(1887), began early in February, without apparent cause, to evince a repugnance to food, and soon afterwards declined to take any whatever except half a cup of tea or coffee. On March 13th she travelled from the north of England, and visited me on April 20th. She was then extremely emaciated, and persisted in walking through the streets to my house, though an object of remark to the passers by. Extremities blue and cold. Examination

showed no organic disease. Resp. 12 to 14; pulse 46; temp. 97°. Urine normal. Weight 4 st. 7 lbs. ; height 5 ft. 4 in. Patient expressed herself as quite well. A nurse was obtained from Guy's, and light food ordered every

1 This illustration differs from that given in the original paper; since, the negative having been destroyed, it was found impracticable to reproduce the woodcut.-ED.

few hours. In six weeks Dr. Leachman reported her condition to be fairly good, and on July 27th the mother wrote, "K is nearly well. I have no trouble now about her eating. Nurse has been away three weeks." This story, in fine, is an illustration of most of these cases, perversions of the ego" being the cause and determining the course of the malady. As part of the pathological history, it is curious to note, as I did in my first paper, the persistent wish to be on the move, though the emaciation was so great and the nutritive functions at an extreme ebb.

66

ON A CRETINOID STATE SUPERVENING

IN ADULT LIFE IN WOMEN.1

THE remarks I have to make upon the above morbid state are drawn from the observation of five cases. Of two of these I am able to give many details, but the three others were only seen by me on one or two occasions.

CASE 1.-Miss B-, after the cessation of the catamenial period, became insensibly more and more languid, with general increase of bulk. This change went on from year to year, her face altering from oval to round, much like the full moon at rising. With a complexion soft and fair, the skin presented a peculiarly smooth and fine texture, was almost porcellaneous in aspect, the cheeks tinted of a delicate rose purple, the cellular tissue under the eyes being loose and folded, and that under the jaws and in the neck becoming heavy, thickened, and folded. The lips large and of a rose purple, alæ nasi thick, cornea and pupil of the eye normal, but the distance between the eyes appearing disproportionately wide, and the rest of the nose depressed, giving the whole face a flattened broad character. The hair flaxen and soft, the whole expression of the face remarkably placid. The tongue broad and thick, voice guttural, and the pronunciation as if the tongue were too large for the mouth (cretinoid). The hands peculiarly broad and thick, spade-like, as if the whole textures were infiltrated. The integuments of the chest and abdomen loaded with subcutaneous fat. The upper and lower extremities also large and fat, with slight traces of œdema over the tibiæ, but this not distinct, and pitting doubtfully on pressure. Urine normal. Heart's action and sounds normal. Pulse 72; breathing 18.

Such is a general outline of the state to which I wish to call attention.

On the first aspect of such a case, without any previous experience of its peculiarity, one would expect to find some 1 Reprinted from the Clinical Society's Transactions,' vol. vii, 1874,

p. 180.

disease of the heart leading to venous obstruction, or a morbid state of the urine favouring oedema. But a further

inquiry would show that neither condition was present; nor, when minutely studied, is the change in the body which I have described to be accounted for from either of these points of view.

Had one not proof that such a patient had been previously fine-featured, well-formed, and active, it would be natural to suppose that it was an original defect such as is common in mild cretinism. In the patient whose condition I have given above, there had been a distinct change in the mental state. The mind, which had previously been active and inquisitive, assumed a gentle placid indifference, corresponding to the muscular languor, but the intellect was unimpaired. Although there was no doubt large deposit of subcutaneous fat on the extremities, chest, and abdomen, the mere condition of corpulency, obesity, or fatness, would not in any way comprehend the entire pathology.

It is common to see patients with a very superabundant accumulation of fat in the subcutaneous adipose tissues, and on that ground more inactive, without the change in the texture of the skin, in the lips and nose, increased thickness of tongue and hands, &c., which I have enumerated. The change in the skin is remarkable. The texture being peculiarly smooth and fine, and the complexion fair, at a first hasty glance there might be supposed to be a general slight oedema of it, but this is not confirmed by a future examination; whilst the beautiful delicate rose-purple tint on the cheek is entirely different from what one sees in the bloated face of renal anasarca. This suspicion of renal disease failing, any one who should see a case for the first time might suppose that the heart was the faulty organ, and that this general change in the features and increase of bulk were owing to venous congestion. But neither would this be confirmed by an exact inquiry into the cardiac condition.

I am not able to give any explanation of the cause which leads to the state I have described. It is unassociated with any visceral disease, and having begun appears to continue uninfluenced by remedies.

CASE 2.-P. M—, æt. 40, a married woman, having had five children and living in good circumstances, came under my cbservation in 1866 complaining of general languor.

Heat was normal. Pulse 60. Catamenia too profuse. There had been gradual and general increase of bulk. The features had become broad and flattened, the skin was peculiarly fair and fine and soft, with a very delicate rose-bloom on the cheeks. The cellular tissue about the eyes was thrown into folds, giving the impression when cursorily looked at, of being œdematous. The eyes were bright, the lips were thickened, and of a light rosepurple. Tongue large, the speech guttural, and, as in the former case, as if the tongue were rather unwieldy. The sounds and impulse of the heart were normal, breathing was normal, urine normal. In fine, there was no discoverable change in any of the viscera, and the morbid state complained of seemed to be some primary change in the integuments, the muscles, and the nervous tissues of the cerebro-spinal system. This change continued to advance, so that in 1873 I made the following notes:

"Tongue large; false teeth cannot be worn, as tongue bitten by them. Lips large, thick, of a light rose (venous) tint. Features broad. Tissue under eyes loose, suggesting cedema. Fine delicate rose-tint on cheeks. Hair soft. Neck thick. Skin and subcutaneous textures lying in resisting folds. Hands broad and spade-like, the textures suggesting oedema, but not pitting. Much subcutaneous fat on chest, abdomen, and extremities. Thighs thirty-nine inches in circumference. Mind generally placid and lazy, but liable to being occasionally suddenly ruffled. Heart's action and breathing normal. Urine normal. Catamenia continue rather profuse."

The following is from a letter written by me on this case, March 7th, 1873, and fairly expresses my views of it at that time, which was seven years after my first observation of it.

"I believe it to be a rare form of constitutional disorder without any internal visceral disease, but characterised by great inaptitude to spontaneous exertion both of mind and body. The deposit of fat and the changes in the skin and connective tissues correspond to a languid condition of the venous circulation, but without any tendency to oedema, or any sign of cardiac defect.

"No doubt, under the stimulus of external circumstances, there is a response of mental activity which seems to prove that the mind requires but an exertion of the will to work up to its normal level. Though this be theoretically possible, I doubt if it be practically so in this state. The peculiar condition of the nervous system will, I believe, be best understood by reference to the external condition of the