The Evolution of Toxic Nodular Goiter

In 1913 Plummer differentiated exophthalmic goiter from toxic adenomatous goiter on the basis of clinical observations on 2,000 operated cases.1He recognized that the former might be superimposed on any stage of endemic goiter, with resultant problems in differential diagnosis that might be difficult to resolve on either clinical or pathological grounds.2That this problem is present 50 years later is clearly attested by literature relating to the treatment of hyperthyroidism with I131. In these writings the term toxic nodular goiter is often used to describe any case of hyperthyroidism occurring in a nodular gland as judged by the inclusion of patients with actual exophthalmos in this category.3,4Other authors use it in a more restricted sense to describe only non-Graves' hyperthyroidism.5 We describe two groups of patients without clinical features of Graves' disease (exophthalmic goiter) as toxic nodular goiter: first, those with a solitary nodule