CHAPTER Vni.
DISEASES OF THE DUCTLESS GLANDS.
Addison's Disease.
Remember that tlie onset is insidious, the patient gradually losing strength and energy. Gastric dis- turbances finally cause him to seek relief.
Remember that, while pigmentation is an im- portant sign, it is variable, both as to the time of its appearance and in its degree. Usually follow- ing the constitutional symptoms, it may precede them or it may not occur until shortly before the fatal termination. The extent of pigmentation is variable, and may be universal, but it is usually partial. It is usually seen first on the face, neck, and back of the hands and fingers. The shade of color varies from lemon-yellow to dark-brown or black; usually darker on exposed parts and natur- ally pigmented portions.
Remember that pigmentation is not pathogno- monic of Addison's disease. The following must be excluded: 1, abdominal growths, as tubercle, cancer, or lymphoma; 2, uterine disease and pregnancy; 3, hypertrophic cirrhosis and diabetes; 4, melanotic cancer and exophthalmic goiter; 5, pernicious ane- mia and prolonged use of arsenic.
The occurrence of fainting fits, nausea, gastric irritability, and asthenia are stronger indications of Addison's disease.
116
Addison's disease. 117
Remember that asthenia is probably the most fre- quent and important symptom. Easily tired at first, the patient finally becomes unable for any exertion of either mind or body.
Remember that there is no emaciation accom- panying the muscular feebleness. There may be ex- treme degree of muscular prostration, while the muscles feel firm and hard, with no emaciation, and therein lies the distinctive quality of asthenia in Addison's disease. This loss of muscular power extends to the cardiac muscle, as is shown by the small, extremely soft, and compressible pulse.
Remember that, as a large percentage of Addi- son's disease is due to tubercular degeneration of the glands, in doubtful cases the tuberculin test may be used.
Treatment.
Rest in bed is imperative because of the exhaus- tion and danger of fatal syncope.
Diet must be nutritious and liberal.
Tonics are indicated. Arsenic and strychnin are best.
For the nausea and vomiting, creosote, phenol, ice, and hydrocyanic acid should be given.
Diarrhea is best controlled by large doses of bis- muth.
For vomiting and diarrhea the following is good;
IJ Bismuthi subnitratis 3 iv
Creosoti ( Beechwood ) TTt v
Aquae menthse piperitae § iij
Misce.
Sig. : Teaspoonful every two or three hours. Shake well.
118 DISEASES OF THE DUCTLESS GLANDS.
Organotherapy gives good results in many cases; some are apparently cured. The medullary portion of the suprarenal gland is the part used. The raw gland, partially cooked, or the glycerin extract may be used.
IJ Suprarenal gland desiccated (U. S.
P.) 3ij
Extract! nucis vomicae gr. iij
Misce et fiant capsulse No. XXIV.
Sig. : 1 or 2 capsules three times daily.
Solution of adrenalin chlorid may be used hypo- dermatically — a dram of 1:1000 solution injected every other day.
Exophthalmic Goiter.
Most common in women between puberty and the menopause.
Remember that there are four cardinal symptoms that render a diagnosis positive when present, and a positive diagnosis is impossible unless some of them are found. They are: goiter, exophthalmos, tachy- cardia, and tremor.
The goiter, as a rule, is small and the right side of the gland is more prominent. The tumor is soft and uniform, but occasionally may be irregular and contain rounded or nodular masses that are hard. Pulsations can usually be seen in the gland and a murmur heard over it. On palpation a systolic thrill may be felt. The goiter rarely produces pressure symptoms, and it varies in size at different times.
EXOPHTHALMIC GOITEK. 119
Remember that exophthalmos is present and often early. It may be unilateral. The amount of pro- trusion varies, and this protrusion produces the fol- lowing signs:
Grafe's Sign. The upper lids lagging behind in the downward movement of the eyeballs, and the scleras become visible between them and the cornea.
Stellwag's Sign. The widening of the palpe- bral fissure. This retraction of the upper lids causes a white ring of sclera to be seen all around the iris.
Diminished frequency of winking.
Mobius' Sign. The inability to converge for near-by objects. An attempt causes a sense of strain, but no double vision. This sign is not al- ways present.
