As regards the alterations occurring in the skin, there is no such general agreement. The important question of the deposition of mucin is undeter mined; the number of cases investigated thus far has been insufficient to settle this point, as the findings have differed.
[Virehow does not consider mucin as a constant and specific product of skin which has undergone myxoedematous changes; and Unna found no mucin in two eases studied by him. A number of studies of the skin in myxcedema have been reported, but as yet there are none on this tissue in cretinism. Since the two diseases seem to be now recognized as identical, we may accept the altera tions found in myxcedema as character istic also of cretinism.
Barclay Ness (Glasgow Med. Jour., Aug., '97) describes the condition of the skin in myxcedema, from the study of one case with autopsy, as follows: "The skin from the back of the hand was ex amined, and it was found that there was an abnormal proliferation of cells in the corium, especially along the courses of the capillary vessels. With regard to the sudoriparous glands, these were not atrophied, but their epithelium was much swelled, indicating a condition which might possibly have interfered with their function, and thus explained the dry condition of the skin." Beck (Monat. f. prakt. Herm., B. 29, No. 12, June 15, '97), in reporting his findings in the skin in a case of myx cedema, reviews all the work done on this subject, and his paper is the most exhaustive one that has as vet been published. He draws the following con clusions: "Regressive and progressive changes both play a part alongside each other. The regressive changes were noted in the epidermis and the different tissue-elements of the cutis; the latter were limited to the collagen and the smooth muscle-fibres of the cutis. In the epidermis the regressive changes present themselves as a 'sterile' con dition, a necrosis and a degeneration of the protoplasm of the epithelial cells; in the cutis these changes are marked by a fibrillation of the collagen bundle and the formation of kol]astin. The pro gressive changes consist of an increase in the collagenous tissue in the middle, and a multiplication of the smooth mus cle-fibres in the middle and lower layers of the cutis. A special place must be
reserved for the changes in the fat-tissue, which, as it appears, not only increases in amount, but also undergoes a chemical change of the fat-globules." Langhans (Virchow's Archiv, B. 149, H. 1, '97) found marked fatty degenera tion of the muscles; it was generally distributed throughout the body, and the fat-globules were everywhere small. He says this condition is very rare and differs from that found, for instance, where it attacks the heart; then the distribution is not so general, and there is variation in the size of the fat-glob ules. He contends that in cretins this may result from the low temperature and imperfect oxidation; but toxic in fluences and the anwmic condition may also play a part.
In reporting a case of cretinism with autopsy Friend (Med. News, Dec. 4, '97) states that study of the pituitary body, thymus gland, suprarenal capsules, as well as of other tissues throughout the body, merely showed an excess of fibroid growth in all; and that the marrow was red in all the bones.
Ness (Glasgow Med. Jour., Aug., '97) in his ease found extreme thickening of the capsule of the kidneys, with fibroid degeneration of the glomeruli; the latter appeared to have been primarily affected, and the capsule secondarily in places. (Although albuminuria and casts are found in the urine in a small number of cases, yet so far as we know there is no characteristic lesion of the kidneys in these cases, nor does the kidney seem in any manner to be seriously affected.) Red marrow in the bones (Friend) is unusual. "The marrow instead of being red is yellow (fat-marrow), which ex plains the anmmic condition of cretinoids. Only at the extreme ends of the bones near the cartilage is red marrow found" (Langhans). WILLIAM OSLER and Ru PERT NORTON.] There seems to be a general agree ment among observers that the blood shows a condition of secondary anaemia; but there is considerable variation in the findings.