184 MYXEDEMA 



These features are not equally developed nor even all present in every ease, 

 and my case was no exception to this rule. 



Of greatest importance in the diagnosis of the disease are the cutaneous 

 symptoms. They make it possible for us to recognize the malady, prima vista, 

 so to speak, and after a comparatively brief examination of the patient. They 

 give the patient the characteristic stamp which I attempted briefly to portray 

 at the beginning of this article. 



1. Most frequently the disease begins unnoticed and insidiously, with a 

 gradual swelling of the skin, at iirst in the face, then in the hands, arms, feet 

 and legs ; finally and least noticeably upon the trunk. In the cheeks, around 

 the eyelids, and upon the chin, pufiiness is noticed; the lips and nose become 

 swollen and thickened, the palpebral fissure is diminished by the swelling of 

 the eyelids, and a hard, elastic edema of the whole face produces a stupid, 

 dull expression. The tongue is thick, clumsy and too large for the mouth; 

 the soft palate, the uvula, and the postpharyngeal wall, as well as the larynx, 

 are swollen. Hence the voice becomes rough and hoarse with a peculiar deep 

 sound. The gums also swell, bleed readily, and retract from the teeth, which 

 have a tendency to caries and frequently drop out without any change of 

 structure. The lobes of the ear are also coarse and misshapen. Upon both 

 sides of the neck above the clavicle, swellings appear, which are soft to the 

 touch, and from about the size of a plum to that of a hen's egg. These pads 

 are not due to swollen glands, but consist of fat, connective tissue, and convo- 

 lution of vessels (veins). The extremities appear swollen and shapeless, the 

 hands like paws ; wider shoes and larger gloves become necessary. 



The skin is pale and looks anemic; occasionally it has a marbled appear- 

 ance; to the touch it is cold, unelastic, hard and coarse. If pressure is made 

 with the finger a slight impression is made, but the pitting does not remain. 

 As a rule, this swelling is by no means uniformly distributed over the entire 

 body. It attacks preferably either the face and the supraclavicular region or 

 the extremities. Occasionally it disappears temporarily at the beginning of 

 the disease (Ord), and then recurs, wandering here and there. The skin is 

 dry, rough, desquamates decidedly, and not even by means of diaphoretics can 

 sensible perspiration be induced, while insensible perspiration is lessened from 

 40 to 60 per cent, in comparison to the normal. The nails show longitudinal 

 fissures and become brittle. The hair of the head and eyebrows falls out, 

 and soon large areas are formed which are perfectly bald. 



Besides these striking changes there is a further defect which indeed can- 

 not always be determined with certainty during life, but which in my patient, 

 for example, was readily demonstrated; I mean the absence of the thyreoid. 

 In place of the lobes of the gland normally situated upon both sides of the 

 wind-pipe, the smooth wall of the trachea may be palpated from the cricoid 

 cartilage to the jugulum. I shall revert later to this remarkable condition, 

 and to its importance in pathogenesis. 



2. The disturbances of the cerebral functions mostly set in with headache, 

 sometimes with a feeling of anxiety, and a heaviness in the limbs. The 

 patients move about slowly and with uncertainty. The power of co-ordination 

 is diminished, as is frequently shown in the attempts at walking. The patient 



