BASEDOW S DISEASE 75 



dominance of the neutrophilic cells. Later there occurs a permanent altera- 

 tion of the hematopoietic apparatus, consisting in a hyperplasia of the 

 lymphatic apparatus. With this alteration stand in harmony the swelling 

 of the lymph-glands so often observed in Basedow's disease (Cowers), espe- 

 cially the swelling of the perithyroidal lymph-glands (Fr. Muller, Passler, 

 Kocher, and others}, and also the perivascular round-cell infiltration of the 

 typical Basedow struma, the hyperplasia of the rest of the lymphatic appa- 

 ratus (Fr. Muller and others), the tonsils, lingual papillae, intestinal follicles, 

 the hyperplasia of the spleen and the thymus gland (Bonnet, Gierke, Thor- 

 becke, v. Hansemann, Rossle, Hart). In severe acute cases, a distinct splenic 

 tumor can appear as an early symptom. Schlesinger, a short time ago, 

 reported such a case. Of late great practical significance has been ascribed 

 to the hyperplasia of the thymus. According to Capelle's statistics, 44 per 

 cent, of the cases of Basedow's disease that died of intercurrent diseases 

 showed a hyperplasia of the thymus, 82 per cent, of the cases that died of 

 Basedow's disease itself, and almost 100 per cent, of the Basedow's cases 

 that died on operation. In these cases it is questionable whether the thy- 

 mus hyperplasia is responsible for the death. Perhaps death was due more 

 to the status lymphaticus, perhaps more to the failure of the chromaffin 

 organs. I shall defer the consideration of the thymogenic Basedow's disease 

 until the discussion of the theory. 



Of the metabolic disturbances should be mentioned first of all the ema- 

 ciation, which is so important practically. A . Kocher found this in 88 per 

 cent, of the cases among his very large number. It is. present in the fully 

 developed form. It may set in very early and progress in a uniform 

 manner; in other cases it may increase in acute exacerbations that may 

 frequently be repeated (crises d' amaigrissement, Huchard). Almost regu- 

 larly such periods of increased emaciation are associated with the increase 

 of other Basedow's symptoms. In the fully developed forms 15-20 kilo- 

 grams may be lost in a few months. Even in the incomplete forms, a slight 

 grade of emaciation is absent relatively seldom. In the case of Basedow's 

 in which the emaciation is marked, there not infrequently develops a severe 

 grade of cachexia (cachexie thyreoidienne, Gauthier). In other patients 

 there may gradually set in a reversal of affairs, in which the loss may be more 

 or less rapidly made up. In rare cases, even obesity may develop. In the 

 great majority of cases the appetite is increased, especially at the beginning; 

 and there is often polyphagia. Of course, the increase of appetite often re- 

 mains behind the much greater requirements. Later the appetite often 

 becomes less. If vomiting or diarrheas are superadded, the body weight 

 rapidly falls. 



The cause of emaciation in spite of the increased appetite depends in 

 part on an increase of the caloric production through the thyroid secretion 

 produced in excess. Fr. v. Muller first pointed out that in spite of the abun- 



