396 NELSOK W. JANKEY 



of creatin probably takes place due to degenerative processes in muscle 

 due to loss of normal thyroid function. The lowered secretion of endogen- 

 ous-uric acid is probably compensatory in nature inasmuch as a normal 

 quantity of this important nuclear element cannot be synthetized in the 

 subthyroid state. It is probable that normal protoplasmic repair and 

 growth take place to some extent through intermediary products from 

 carbohydrates. The disturbances of carbohydrate metabolism appearing 

 in hypothyroidism may therefore be connected with the failure of normal 

 cellular nutrition. The adiposity of hypothyroidism may very possibly 

 be due to the diversion into fatty tissue, through synthesis, of products 

 of carbohydrate metabolism which normally would at least in part be- 

 come anabolized into protoplasmic components." 



Symptomatology 



Diversity of the Symptoms and Signs. That the thyroid is certainly 

 one of the most important endocrin organs maintaining cellular nutrition 

 has been emphasized by recent advances in knowledge of the chemistry, 

 histology, pathology and physiology of this gland. Injury to its function 

 may lead, therefore, to a very varied symptomatology as all tissues and 

 organs may become involved. One must, therefore, be prepared to en- 

 counter a number of apparently unrelated symptoms and signs of very 

 diverse distribution. In cretins, all organ groups may be affected. Many 

 physicians who were students of medicine one to two decades ago are 

 accustomed to regard cretinism and myxedema as the only forms of hypo- 

 thyroidism to be encountered. At this time, however, only typical hypo- 

 thyroid cases were usually recognized. The present day situation is, 

 however, materially changing. Refinements of diagnostic technic per- 

 mit us to detect hypothyroidism in many more instances than formerly. 

 All groups of organs apparently may not be equally affected. For example, 

 the skin and its appendages rarely escape though no demonstrable clinical 

 changes may be observed in the gastrointestinal tract in numerous in- 

 stances. If we are alive, however, to the manifold possibilities, many 

 more morbid manifestations will be correctly ascribed to hypothyroidism 

 than hitherto. 



Relative Frequency of the Clinical Types of Hypothyroidism. Cases 

 of hypothyroidism fall very roughly into three types, 1. Hypothyroidism 

 in the young, cretinism, 2. Hypothyroidism in adults, myxedema, 3. 

 Masked hypothyroidism. Although statistics are unobtainable, it is cer- 

 tain that the atypical or masked hypothyroid cases are much more com- 

 mon than cretinism or myxedema in their typical expression. It is very 

 likely that cretins of the sporadic type will gradually become less fre- 

 quently encountered in countries in which scientific medicine flourishes, 



