186 MYXEDEMA 



sists of mucus, i. e., of an edematous fluid containing considerable amounts of 

 mucin, is not yet certain. This much, however, is assured, that the degree of 

 this infiltration may vary decidedly in individual cases. In my patient there 

 is now only slight swelling of the eyelids and of the cheeks, but at the height 

 of the disease the entire face, shoulder-girdle, hands, forearms, and feet showed 

 swelling which was everywhere unmistakable, and here and there extreme. 

 In a case observed by Kast (Ponfick) the thickening of the skin was so 

 extreme that numerous fissures formed, with intertrigo-like excoriations 

 which were followed first by a phlegmon of the arm and later by a general 

 fatal sepsis. 



In the internal organs usually no changes are found apart from the pre- 

 viously mentioned atrophy of the thyreoid gland, but occasionally cirrhotic 

 processes in the liver and kidneys, endarteritis obliterans, and enlargement of 

 the pineal gland have been noted. 



The changes in the thyreoid gland are undoubtedly the most remarkable 

 feature of this disease. In most cases, even during life, we observe that it 

 is impossible to palpate the lobes of the thyreoid gland in the neck. It may 

 be said that this condition is found in about 80 per cent, of the cases. In 

 some instances, however, the atrophy of the gland cannot be determined with 

 certainty, and in a few an enlargement has been noted. Yet in these cases, 

 in so far as accurate observations have been obtained, there has always been 

 found a strumous degeneration of the organ, which may also have resulted in 

 a loss of function. I have been able to collect 36 reliable autopsy reports, 

 in 33 of which, or 94.4 per cent, of the cases, there was atrophy of the thyreoid 

 gland. The necropsy reports show that the gland substance had lost its char- 

 acteristic structure, and had been changed into a mOre or less shrunken rem- 

 nant, of hard, fibrous consistence and yellowish white color. Connective tissue 

 proliferation leads to destruction of the parenchyma, so that only isolated re- 

 mains of degenerated alveoli can be detected. Very recently Ponfick has 

 reported an extremely careful histological investigation of the remains of the 

 gland in a well-developed case of myxedema. He found " in wide areas almost 

 total destruction of the follicles; here and there were the remains of rudi- 

 mentary alveolar structures, all filled with colloid. Besides this atrophy there 

 was an enormous increase and thickening of the connective tissue structure; in 

 a word, a picture which markedly resembled the terminal stage of degenera- 

 tive inflammatory processes, such as are met with so frequently in the kidneys, 

 liver, etc." 



PATHOLOGY 



I need hardly say that this degeneration of the thyreoid gland is the key to 

 the entire pathological condition. Atrophy of the thyreoid gland is not only 

 one of the symptoms of the disease; it is the causative factor. This fact is 

 absolutely certain in spite of occasional objections. Its recognition forms a 

 glorious page in the history of pathology. We owe this to the united labors 

 of physiologists and clinicians, the fruit of which is a therapy which, as re- 

 gards the certainty of success, may be placed side by side with the most reliable 

 remedies of our therapeutic armamentarium. 



