goiter. For convenience these may be designated (a) exophthalmic goiter, and (b) toxic adenoma. Except for such differences as may be due to variations in intensity and duration of disease, we find it inconsistent with our personal experience to accept a fundamental distinction between these two supposedly definite, and, in some respects, diametrically opposed clinical entities. However, in deference to differences of opinion that may exist, the terms, “exophthalmic goiter” and “toxic adenoma” will be used in referring to the clinical state of patients, but not to the condition of the thyroid gland. We take the view that the clinical condition called “toxic goiter” does not originate as a disorder of the thyroid gland primarily. There are no facts that warrant ascribing to the thyroid the unique property of initiating its own pathological processes. The pathological changes found in the thyroid in toxic goiter are secondary; they are effects and not causes. These and other considerations render the theory of the thyrogenic origin of toxic goiter improbable. As an alternative we are willing to accept, at least tentatively, two essential factors of etiological importance: (a) a fundamental constitutional factor, the exact nature of which is unknown, capable of being affected by (b) a number of exciting or accessory factors of a more tangible or understandable nature. Among the latter may be mentioned various forms of psychic or traumatic shock; various infectious diseases (tuberculosis, tonsillitis, influenza, pneumonia, typhoid fever); various physiological states, such as puberty, pregnancy, and the menopause; overwork, worry, anxiety, and fear; possibly various endocrine and metabolic disorders, and possibly the administration of too much iodine. The constitutional factor mayor may not be specific; it is commonly referred to as “hereditary predisposition,” “instability of the nervous system,” “constitutional dyscrasia,” “autonomic imbalance,” etc.; the fact is, we know very little about it. The accessory factors are non-specific. The alternative conception of the etiology of toxic goiter appeals to us because it seems to harmonize with clinical experience and is not at all inconsistent with the pathological changes encountered in this disease.