MYXEDEMA

Synonyms.—Cretinoid edema (Gull); Fr., Myxœdème; Cachexie pachydermique
(Charcot); Athyroidie (Besnier); Ger., Myxœdem.

Definition.—A constitutional affection, chiefly in women, in­
duced by atrophy or ablation of the thyroid gland, and characterized
by cretinoid changes and edematous swelling, and thickening and indu­
ration of the skin and subcutaneous tissues.

Symptoms.—This somewhat rare malady, which was first clearly
described by Sir William Gull⁷ in 1873, is usually of slow and insidious
development, the earliest symptoms presenting, as a rule, being those
of ill-defined general poor health, with, more especially, an anemic con­
dition and disinclination to physical or mental exertion. These become

¹ Quoted by Manson, Davidson‘s Hygiene and Diseases of Warm Climates, p. 835,
with references.

² Hardaway, St. Louis Courier of Medicine, May, 1879.

³ Silva Aranjo, Atlas des Maladies de la Peau, Rio de Janeiro, 1889, p. 3; Mon-
corvo et Silva Aranjo, “Du traitement de l‘ephantiasis par l‘électricité,” Journal de
Thérapeutique, 1882, vol. ix, p. 1.

⁴ Leonard, Brit. Med. Jour., 1879, vol. i, p. 934, states that he has found statistics
(but references and particulars not given) of 69 cases; of these, 40 were cured (3 by
digital compression), 13 improved (3 temporarily), and 16 unsuccessful.

⁵  Curl, Jour. Cutan. Dis., 1905, p. 402.

⁶Havelock Charles, Indian Med. Record, 1897, vol. lxii, p. 165, reports a series of
60 cases successfully treated (abstract in Sajous’ Annual and Analytical Cyclopœdia,
1899, vol. iii, p. 91).

⁷ Gull, London Clin. Soc'y Trans., 1874, vol. vii, p. 180.

602

HYPERTROPHIES

more marked, and then consist of sluggishness of movement, unsteadiness
of gait, slow and halting speech, and mental hebetude. The subject
becomes mentally dull and listless, the temperature subnormal, and often
shows glycosuria or albuminuria. At the same time is noted atrophy
in the thyroid, the gland partly or almost wholly disappearing or under­
going fibrous change.

Along with these constitutional symptoms the skin also becomes
the seat of peculiar changes. It becomes yellowish and waxy in appear­
ance, thickened, firmly edematous, and swollen, particularly the face,
neck, and the extremities. The face is noted to be enlarged and rounded,
more or less moon-shaped, the lips, nose, and eyelids are swollen, thick­
ened, and variably indurated, giving the coarsened features an immobile
or fixed, expressionless aspect. As a result of these tumefactive changes
there is only a slit-like opening between the puffy and swollen eyelids,
the nostrils are broadened and thickened, and the lower lip everted and
pendulous. There is often an ill-defined, dull-red flush on the cheeks,
although, as a whole, the countenance is of a dead yellowish or waxy
appearance. The neck also undergoes similar changes, especially the
supraclavicular region, where there may be a cushion-like accumulation
of fat. The hands show like conditions, becoming massive, deformed,
and shapeless, the fingers so swollen and thickened as to give it a broad­
ened, spade-like aspect. The entire surface more or less shares in this
peculiar development, the regions of the joints especially showing the
thickening and edema-like infiltration, and often to such an extent as
seriously to compromise the natural suppleness and mobility of the
parts. In some instances there is variation in the degree of swelling,
and, according to Ord,¹ this is particularly so with the face, and generally
having a relationship with the intensity of the general symptoms, espe­
cially the nervous symptoms, partial amelioration of the swelling being
followed by headache and neuralgia, and its increase or recurrence by
relief of the severity of the nervous phenomena.

The skin is usually dry and rough, with, in some places, a trans­
lucent look. It is, as a rule, harsh and hard to the touch, with often a
fine branny scurfiness, occasionally lamellar, and perspiration is lessened
or wholly absent. The hair likewise becomes harsh, dry, and scanty,
and there may finally be partial or almost complete scalp alopecia. In
addition, especially later in the malady, the skin may be more or less
pigmented, in areas or generalized, as in Addison's disease, although
rarely to so pronounced an extent or depth. The soft parts of the buccal
cavity, especially the tongue and uvula and the arches, share in the
swollen, edematous process. The edema, while apparently similar in
appearance to the edema of renal disease, differs in being firm and not
pitting on pressure; nor is it influenced by position.

