The symptoms are those of the causative disease, of amyloid degeneration
of other viscera with emaciation, weakness and splenic enlargement.

The condition is a serious one and its treatment is that of the underlying
affection.

NEOPLASMS OF THE SPLEEN.

The most common of these are syphilitic gumma and tuberculoma. Cysts,
echinococcus and of other types, as well as secondary carcinoma and sarcoma
have been observed. The condition is often unrecognized during life. The
spleen is enlarged and its surface may be nodular. The diagnosis depends
upon the presence of associated lesions. Such a spleen as that above described



ECHINOCOCCUS CYSTS OF THE SPLEEN. 515

occurring with gastric cancer may be attributed to carcinomatous growths;
in the presence of sarcomatous tumors elsewhere it is probably sarcomatous;
when observed in connection with specific disease it may be considered as
sj^jhilitic.

ECHINOCOCCUS CYSTS OF THE SPLEEN.

Echinococcus infection of the spleen occurs in connection with similar
disease elsewhere in the body. The organ usually presents a fluctuating
tumor the character of which cannot be definitely determined when unasso-
ciated with echinococcus disease in another organ, or unless the characteristic
booklets are demonstrated in the aspirated fluid. Abscess, in which a fluc-
tuating enlargement of the spleen may be detected, is associated with the
typical temperature of pyogenic infection.

SPLENIC AN^MLA..

Synonym. Splenic Pseudo-leucaemia.

Definition. An anaemia characterized by enlargement of the spleen and
to be differentiated from Hodgkin's disease and leucaemia by the absence
of increase in the size of the lymphatic glands.

.etiology. While the definite cause of the affection is unknown it is believed
that the infectious diseases and intestinal infection may be predisposing
factors in its occurrence.

Pathology. The spleen is greatly enlarged, often to several times its nor-
mal size; its shape is not affected. Perisplenitis with capsular thickening
is often present and adhesions to adjacent structures may be observed. Upon
section the organ is found to be more dense than normal owing to increased
connective tissue which may even replace the Malpighian bodies. Sclerosis
of these elements is characteristic of the disease. Changes in the marrow
analogous to those met in pernicious anaemia may be noted. Thrombosis
of the splenic vein may be present.

Symptoms. These are a gradually increasing pallor, dyspnoea, palpitation,
progressive weakness and enlargement of the spleen. The patient ultimately
becomes cachectic, the skin is yellow, and fever, dropsy of the subcutaneous
tissue and of the serous cavities may appear. Haemorrhages are not un-
usual.

The blood contains a relatively high number of red cells as a rule (3,000,000
to 3,500,000). The haemoglobin percentage is also lowered; the leucocytes
are not increased but a relative lymphocytosis may be present. In the late
stages of the disease poikilocytosis with normoblasts and megaloblasts may
be observed in rare instances.



5l6 DISEASES OF THE DUCTLESS GLANDS.

The diagnosis is distinctly difficult but the striking features of the condi-
tion are the anaemia, preceded by the splenic enlargement and the absence of
increase in the size of the lymph nodes, with a diminished or normal number
of leucocytes, a tendency to haemorrhages, particularly from the gastro-intes-
tinal tract, and a protracted course.

The prognosis is uniformly unfavorable but the patient may survive for
several years.

Treatment. The patient's nutrition shoidd be maintained by plenty of
good food and the other means indicated in the more ordinary types of anaemia.
Arsenic, iron and bone-marrow may be prescribed.

When the splenic enlargement is marked and the haemorrhages are severe
and frequent the operation of splenectomy may be considered; about 75 percent,
of recoveries are said to have followed this procedure.

BANTI'S DISEASE.

This is a rare affection characterized by enlargement of the spleen, subse-
quent anaemia and secondary hepatic cirrhosis of atrophic type with jaundice,
ascites and other symptoms of this lesion. The anaemia is analogous to that
of chlorosis and there are no especial leucocytic changes. Necropsy has
revealed chronic splenitis with interstitial changes in the liver and sometimes
an increased redness of the bone-marrow.

The course of the disease is protracted, lasting ten years or even longer.

The indications for treatment are practically identical with those in splenic
anaemia.

PSEUDO-LEUC^MIA.

Synonyms. Hodgkin's Disease; Lymphatic Anaemia; Lymphadenosis
General Lymphadenoma.

Definition. An affection characterized by enlargement of the lymphatic
glands and spleen, the appearance of lymphatic growths in the lungs, liver,
spleen and other organs and a consequent secondary anaemia.

Etiology. The causation of this disease is unknown. It is most fre-
quently observed in males before the incidence of middle life. It may occur
in children. In numerous instances the cervical glands are first involved
following some buccal or pharyngeal irritation which fact has given rise to
the theory that the affection is due to an infection which effects its entrance
through the structures drained by the cervical lymphatics.