Joifroy's Sign. The head is bowed forward and the patient asked to look up without changing the posture. The forehead is not wrinkled, as oc- curs in health.
Tachycardia is not only prominent, but one of the most constant signs. The rate of the pulse may be very high, but there is no irregularity, except to- ward the close.
Remember that the area of cardiac pulsation is increased and the action is heaving and forcible. The large arteries of the neck throb and a capillary pulse is readily seen. Frequently a pulse can be seen in the veins of the hands.
120 DISEASES OF THE DUCTLESS GLA]!^DS.
Remember that the tremor is most always found, and may be the chief trouble of complaint by the patient. It varies in degree, and may be discovered by the physician only after careful observation. The tremors usually run from eight to ten per sec- ond, and may be best observed by the patient standing, hands and fingers extended, and a piece of paper laid across the back of the fingers. The tremor is made worse by excitement and worry.
There are some signs that are of secondary im- portance in making a diagnosis. The most promi- nent are the following:
Emaciation is the most constant. The loss of strength is dependent upon the emaciation.
Sweating is frequent and often a troublesome symptom. The falling of the hair is due to its dis- turbed nutrition, A dry cough is frequently ob- served, due to pressure upon the trachea.
Edema of the feet may occur, and is due to the cardiac weakness.
A change in the mental condition will often be the earliest sign. The patient becomes irritable, excitable, emotional, fidgety, and restless; is unable to concentrate his mind and longs for continuous changes.
Treatment.
Rest, free from worry and anxiety, is imperative, and in severe cases it is best to confine the patient to bed. The quietude of a country place, where
EXOPHTHALMIC GOITER. 121
there is plenty of good, fresh air and sunshine, is the best place.
Diet must be abundant and mixed. It is better to somewhat limit the amount of meat, but plenty of proteids must be given because of the large amount of nitrogen eliminated. Stimulants — as coffee, tea, alcohol, chocolate, and condiments — must be prohibited.
Hydrotherapy often gives good results. The baths may be given at home. The only thing to keep in mind is to avoid all forms of stimulation, as cold douche along the spine or hot pack, until per- spiration begins. In all forms the bath should be sedative and cold kept to the head.
Electrotherapy is recommended by some. Gal- vanism is the form used. The positive pole is placed under the angle of the lower jaw with moderate pressure. The negative electrode is placed on the neck at the height of the lowest cervical vertebra. The strength of the current, which is gradually in- creased and then gradually decreased, is applied for two to three minutes. Both sides of the neck should be treated in this way.
Medication. If chlorosis or anemia be present, iron and arsenic should be used.
For marked nervous symptoms sodium or stron- tium bromid should be exhibited. Or camphor monobromate may be tried, as:
IJ Camphorse monobromatae gr. v-gr. x
Sacchari lactis gr. ii j-gr. v
Misce et fiat pulvere No. I. Dentur tales pulveres No. XX. Sig. : Powder three times daily.
122 DISEASES OF THE DUCTLESS GLANDS.
Forcheimer's metliod gives excellent results and consists in giving quinin hydrbbromate gr, v in gela- tin-coated pill four times daily, and, if no improve- ment within forty-eight hours, he adds ergotin gr. j. He claims a cure in from 70 to 90 percent of cases. The time of treatment varies from four months to three years. Cromium sulphate gr. v three or four times daily often gives surprisingly good results.
Beebe and Rogers have prepared a serum by in- jecting animals with pathological glands. They claim remarkably favorable results, but it must be used early. After the profound anatomical changes occur in other organs it appears to be less potent.
Sodium phosphate in % to 2 drams daily acts beneficially, especially upon the nervousness.
Ortner highly recommends dilute sulphuric acid, 10 drops three times daily, for the vasomotor dis- turbances so often occurring.
Tincture of convallaria and belladonna in full doses will often quiet the heart and reduce the pulse rate.
lodin in any form, locally or internally, should be studiously avoided in malignant goiter. Theoretic- - ally, the same advice applies to thyroid extract.
Surgery, while responsible for some sudden deaths from acute cardiac dilatation, does in some cases offer relief, or even a cure.