Etiology and Pathology.—The disease is rare and chiefly seen
in adult life, usually about the middle period, and is predominantly
confined to the female sex. While in many respects the disease is
etiologically obscure, it is now known that it is connected with atrophy

¹W. M. Ord, “Myxedema and Allied Disorders,” Brit. Med. Jour., 1898, ii, p.
1473.

MYXEDEMA                                           603

or loss of the thyroid gland. This is disclosed by clinical observation
as well as by the fact that the condition (so-called “sporadic cretinism")
is noted sporadically in congenital deficiency of the gland and also fol­
lowing, in a large proportion of instances, its partial or complete surgical
removal. According to the analytic study of the committee (Ord,
Cavafy, Goodhart, Horsley, Mackenzie, and others) of the London
Clinical Society,¹ it developed in 69 out of 408 instances in which the gland
was completely extirpated, and in no case in which removal was not com­
plete. Billroth,² on the other hand, has never noticed the occurrence of
myxedema after the extirpation of goiter. Moreover, question has been
raised by some observers as to the identity of true myxedema and that
condition, the so-called “cachexia strumipriva” of Reverdin and others,
which develops after the extirpation of goiter. Aggregate observations,
however, fortified as they are by the investigations of the London Clinical
Society Committee and those of Hun and others, do not afford substan­
tial support to this doubt.

Ord, who gave the malady the name of myxedema, found that the
edematous infiltration was due to a proliferation and deposit of mucin
in the superficial connective tissue, the amount present estimated to be
fifty times the normal quantity. According to Hun, however, the con­
nective-tissue spaces in the corium were pushed asunder by a fluid which
was not mucin. This observer also found a general atheromatous
endarteritis, although this is not in accord with the observations of
Caspary, Grawitz, and others (quoted by Kaposi). There is, however,
fairly general agreement as to the involvement of the nervous system,
and Charcot considered the implication of the nerve-centers as the pri­
mary factor, and the other pathologic changes as secondary to this.
The thyroid gland, with rare exceptions, has always been found atro­
phied. Kaposi (loc. cit.) has stated that various observers (not named)
were unable to demonstrate clinically atrophy of the thyroid gland;
Adami,³ on the contrary, as more in consonance with common belief, was
not able to find an account of any autopsy upon cases diagnosed clinically
as myxedema in which the gland was found normal or but little affected.⁴

Diagnosis.—This is rarely a matter of difficulty if the case is
at all developed, as the aggregate symptoms are striking and charac­
teristic; there is merely a faint similarity, never a puzzling resemblance,
to some cases of acromegaly, as in the latter the bones are greatly en­
larged and there is also lacking the rounded or moon-shaped face, that
of acromegaly being an elongated oval. The nervous symptoms and
the changes in the thyroid are also distinctive of myxedema. The mal­
ady can scarcely be confused with the edema of renal disease or with
the infiltrated nodular swelling of leprosy.

¹ “Report on Myxedema,” London Clin. Soc'y Trans., supplement to vol. xxi,
1888 (a most exhaustive and comprehensive investigation).

² Billroth, quoted by Kaposi, Diseases of the Skin, p. 475.

³ Adami, “Internal Secretions Considered in Their Physiologic, Pathologic, and
Clinical Aspects,” Trans. Cong. Amer. Phy. and Surg., 1897, vol. iv, p. 103 (a valuable
and suggestive paper, with review of the subject and bibliography.

⁴ See also Hun's paper (150 collated cases), Amer. Jour. Med. Sci., Aug., 1888,
p. 196.

604

HYPERTROPHIES

Prognosis and Treatment.—The course of myxedema is per­
sistent, progressive, and chronic, and if untreated usually leads sooner
or later to the development of a grave mental and physical disorder,
marasmic condition, and a fatal ending. Fortunately, since the dis­
covery of the value of thyroid extract, a greater control has been exer­
cised over the disease, as noted by Bircher, Beatty, Putnam, Osier,
Murray, and others.¹ The dose should at first be small and cautiously
increased, as emphasized by 2 instances in patients suffering from heart
disease, under Murray‘s observation, in which death from syncope
immediately due to exertion followed the prolonged administration of
thyroid for myxedema.

But first, if you want to come back to this web site again, just add it to your bookmarks or favorites now! Then you'll find it easy!

Also, please consider sharing our helpful website with your online friends.