before her admission to the asylum the woman was delivered of her fourth child. 
Within a few months thereafter it was noticed that her face was growing very full, and 
that the hands and arms were abnormally large. An actual alienation did not develop 
until three years after the parturition, but since that time she has had alternations of 
mania, melancholia, and lucidity. Fig. 29 shows the facial expression in the depressed 
period ; Fig. 30, that in the excited state. The myxoedematous condition is best devel- 
oped about the face, scapular and clavicular regions, and the skin has the characteristic 
bogginess and earthy tint. The height of the woman is 142 centimetres ; the circum- 
ference of the neck, 34.5 centimetres over the thyroid region; that of the right wrist, 
18 centimetres. The thyroid gland is palpable, and seems a little enlarged. Under 
treatment with extract of thyroid gland she improved greatly, the periods of mania and 
melancholia completely subsiding. After being under observation for twenty months