Milk from thyroidectomized goats has given re- sults in a few cases. Chemists have produced a sub- stance from the milk called rodagen, and is said
EXOPHTHALMIC GOITEE MYXEDEMA. 123
to contain 50 percent of the active constituent of the milk and 50 percent milk sugar. From 1 to 3 drams are given daily. Patients sleep better and are less nervous while taking it.
Merck prepares a serum from thyroidless sheep that is said to be useful, but the expense of both of these preparations limits their use.
Myxedema.
There are two forms, and the division relates only to age, as both are caused by the atrophy of the thyroid. The forms are cretinism, occurring in children, and myxedema of the adult.
Remember that it is difficult to diagnose cretin- ism prior to the first year.
Remember that a child that stops growing, and there is lack of proportion between the various parts of the body, so that there is a plump head, a short and deformed body, and thick, "pudgy" arms and legs, should strongly suggest cretinism. The large head is flat at the top, narrow in front, and broad behind. The face is broad and expres- sionless. The forehead is low and broad. The eyes are dull and appear to be half closed, caused by the swollen lids, and are wide apart. The nose is stub- by, depressed at the root, nostrils widely opened, and the alse thickened. The ears are thickened. The lips are thick and protruding. The tongue is swollen and protrudes.
Remember that the skin is dry and harsh, and ap-
124 DISEASES OF THE DUCTLESS GLANDS.
parently dropsical, but will not pit in cretinism, while in rickets there are the sweating head, cranio- tabes and swollen, tender joints.
Remember that mental dullness, backwardness about learning to talk and walk, and the disturbance of the special sense of taste and hearing character- ize cretinism.
Myxedema occurs more frequently in women and between the fifteenth and forty-fifth years — ^the child-bearing period.
Remember that the onset is insidious, but languor, undue sensitiveness to cold, with slight auditory and visual hallucinations, and swollen eyelids mark the onset of athyria.
Remember that there are some characteristic signs that are found in no other conditions, and the following are the most prominent:
Dense, inelastic swelling of the subcutaneoug tissues, which do not pit upon pressure. It is most abundant where subcutaneous tissues are lax, and thus gives a peculiar appearance to the face and hands.
A change in the facial expression, due to the obliteration of the lines of expression — the swollen eyelids, the transverse wrinkles of the forehead, the thickened and enlarged nose, and swollen lip.
The swollen and shapeless hands and feet.
Increase of size and body weight.
Subnormal temperature.
Mental dullness and muscular weakness.
myxedema. 125
Treatment.
There is nothing else in our therapeutics that is so satisfactory as the treatment of this condition.
The thyroid gland, or extract made from it, may be given. It is better to give the extract put up in tablets. The dose at the beginning should be small and cautiously increased. Whenever the following symptoms appear, the treatment must be stopped for a few days: these are palpitation, faintness, dyspnea, anorexia, nausea, vomiting, nervousness, tremor, and sense of fear. It is better to begin with from 1 to 2 grains and gradually increase until from 15 to 30 grains are taken.
I^ Tablet thyroidin ( Merck ) aa gr. i j
No. C.
Sig. : Tablet three times daily, gradually increasing until four are taken.
Or:
IJ Thyroidin gr. xxx-gr. xl
Arseni trioxidi gr. j
Extracti nucis vomicae gr. ii j
Misce et fiant pilulae No. LX.
Sig.: Pill three times dailyj gradually increasing until three or four are taken. Interrupt treatment occasionally.
In infantile form or cretinism Forcheimer's rule of dosage is good, and is as follows: the adult dose is taken at 5 grains and the dose for an infant is obtained by taking one-twentieth of the fraction ob- tained by dividing the age in months by twelve. Thus for a child four months old, Vzo of %2 of 5 equal H2; hence the dose would be gr. %2 for a child four
126 DISEASES OF THE DUCTLESS GLANDS.
months old. He cautions against even the small dose and advises to begin by giving it once a day, then twice, and finally thrice. The untoward symp- toms in children are restlessness, poor sleep, loss of appetite, and irritability. It should not be pushed until the graver symptoms of rapid pulse, vomiting, or collapse occur.