i INTERNAL PROTECTIVE SECRETIONS 15 



the face and limbs, which he proved to be due to a pronounced 

 accumulation of mucin in the subcutaneous connective tissue. 

 He observed that the disease was accompanied by a shrivelling of 

 the thyroid, and the destruction of its follicles by proliferation of 

 the connective tissue ; but he did not suspect that this degenera- 

 tion of the gland was the internal cause of the myxoedenia. He 

 further noted the numerous analogies between myxoedema and 

 cretinism ; but did not regard the latter as dependent on the 

 alterations of the thyroid. 



It was the cousins Reverdin who recognised these relations, 

 more particularly the great resemblance between the phenomena 

 of spontaneous myxoedema and cachexia thyreopriva, to which they 

 gave the name of operative myxoedema. Kocher, on the other 

 hand, particularly emphasised the points of contact between 

 cretinism and cachexia thyreopriva. In 75 per cent of the cases, 

 cretins exhibit goitre with thyroid degeneration ; and in cases in 

 which there is no goitre, absence of this gland has been noted 

 (Curling). In many non- goitrous cretins Kocher verified its 

 absence by palpation, or at least such a diminution in its volume 

 that it was not perceptible to touch. It is not surprising that 

 the resemblance between cretinism and cachexia thyreopriva 

 should be incomplete, seeing that cretinism is a congenital disease, 

 and is almost always hereditary. But they may legitimately be 

 grouped together, since in both the disease depends on a defective 

 or insufficient function of the thyroid gland. 



V. Following the initiative of the Swiss surgeons, the excision 

 of the thyroid in cases of goitre was practised by many, notably 

 by Billroth in the Vienna clinique. The results differed from 

 those described by the cousins Reverdin and by Kocher, in that 

 the morbid syndrome of slowly developing cachexia thyreopriva 

 was frequently replaced or accentuated by acute phenomena of 

 " tetany," which usually caused the rapid death of those operated on. 

 Out of 53 cases of total thyroidectomy for goitre, reported on by 

 von Eiselsberg in 1890, there were 12 cases of tetany, 8 with fatal 

 results. In 8 cases operated on by Mikulicz 4 were attacked by 

 tetany. Since the first 13 cases of tetany collected by Weiss were 

 all very young women, it seemed as if this complication were 

 peculiar to females. Subsequently this was found to be erroneous, 

 cases of tetany having also been observed in' young males by 

 Kocher, Mikulicz, Hicquet, and Walkowitsch. Tetany is more 

 frequent in women than in men, because cases of goitre are 

 notoriously more frequent in females, and the majority of indi- 

 viduals operated on accordingly belong to that sex. 



" Tetania thyreopriva " may appear on the day of operation ; 

 more frequently it commences on the second, the fifth or sixth, or 

 at latest on the tenth day after the operation (Weiss). It begins 

 with muscular cramp which is usually localised in the limbs, and 



