352 C. P. HOWAKD 



does not indicate the severity of the disease; he, however, noted that 

 strumectomy resulted in a diminution of the lymphocytosis as well as an 

 improvement in the other symptoms. Finally it is believed by careful 

 students of, the endocrin glands that the relative mononucleosis is not 

 distinctive of hyperthyroidism but is common to all forms of hyperactivity 

 of the internal secretions. 



Viscosity. The viscosity of the blood is usually lowered so that the 

 coagulation time is delayed according to Fr. Mueller and the Kochers. 

 Further, Crotti as well as others found that the blood shows a diminished 

 coagulability in Graves' disease in contrast to the materially increased 

 coagulability in myxedema. This is due, according to Kottmann (quoted 

 by Crotti), to the increase of the antithrombin content of the blood. 

 Kocher believes that this contrast in the coagulation time of hyperthyroid- 

 ism and hypothyroidism serves as an excellent differential diagnostic symp- 

 tom in doubtful cases. 



Hemorrhages. Occasionally according to von Leube there is a pro- 

 nounced inclination to hemorrhage from the various mucous surfaces in 

 the form of epistaxis, hematemesis, hemoptysis, and melena. Purpura has 

 been mentioned under the cutaneous manifestations. 



Lymphatic Glands. The lymphatic glands of the neck are always 

 found enlarged at the operation on exophthalmic goiter. In many cases 

 the cervical glands are palpable clinically as was first noted by Gowers; 

 they are not as a rule tender. In a small proportion of cases the axillary 

 and inguinal glands are also enlarged, and in very rare cases all the 

 superficial glands have been perceptibly increased in size. 



The Spleen. Stewart and Gibson have reported the occasional en- 

 largement of the spleen in exophthalmic goiter, though sometimes, as in 

 one of their own cases, there was a history of previous attacks of malaria. 

 A palpable spleen, however, is not difficult to explain as a part of the 

 general lymphoid hyperplasia that is so frequent in this syndrome. 



The Thymus is rarely found clinically enlarged in spite of the fre- 

 quency of post-mortem findings, which have been discussed by us elsewhere. 

 Nevertheless Becbe (&) states that he found a clinical enlargement of the 

 thymus gland in 35 per cent of his cases. Careful percussion of the retro- 

 sternal region and a skiagram should be made in every case. 



Complications 



Some of these have already been considered under the symptomatology 

 as unusual symptoms of exophthalmic goiter rather than complications. 

 As far as possible repetition will be avoided. 



In Endocrin Glands. Myxedema is more usually a sequel and not 

 a complication ; however, sometimes the symptoms of the two diseases run 



