described. Myxedema congenitum is attended, in addition to the symptoms described, with dwarfism, macroglossia, and idiocy.

Anatomic Alterations and Nature of the Disease.Deposition of mucinous substances in the skin has been described. Occasionally cellular proliferation also has been demonstrable. Both in the skin and in the various internal viscera obliterating

Pos

endarteritis has been encountered, in the liver and in the kidneys also interstitial connective-tissue hyperplasia. Tuberculous lesions have developed in the lungs with remarkable frequency. The alterations in the thyroid gland are of pre-eminent interest. In cases of both spontaneous and congenital myxedema the glandular tissue disappears, while the interstitial connective tissue increases progressively. It has been assumed, not without reason, that myxedema is the result of auto-intoxication dependent upon the deranged function of the thyroid gland. sibly the thyroid gland should abstract from the blood and disintegrate certain substances, which, if retained in the blood in consequence of disease of the thyroid gland, cause intoxication and give rise to myxedema. Accordingly, certain relations would exist between scleroderma, exophthalmic goiter, akromegaly, and tetany, which also are referred to disturbances in the functional activity of the thyroid gland. In favor of the thyroid origin of myxedema also are the development of myxedema after operative removal of the thyroid gland, and the cure of myxedema by administration of preparations of the gland.

Prognosis. Although in recent times thyroid extract has proved an efficient remedy in the treatment of myxedema, the disease remains a serious disorder, as recurrence generally takes place as soon as the administration of thyroid gland is suspended.

Treatment. Prophylactic measures are applicable in connection with operative attack upon the thyroid gland. Complete

removal of the gland should, whenever possible, be avoided. Treatment of myxedema with thyroid gland constitutes a specific measure, and the only one to be recommended. Thyroid tablets constitute the most convenient means of administration, being manufactured on a large scale and easily secured. Further, certain precautionary measures should be observed. In the first place, the tablets should not be prepared from decomposed thyroid tissue, and, besides, they should not be administered in too large amount, as they may then readily give rise to palpitation of the heart, vertigo, albuminuria, glycosuria, and excessive emaciation, symptoms that have been grouped together under the designation of thyroidism. It is, therefore, necessary to intermit from time to time the administration of thyroid preparations. Some clinicians prefer tablets of thyroiodin, which Baumann has separated as the active ingredient of thyroid tissue.

EXOPHTHALMIC GOITER.

Symptoms. The principal symptoms of exophthalmic goiter consist in palpitation of the heart,' goiter, exophthalmos, and tremor. Palpitation of the heart-tachycardia-is generally the symptom that first attracts the attention of the patient. At the beginning this often appears only after physical or mental exertion; but gradually it becomes persistent, and greatly annoys the patient in consequence of the distressing sense of pulsation in the chest, with which a sense of fear, constriction, and oppression becomes associated. The number of heart-beats is frequently increased from 60 to 80 to 120, and even much more, and the pulse occasionally can scarcely be counted. Often attacks occur, in the course of which the number of heart-beats is especially increased. At the same time the action of the heart is likely to be augmented. The chest-wall is, therefore, vigorously shaken by the cardiac impulse, a prominence gradually develops in the precordium, and the exaggerated activity of the heart is manifested by marked pulsation and throbbing of the carotids in the neck. Occasionally pulsation is visible in the palate, or palpable over the spleen or over the kidneys. Often dilatation and hypertrophy of the heart develop gradually. Systolic heart-murmurs also are not rarely audible. These are frequently of anemic or accidental origin, although occasionally a valvular lesion develops, most frequently insufficiency of the mitral valve. A cardiac-systolic arterial sound is frequently heard in the larger peripheral vessels. In the femoral artery a double sound has not rarely been observed.

In some instances the occurrence of palpitation of the heart has

It would seem preferable to employ the term "palpitation" to indicate the subjective perception of pulsation, and "tachycardia to indicate accelerated action of the heart. Either may be present without the other.-A. A. E.

been preceded by increase in the size of the thyroid gland, while in other instances the latter follows or appears simultaneously with the cardiac palpitation. As a rule, both lobes of the thyroid gland share in the increase in size. The enlargement depends especially upon an increase in the glandular tissue, but the goiter is frequently rich in blood-vessels, so that on palpation a continuous thrill, increased with each cardiac systole, can be felt, and can also be heard on auscultation.

Exophthalmic goiter will especially attract the attention of the friends of the patient if protrusion of the eyeballs or exophthalmos

FIG. 24.-Case of exophthalmic goiter in a male (Cohen and Eshner).

(almost always bilateral) develops. The eyes project more and more from the orbits, and at times to such a degree that the lids are no longer capable of wholly covering the eyeballs. The latter condition is not without danger to the eye, as the cornea may readily undergo desiccation, foreign bodies, especially bacteria from the air, may find lodgment upon it and are not removed by closure of the lids and the secretion of tears, and thus ulceration of the cornea readily results, and may be followed by loss of the eyeball. When the exophthalmos is marked the eyeball can be moved with difficulty, and insufficiency of the ocular muscles

develops. Convergence of the eyes, especially, cannot be maintained for any length of time. Advanced protrusion of the eyeballs causes marked disfigurement of the face. The patient acquires a surprised, frightened, and perplexed expression.

Occasionally the Graefe symptom is encountered, which consists in incongruity between the movements of the eyeball and the upper eyelid. If the patient be requested to fix his vision upon a finger held above his head, and to follow carefully the movements of the finger with the eyes, and the finger is suddenly displaced downward, the eye will follow more quickly than the upper lid, so that the latter remains behind the former. Stellwag's symptom consists in the faculty on the part of patients with exophthalmic goiter to keep the eyes open for a long time, without a sense of the need of frequent winking. The pupils occasionally are unequal, generally react well to light, and are at times unchanged in size, although at other times dilatation or contraction has been reported. Examination of the fundus has often disclosed pulsation of the retinal arteries.

The patients generally suffer from tremor, which is usually fine and rapid (from eight to nine and a half movements in the second).

Among the typical symptoms of exophthalmic goiter diminution in the electric resistance of the skin has recently been described, but this phenomenon is not directly related to the disease, but to the fact that sweating is generally profuse, and a moist skin is a better conductor for the electric

current.

Individuals with exophthalmic goiter are often pallid, blond, blue-eyed, and delicate persons, in whose temperament a neurotic element is generally discoverable. They are excitable, and not rarely complain of sleeplessness. Other nervous disturbances also are often present. Generally slight sweating occurs. Increased secretion of saliva and of urine also has been observed. Occasionally scleroderma, circumscribed alopecia, circumscribed cutaneous edema, urticaria, or articular swelling appears. Often attacks of profuse watery vomiting and alarming, profuse diarrhea, neuralgia, paralysis, and muscular atrophy also have been reported. Occasionally nuclear paralysis of a number of cerebral nerves occurs. Now and then myxedema or akromegaly has been superadded to exophthalmic goiter. Occasionally psychopathies have developed. At times exophthalmic goiter is complicated by glycosuria, or even by diabetes mellitus. In the majority of cases exophthalmic goiter pursues a chronic course. Often periods of remission and exacerbation alternate with each other. Aggravations occur with especial readiness after physical and mental exertion. The disease is generally unattended with fever. The principal danger consists in progressive exhaustion and in insufficiency of the heart-musele, with progressive general venous stasis.

Diagnosis. The recognition of exophthalmic goiter is easy if the typical symptoms are kept in mind. Nevertheless, similar conditions may occur in anemic individuals. In these, goiter may