HYPOTHYKOIDISM 417 



muscle tone. Shoulders and hips are heavy and thick, the musculature 

 being hidden in fat and myxedematous skin. 



The bone changes more properly belong to section on pathology. The 

 changes are those of underdevelopment and imperfect nutrition. As re- 

 gards general features, scoliosis and lordosis of the vertebrae are frequent. 

 Genu valgum and pes planus may occur. Mechanical apparatus may be 

 applied to remedy these defects without knowledge of the underlying 

 hypothyroidism. The writer has observed flat-foot so often in subthyroid 

 individuals that he regards it as a not uncommon symptom of this disease. 

 It is aggravated by the obesity of such patients. Hertoghe lays great 

 stress on the crackling sensation (like snow) elicited by palpation of the 

 flexing knee-joint. Perhaps this sign would be observed more often did 

 we seek it. The relation of fractures to thyroid disease is of much interest. 

 On empirical grounds, thyroid substances have been administered and 

 are at times apparently successful in aiding union of ununited fractures. 

 It is likely that defective thyroid function plays quite a part in such cases 

 for the secretion of the thyroid is essential in the regeneration of tissue. 



The ligaments are affected as a part of the general state of malnutri- 

 tion. They tend to become lax, explaining the aching palms and soles of 

 hypothyroid patients. Contractions of the palmar fascia and tendinous 

 shortening have been reported by Levi et al. and are said to be relieved 

 by thyroid therapy. Spacing between the great and second toes is com- 

 mon. 



The muscles, being the seat of active metabolic processes, suffer par- 

 ticularly severely. They lose their normal contour and tonus, becoming 

 obscured by fat and myxedema. Muscular fatigability and weakness are 

 among the very earliest signs of hypothyroidism. Women complain of 

 the inability to put up their hair. Industrial workers whose occupations 

 require many repetitions of the same movements, such as weaving, become 

 quite early unfit for work. A country woman shown me by Henry Plum- 

 mer complained of being unable to milk her cow. Stumbling is common. 

 The gait is neatly described by George Dock as "like that of a person stiff 

 from over-exertion." Sudden cramp-like contractions of the muscles may 

 occur, Chvostek's phenomenon may be present, also sudden dropping of 

 the hand and unexpected giving away of the legs. Severely affected cretins 

 cannot stand or walk. 



Evidence is beginning to accumulate connecting the chronic myopa- 

 thies with disorders of the endocrin glands including the thyroid. Thus, 

 progressive muscular dystrophy according to recent studies is probably to 

 be regarded as of endocrin origin. (Timme; Janney, Goodhart and 

 Isaacson ; McCrudden and Sargent.) Though various ductless glands may 

 be affected, certain evidence points to the thyroid in certain cases. Sev- 

 eral of the writer's series showed, in addition to the myopathy, the bone 

 and metabolism changes characteristic of hypothyroidism, including 



