9O THE DISEASES OF THE THYROID GLAND 



cold (can scarcely warm herself), skin dry and cold, mental sluggishness, constipation. 

 For several months thyroid medication. The skin again became moist, cardiac manifesta- 

 tions, tachycardia, and arrhythmia again appeared, the patient was excited, the consti- 

 pation disappeared. Body weight decreased. When the thyroid medication was discon- 

 tinued, the weight increased again and the myxedematous symptoms reappeared. Since 

 that time, periods of thyroid administration were many times introduced, and regularly 

 after the use of only two to three tablets a day for a short time Basedow's manifestations 

 appeared. At present, after a three weeks' thyroid treatment, there is a slight tachycardia 

 and especially marked arrhythmia. The heart is dilated, the pulse is poorly filled, the 

 skin is moist, there are stary eyes and a very slight fine-waved tremor. 



Later, in the chapter on myxedema, I shall cite similar cases. The 

 slight tolerance toward thyroid preparations is in this case certainly re- 

 markable, as high tolerance is characteristic for typical cases of myxedema. 

 To my mind there is in this case no necessary basis for the assumption of a 

 dysthyrosis. It is well known that a degenerated heart muscle is extra- 

 ordinarily sensitive toward thyroidin. It can very well be conjectured that 

 a slight excess of thyroidin would already damage the .heart muscle, if the 

 myxedematous symptoms have not as yet altogether disappeared. Finally, 

 it remains to be investigated whether in similar cases the myxedematous 

 swellings of the skin are always dependent exclusively on the thyroid glandu- 

 lar insufficiency. Much speaks for the fact, as above indicated, that in 

 such cases frequently also other ductless glands are degenerated. Especially 

 frequently there occurs a simultaneous affection of thyroid and hypophysis. 

 As is known, there is found an insufficiency of the pituitary gland, alterations 

 of the skin and trophic disturbances that are similar to those of myxedema. 

 In many Basedow's cases with myxedematoid symptoms, and in cases of 

 myxedema that react to thyroid treatment with only partial improvement 

 and that may even show signs of hyperthyroidism rapidly, it is quite prob- 

 able that these myxedematoid manifestations depend on a hypophysial in- 

 sufficiency (see also the chapter on the hypophysis). 



Many authors are disposed to ascribe to thymus hyperplasia an important 

 role in the pathogenesis of Basedow's disease. Already v. Hansemann was 

 of the opinion that the cases of "thymus Basedow" could be distinguished 

 also clinically. Hart refers the cardiac manifestations in Basedow's disease 

 to the thymus hyperplasia alone and sees in such cases thyroid hyperplasia 

 as something secondary. On the other hand, Gebele regards the enlargement 

 of the thymus gland as a compensating process that serves to weaken the 

 hyperthyroidism. Especially worthy of notice are the reports of Garre and of 

 Capelle and Bayer, concerning the extirpation of the thymus gland in Base- 

 dow's disease. In the case of Capelle and Bayer, thymectomy seemed to have 

 no influence on the struma, the exophthalmus, or the bulbar symptoms, but 

 the cardiac symptoms seemed to improve. After some weeks the mononu- 

 cleosis had disappeared. Gebele, however, does not regard the thymus in 

 this case as enlarged, and points out that five months after the thymectomy 



