CLINICAL SYNDROMES 351 



nor Theodore Kocher (g) was able to find any tendency to chlorosis in 

 their cases. Plummer (e)' found from a study of 578 cases of Graves' dis- 

 ease that the percentage of hemoglobin averaged 83.1 and the number of 

 red cells 4,790,000 per cubic millimeter figures within the normal limits 

 or at least not to be considered indicative of a chlorosis. No doubt %> 

 mild secondary anemia may occasionally occur. 



Leukocytes. There is a general impression that there is a leukopenia 

 in exophthalmic goiter. However this is not the rule, as Plummer's 

 average leukocyte count for his 578 cases, 6,973.5 per cu. mm., shows; 

 this is a low but normal figure. According to Naegelsbach it was Cuiffini 

 who, in 1906, was the first to note a peculiar leukocytic formula in hyper- 

 thyroidism. This has received ample confirmation by many clinicians. 

 There is first a relative or even an absolute increase in the lymphocytes 

 which sometimes amount to from 35 to 60 per cent of the white cells. 

 The large mononuclear cells may also be increased and form 6 to 8 per 

 cent. There is a corresponding neutrophilic leukopenia, sometimes, accord- 

 ing to Albert Kocher, to such an extent that the polynuclear neutrophils 

 may be actually fewer than the lymphocytes and large mononuclears. 

 While usually the eosinophils are diminished in number, there is occa- 

 sionally an eosinophilia, an evidence, according to Eppinger and Hess (&), 

 of irritation of the parasympathetic nerves. In rare cases two to three 

 per cent of myelocytes have been noted. Reckzeh suggests from his ex- 

 perimental work in dogs that the relative lymphocytosis and leucopenia 

 indicate a bone-marrow injury resembling that in the toxic experimental 

 anemia. Salis and Vogel found that a short course of iodin-therapy in 

 typical cases of Graves' disease caused a disappearance of this lympho- 

 cytosis, while a prolonged course of the same drug caused a return 

 of the lymphocytosis to a point higher than formerly. The exact sig- 

 nificance of this observation is questionable, to say the least. Plummer 

 believes that this change in the leukocytic formula is due to two more or 

 less independent variables, one which causes the lymphocytosis, namely 

 the hyperplasia of the lymphoid tissues; the other which influences the 

 neutrophils a fluctuating abnormal distribution of the polynuclear 

 neutrophils in the vascular tree. Barker (b) states that recent studies point 

 to the status thymico-lymphaticus as responsible for the lymphocytosis. 

 Klose maintains that the thyroid intoxication leads to a hypogenitalismus 

 which, in turn, causes the status thymico-lymphaticus with its lympho- 

 cytosis. Albert Kocher insists that the lymphocytic increase is propor- 

 tional to the severity of the disease, but that it is sometimes absent in 

 severe cases, when the prognosis is serious ; in the stage of improvement 

 the differential picture returns to nearer normal. In Plummer's opinion, 

 however, there is nothing to show that the degree of lymphocytosis is 

 correlated in any way with the duration of the symptoms of Graves' 

 disease. Naegelsbach further admits that the degree of lymphocytosis 



