HYPOTHYROIDISM 397 



for it is probable that they will be detected before their malady reaches 

 full development. The same holds true for myxedema. 



Acuteness and Chronicity of the Symptoms. Acute myxedema is a 

 medical curiosity. Such, however, appears to have been the unusual case 

 reported by Osier (c), which exhibited rapid development of great obesity, 

 swelling of the face and abdomen, followed by diarrhea, bloody stools', 

 tachycardia, collapse and death. Similar cases have been reported by 

 Anders which exhibit a mixture of hypothyroid and thyrotoxicosis symp- 

 toms. 



Usually hypo thy roidism is an eminently chronic disease. The morbid 

 changes develop so slowly and insidiously that at times neither the patient 

 nor his friends and relatives become alive to the situation until some un- 

 duly prominent symptom, such as stubborn obesity or weakness, causes 

 medical advice to be sought. 



The effect of the loss of thyroid function upon the growing individual 

 is frequently most serious. The thyroid plays a very important role in 

 controlling growth and development, a part not secondary to the pituitary. 

 The results, therefore, of even a slight injury to this gland in the young 

 individual are often severe. Retardation of growth is one of the earliest 

 and most important signs of hypothyroidism. In certain very light cases, 

 it would appear to be the only symptom. In the observation of hypo- 

 thyroidism in children, it becomes then necessary to make very exact 

 studies by observation of weight, measurements of the height and charting 

 the growth curve. The study of the bony changes has already been de*- 

 scribed in detail in a previous section. 



In two instances, the writer has noted in children an abnormal rate 

 of growth preceding the development of hypothyroidism and growth cessa- 

 tion. One child was accustomed to wear clothing two years above his 

 size before becoming subthyroid. ~No suggestion of pituitary disease 

 was present but these instances may be analogous to the overgrowth of 

 acromegaly before the development of the degenerative period. 



In the succeeding clinical description of hypothyroidism, there will 

 first be given the general description of fully developed hypothyroidism 

 in the young (cretinism) and in the adult (myxedema), then will follow 

 the special symptomatology beginning with local manifestations in the 

 thyroid gland itself. It will be observed that simple goiter, sporadically 

 occurring, for pathological reasons already developed, is regarded merely 

 as an early symptom of hypothyroidism rather than as a disease per se. 



Athyreosis (Thyroaplasia) . Well authenticated cases of congenital 

 absence of the thyroid gland are extremely rare and depend on their 

 recognition on the histo-pathologic findings (see Pathology of Hypothy- 

 roidism) as little reliance can be put upon palpation (Bircher, Ewald, etc.). 

 About a dozen authenticated cases are on record. Clinically the appear- 

 ance is that of grave cretinism beginning at or shortly after birth. The 



