and feet are enlarged with cushion-like swellings on their dorsal surfaces; the digits are thick and clumsy. The scrotum is often much thickened. The epidermal structures are greatly affected. The skin is dry, harsh, and branny. The hair becomes dry and scanty on all portions of the head and body. The nails are dry, fragile, striated, atrophic. Perspiration and sebaceous secretions are defective. The mucous mem branes, wherever visible, are tumefied, pale, dry, and elastic. Mucous polypi in the nasopharynx are not uncommon. The tongue is thickened and, with the infiltrated condition of the buccal, pharyngeal, and laryngeal mucous membranes, explains the muffled voice and difficulty of swallowing.

The intellectual state in myxedema is uniformly marked by apathetic enfeeblement, and cerebral torpor shows itself in sluggish mentation, defective memory, slow speech, and lethargic movements. Myxedemic patients are usually indolent both mentally and physically, and are irritable and somnolent. Some cases show nocturnal insomnia and are troubled by disturbing dreams. The sluggishness of movement and the clumsiness of the hands and feet are due to the cerebral torpor and the local thickenings. These patients have no muscular energy and are promptly fatigued on the slightest continuous effort, but there is no palsy.

The thyroid in the great majority of cases can not be detected by palpation. There may be a history of its former presence or actual

enlargement, and even a goitrous condition may persist. In rare instances exophthalmic goiter has preceded myxedema and they have also been found associated.

Less prominent and constant conditions in myxedema are: cardiac weakness, irregular pulse, hemorrhages (especially metrorrhagia), a subnormal temperature, loss of teeth, habitual constipation, and occasionally albuminuria in advanced cases. The patients complain of headaches, vertigo, throbbing in the ears, and particularly and almost constantly of a sensation of cold. Sensations objectively, motor conditions, and the reflexes are normal.

Usually insidious in onset, the disease runs a slow, tardy, progressive course. Remissions of longer or shorter duration may occur, as in summer, or by removal to a warm climate, and pregnancy sometimes has a similar retarding effect. The general tendency is toward cachectic helplessness and death by marasmus. In the very last stages the tumefaction may disappear. Pulmonary complications, especially tuberculosis, are common, and cardiac asthenia may strike the final note. Fortunately, treatment is now equal to the requirements of these otherwise hopeless cases.

Operative myxedema is usually the result of the total extirpation of the thyroid, which it follows in from three to six months. Removal of a part of the thyroid, the remainder being completely disabled,—by cystic disease, for instance,-results in myxedema. This is initiated by lassitude, physical enfeeblement, sensations of cold, heaviness in the limbs, sluggish and clumsy movements. Shortly the integument tumefies and becomes discolored, the hair falls, and cutaneous functions lag. The cerebral torpor follows and myxedema is fully established. The course is usually progressive, but is more subject to remissions than in the spontaneous variety. Other cases improve, owing to the compensatory action of unremoved portions of the gland, or to the development of accessory thyroids, or through the vicarious activity of other hematopoietic structures. The gravity of operative myxedema is great in proportion as the patient is young. Occurring in childhood, or at any period before adult life, it retards or completely checks growth, and produces a persistent infantilism or a myxedematous idiocy. It is, however, completely amenable to the thyroid treatment.

Congenital myxedema, myxedematous idiocy, or sporadic cretinism is usually first noticed at about one year of age, or upon weaning, and thereafter presents all the characteristics of adult myxedema, excepting that the mental faculties never develop and physical growth is retarded to the last degree. It is frequently congenital, and Horsley has found it in a dead-born fetus. It is encountered in the offspring of degenerate, alcoholic, or phthisical parents. At twenty years of age these cretinoid idiots may be of little more than two feet of stature. The relatively normal size of the head contrasts with the dwarfish body. The skull is full behind, contracted and narrow in front, often with persisting fontanel. The flabby, thickened features; snubbed nose, thick lips, drooping eyelids, mouth agap, lolling, hypertrophic tongue, and drooling saliva make up a peculiarly repulsive

appearance. Add, now, the short, often lipomatous, neck; a protuberant abdomen, often showing inguinal and umbilical ruptures; a deviating spine, rudimentary genitals, and dwarfish, crooked limbs, and it is impossible to imagine a less human-looking object with human attributes. Sparse hair, eczema, and an infiltrated, inactive skin are commonly present. The thyroid is absent. Idiots mentally, they can ordinarily exercise a little attention and even show some affection. In some instances they assist themselves in eating and dressing. They never learn to speak, and never show signs of pubescence. Often even the first dentition is extremely defective. On the other hand, they lack the destructiveness, noisiness, ties, convulsions, onanism, balancing and motor disturbances so common in idiocy from cerebral lesion.

