HYPOTHYROIDISM 439 



the discovery of a cervical rib makes a secondary general neurosis not 

 unlikely. The pain in the neck and shoulder is accounted for by the 

 presence of the rudimentary cervical rib. The possibility of a chronic 

 colitis with intestinal toxemia was eliminated by the negative results of the 

 Schmidt dietary regime. The height, gracile hands, fat and hair distribu- 

 tion suggest the possibility of dyspituitarism or ovarian dystrophy, which 

 might also account for the decreased basal metabolism, the leucocyte form- 

 ula and sterility. The family history of slow pulse and beneficial results of 

 thyroid treatment in the case of a cousin is suggestive of familial hypothy- 

 roidism. Only the slowness of pulse, temperature and respiration, the 

 asthenia and sterility are indicative of hypothyroidism. The lowered basal 

 metabolism and abnormal leucocytic formula rendered the diagnosis pos- 

 sible. This diagnosis was confirmed by the therapeutic test. After one 

 month's treatment of 0.4 mgm. thyroxin (Kendall) daily, complete recov- 

 ery ensued except for the pains in neck and shoulder due to the cervical 

 rib. The basal metabolism was maintained at the normal level. Patient's 

 temperature, pulse and respirations rose to normal. Evidently the neu- 

 rasthenia in this case was an expression of hypothyroidism. On account 

 of the good result of thyroid therapy, additional clinical and therapeutic 

 studies of the possible presence of other endocrin dystrophies were not 

 undertaken. 



An interesting feature in this case was that conception took place 

 during the first year of thyroid treatment. About the fourth month of this 

 normal pregnancy, the neurasthenia and asthenia returned, although the 

 obstetrical condition was satisfactory. The patient was regularly taking 

 0.4 mgm. thyroxin daily. Basal metabolism rate fell again to 20 but 

 rapidly rose to normal on increasing the dose of the thyroid hormone to 

 0.8 mgm. which was followed by a subsidence of the hypothyroid symp- 

 toms. The amount of thyroxin available on the lower dosage evidently did 

 not suffice for the added requirements caused by the developing fetus. 



Cachexia Strumipriva. Case 1960, female, nurse, aged 40 years, 

 single. Family history: Mother asthenic, obese, glycosuria at times; a 

 niece was a goiter. Patient's history: A highly strung, sensitive child. 

 Graves' Disease developed at 17, which persisted until the 31st year when 

 right lobe of thyroid and isthmus were removed. The thyrotoxic symptoms 

 gradually subsided during the first post-operative year, the pulse falling to 

 70 from 140 pre-operative. 



Hypothyroidism then gradually developed ; asthenia, mental hebetude, 

 inability to carry out duties, uncontrollable gain of weight to 140 pounds. 

 At 33rd year, diagnosed hypothyroid. Symptoms relieved by gr. 2 thy- 

 roid extract daily, weight falling to 123 pounds. Has taken thyroid 

 extract irregularly since. Much larger doses fail to relieve patient at 

 present. 



Physical examination : Typical, well developed myxedema. The eyes 





