424 NELSON W. JANKEY 



is normal and the hypothyroid manifestations in the hair, skin and other 

 organs are lacking. The X-ray makes clear the ossification changes pecu- 

 liar to this disease. Congenital idiocy may exhibit amentia resembling 

 advanced cretinism but examination will disclose spasticity, paraplegia or 

 monoplegias, and disturbances of reflexes, the characteristic stigmata of 

 hypothyroid ism being absent. 



Differential Diagnosis in Adults. Fully developed myxedema, like 

 cretinism, is unlikely to be confused with other maladies. On account of 

 the pasty complexion, facial swelling particularly when limited to beneath 

 the eyes, the cachexia and anemia, there is a superficial resemblance to 

 nephritis with edema. Presence of albumin in the urine, also moderate 

 number of casts, is not conclusive evidence of a renal condition, as such 

 urinary findings are not uncommon in myxedema. Even mental dullness 

 may be present if uremia threatens. A careful history, physical examina- 

 tion and a chemical study of the blood should, however, preclude any error. 



Falta mentions the possibility of persistent erysipeloid or indurative 

 syphilitic edema, also pacliy derma being mistaken for myxedema. Rarely 

 cachectic diseases and anemias have been confused with myxedema by 

 superficial observers. 



The pains in joints and muscles, heaviness and inhibition of the move- 

 ments of the extremities resemble chronic rheumatism, as Kocher first 

 pointed out. In differentiating between a rheumatoid condition due to 

 inadequate thyroid function and chronic types of articular rheumatism, 

 the therapeutic test is not always of diagnostic service as Rothschild and 

 Levi found a large percentage of the latter cases benefited by thyroid 

 treatment, probably indirectly through increasing resistance. 



Gastro-intestinal conditions may be the cause of confusion with sub- 

 thyroidisin. The gastroenterologist is occasionally consulted by hypo- 

 thyroid individuals complaining of loss of appetite, gastric indigestion, 

 constipation and dragging sensations in abdomen (due to fat, relaxed 

 musculature, and cecal fermentation), these symptoms being so thrust into 

 the foreground that an enthusiastic specialist may fail to detect the latent 

 signs of hypothyroidism. The prompt improvement of the gastro-intesti- 

 nal symptoms on thyroid therapy in myxedema is a sufficient proof of 

 then- thyrogenie origin. A case in my series had been treated for colitis 

 with toxemia for many years. The slow pulse, chilliness, slight myxedemic 

 expression aitd vague psychic symptoms found to be present suggested 

 hypothyroidism which was confirmed by the additional evidence of mono- 

 nucleosis, lymphocytosis in the blood formula and a basal metabolism of 

 minus 20. A carefully controlled exhibition of thyroid extract led to a 

 complete recovery of the intestinal function as well.' 



Psychoses. The mental symptoms may rather frequently be the pre- 

 senting and may occasionally lead to a wrong diagnosis. The indefinite- 

 ness ot the suhthyroid psychoses in combination with evident signs of hypo- 



