SYMPTOMS 185 



then conveys the impression of being under the influence of a high grade of 

 nervous irritability with severe muscular tremor, so that it is impossible to 

 maintain an erect attitude. 



The patient's appearance is peculiarly quiet and suggests mental limita- 

 tion, an impression which is increased by the fact that the head is mostly bent 

 forward so that the chin is held, or, more correctly, falls upon the chest, for 

 the patient cannot keep the head erect. The power of thought lessens, and 

 its exercise is apparently difficult. There is loss of memory, particularly in 

 regard to the true duration of the illness ; now and then actual hallucinations 

 appear. Speech itself is peculiar, being monotonous with a nasal or rough 

 quality, and this, combined with a certain tendency of the patient after hav- 

 ing once begun to speak to continue uninterruptedly like a wound-up clock- 

 work, is looked upon by Ord as especially characteristic. I must admit that 

 this latter condition has not yet been noticed by me in my very much more 

 limited experience. Finally, actual convulsions and coma have been observed. 

 The reports in regard to reflexes, cutaneous sensation, and electric irritability 

 vary. In my case no disturbance of these functions was present. The tendon 

 reflexes were prompt, and electric irritability both for the faradic and constant 

 current was normal. The sensation of cold, and the lowered body tempera- 

 ture which is the cause of this, may be considered as due in part to the nervous 

 disturbances. The temperature in the axilla varies between 96.8° F. and 

 98.6° F. The patients feel " as if they were living in an eternal winter." 

 Unquestionably, this sensation of cold depends upon the inability of the 

 patients to regulate the body temperature so as to correspond with variations 

 in the external temperature; they suffer particularly in cold and frosty 

 weather. On the other hand, there is deficient energy of oxidation, a dimin- 

 ished heat production, in the organism. 



This leads us to the discussion of the last point : 



3. Disturbances of metabolism and of the circulation. The former is 

 decidedly decreased. The urea or N-excretion as well as the respiratory metab- 

 olism (Magnus-Levy) is decreased. Albumin is occasionally found in the 

 urine, sometimes only in traces, sometimes in larger amounts. According to 

 the observations of Byrom Bramwell, as well as of Hun and Prudden, albumin 

 is found in about 18 per cent, of the cases. In rare instances at the acme of 

 the myxedematous stage, mucus is also found in the urine. In the blood there 

 is a slight oligocythemia or a polycythemia. In women there is amenorrhea. 

 The pulse is small, low and weak. Hemorrhages from the mucous membranes, 

 particularly from the nose and mouth, are not rare. 



I have now sketched the most important symptoms. I omit the rarer ones 

 as, for example, synovitis of the knee-joint, premature climacteric, tremor of 

 the eyelids, contractures of the hands and feet, salivation. The characteristic 

 symptoms of the afEection under discussion are limited to tissue changes, par- 

 ticularly of two organs, the skin and the thyreoid gland. The connective tis- 

 sue of the corium is loosened, its individual fibers thickened and hyperplastic. 

 The cell nuclei and the fibrillary elements of the gelatinous substances be- 

 tween the individual fat lobes are increased. It seems as if the skin were 

 saturated with a fluid or semi-fluid substance. Whether this actually con- 