These

unfortunate creatures may attain thirty or forty years of age, and usually die of pulmonary concomitants.

The disease is also amenable in some degree to the thyroid treat

ment.

Cretinism is a term of ancient lineage and honored usage, but of somewhat uncertain definition. It has been applied to the goitrous and feeble-minded natives of localities where goiter is endemic. Certain valleys in France, Spain, Italy, and Switzerland, and some parts of Great Britain, Sweden, and of other countries widely scattered over the globe present endemic conditions that predispose to goitrous enlargements. Such an endemic has been noted in Minnesota and Ontario. A few definite facts are the results of observations extending over generations in some of these communities. The offspring of two goitrous parents, according to Kocher, is invariably a

cretin, who may or may not be goitrous, but is myxedematous. A non-goitrous cretin invariably has goitrous antecedents and is indistinguishable from the myxedematous idiot or sporadic cretin, the condition also being congenital. In the goitrous cretins the thyroid disease may appear at any period of life, and acts then, exactly as does spontaneous myxedema or operative myxedema, to stunt growth and stop mental development. The goitrous cretin is usually also myxedematous and may present any degree of mental impairment, from mere simplemindedness to abject brutishness. The distribution of endemic cretinism. is identical with that of endemic goitrous disease, and Kocher believes this to be due to organic infections through the water-supplies.

The only distinction between endemic cretins and other myxedemic patients is the goitrous enlarge

ment. This may be only a difference of degree, because the cystic degeneration and interstitial hypertrophy at the bottom of the goitrous enlargement of the thyroid is destructive in character and effect. It is easily conceivable that myxedema and mental disturbances will be developed proportionately to the lack of functionally active thyroid. When the thyroid is entirely wanting, as in the non-goitrous congenital cretin, or completely destroyed in some goitrous cretins, the myxedema is correspondingly intense and the mental degeneration proportionately developed. It would seem, therefore, that the causes at the bottom of endemic cretinism are those that produce endemic goitrous disease, to which the cretinoid state is secondary. These are not well understood, but usually the soil, drinking-water, and atmospheric condition are incriminated.

Infantilism and Myxedematous Retardation.-Occupying a middle ground between myxedematous idiocy and acquired myxedema there are numerous cases showing slight cutaneous tumefaction, retarded mental development, and diminished growth. These patients retain their childishness both in mental attributes and physical conformation. Perhaps here belong some of the idiots classed as Mongolian by the English, and some of the enfants ariearré of the French. In at least one well-marked instance Brissaud found the thyroid body scarcely perceptible. At the age of ten numerous and large cervical glands had been removed with probable resulting damage to the thyroid.

Thereafter the physical, genital, and mental growth of the lad had remained stationary. Schmidt 1 has treated three cases of this sort in which growth was retarded, by the administration of thyroids, with immediate improvement.

Etiology. If we look upon myxedema as the manifestation of defective thyroidation, its causes are those of disease or absence of the thyroid body. In some cases it is a teratological defect; in others it is the result of a thyroiditis which may be dependent on infectious processes,

as the infectious fevers, rheumatism, etc.; in others it is cystic degeneration; in others the result of trauma or surgical extirpation. Taking all causes of myxedema together, there is a preponderance of females which reaches large proportions in the spontaneous adult varieties. It is probable that the close relation of the thyroid with uterine functions is at the bottom of this fact. It is only necessary to mention the increased size of the thyroid in pregnancy, its frequent enlargement in pubescent girls, its usual congestion in some women during menstruation, and its final retraction at the menopause. Erysipelas of the neck and head and syphilis of the thyroid gland have induced myxedema.

Regarding the manner in which defective thyroidation affects the trophic apparatus and induces the mucoid deposits, two general points of view depending upon opposite physiological hypotheses are maintained. As yet all is theory. Many, with Schiff, believe that the normal thyroid elaborates some substance indispensable to the proper action of the nervous system. This substance, however, has never been isolated nor its characteristics determined. Others, with Horsley, conceive that the thyroid transforms the mucinoid elements of the blood into utilizable metabolic constituents, or, as a modification of this idea, that the thyroid eliminates certain harmful elements from the blood. The blood in myxedema is poor in oxygen and the urine is of an increased toxicity. Both of these conditions are favorably modified, as is the myxedematous state, by the administration of thyroids. It is determined that the thyroid gland is essential to life and to the proper neurotrophic balance.

Fig. 195.-Myxedematous infantilism, youth nineteen years old (Brissaud).

Morbid Anatomy.-The primal lesion of myxedema is located in the thyroid. In myxedematous idiocy the gland is either wanting, rudimentary, or atrophic. In acquired myxedema it is atrophic, yellowish At first there appears to be an embryonal vesicular

1 "Therapeutische Wochen.," Nov., 1896.