The hypothesis that tuberculous infection is responsible for Hodgkin's
disease is disproven by the facts that the tubercle bacillus is not constantly
found in the lesions, that inoculation experiments and the tuberculin test may
be negative in typical instances of the affection and that the pathological



\



1



PSEUDO-LEUCiEMIA. 517

changes in the glands are distinctive and characteristic. Tuberculosis may,
however, become engrafted upon the enlarged glands of the disease.

Pseudo-leucaemia is likewise to be separated from malignant adenoma by
the absence of the characteristic histologic appearances of cancer.

Pathology. The enlargement involves first the superficial groups of lymph
nodes, those of the neck often showing increase in size before there is noticeable
affection of those of the axilla and groin. Later the deep glands, those of
the retro-peritonaeal, bronchial and other groups, are at times so markedly
increased in size as to cause abdominal enlargement or respiratory difl&culty.
Pressure upon the trachea, oesophagus, thoracic vessels, ureters, and lumbar
nerves may occur. At first the diseased lymph nodes are soft but later become
hard and firm; they often tend to fuse and they seldom become adherent to
neighboring structures. When cut the section is grayish white and, if the
gland is soft, a whitish fluid exudes; the hardened glands are firm under the
knife and show fibrous trabeculae.

Splenic enlargement is present in a large majority of instances and is of the
hyperplastic type. It is often considerable but less extreme than in leucaemia.

The marrow of the long bones is sometimes converted into lymphoid tissue
and may be much softened.

Lymphoid growths are present in the spleen in more than 50 percent, of
the cases and these may occur in the liver, which at times is found enlarged,
the kidneys, the lungs and other organs and tissues. Even the nervous
system may be invaded and the lymphoid structures in the pharynx often under-
go marked increase in size.

Symptoms. The first of these is usually an enlargement of the cervical
lymph nodes which often follows an inflammation of the tonsils or pharynx.
Rarely the deep glands are first involved. Later, but perhaps not for months
or even years, the axillary and inguinal glands are affected. The enlarge-
ment may cease for a time and later begin again. The glands usually are
soft, discrete and very seldom are painful or tender. Late in the disease
they may become hard and firm.

The spleen is usually enlarged and the lymphoid grovsrths upon the surface
of this organ and the Hver may be palpable.

As the affection progresses the patient becomes anaemic, is pale, and com-
plains of weakness, vertigo, palpitation and dyspnoea.

Pressure symptoms often become evident; the axillary enlargement causing
pain in the arms and hands by reason of pressure upon the nerves, and oedema
due to interference with the circulation. Analogous manifestations are
observed in the lower limbs resulting from the inguinal enlargement. Pres-
sure upon the bronchi or trachea causes cough and dyspnoea. Transudates
may appear in the serous cavities and pupillary disturbance from pressure
upon the sympathetic may be noted. Involvement of the vagus may cause



5l8 DISEASES OF THE DUCTLESS GLANDS.

a disturbance of the cardiac action. The skin may become bronzed; crops
of furuncles and pruritus have been noted.

The temperature in the early stages is irregularly elevated from time to
time to a slight degree; later there is a more marked febrile movement, a daily
ascent of several degrees with chills and perspiration, being not unusual.
Rarely paroxysms of fever occur lasting for a week or two. These appear at
intervals, the temperature during the intervening periods remaining normal;
coincident with the fever there may be a rapid enlargement of the glands
which, to some extent but not wholly, disappears during the afebrile period.
Such febrile paroxysms have been attributed to reciuring infection.

The late stages of the disease are marked by extreme weakness and ema-
ciation; general oedema is sometimes present.

The blood shows a moderate anaemia of chlorotic type, the number of
red cells being relatively high while the haemoglobin percentage is low. Changes
in the form of the red cells are not constant nor marked. The leucocytes
usually show no characteristic change in number or in type. In some instances
a relative lymphoc)Atosis has been observed; an ante mortem leucocytosis has
also been described.

The diagnosis should be made with care, there being several conditions
which resemble Hodgkin's disease sufl&ciently to render mistakes easy.

Glandular tuberculosis may be differentiated by the greater tendency of
the glands to coalescence and suppuration. The tuberculin test should be
employed and, if necessary, a portion of the involved tissue may be excised
and examined microscopically.

Malignant disease is more likely to be limited to a single group of glands
and the neighboring structures are as a rule invaded; microscopical examina-
tion of a section of the tumor will confirm the diagnosis. In lymphosarcoma
the lymphoc)^es are usually considerably increased unless there is involve-
ment of the entire lymphatic apparatus, when these elements are greatly
reduced as a result of the disease of the tissues which form the lymphocytes.

Leucaemia may be differentiated from Hodgkin's disease by blood exami-
nation and by histological examination of the glandular tissues which are
affected.

The prognosis is distinctly unfavorable but the course of the disease is not
constant. Certain instances, in which the evolution of the lymphoid enlarge-
ments is rapid, may terminate fatally in a few months but the average dura-
tion of life after the onset of the disease is about two years. Temporary
periods of remission during which all the symptoms become ameliorated, the
swellings diminish and the patient shows marked improvement, are not
uncommon.

Treatment. The general management of this affection as regards hygiene,
diet, etc., is identical with that of leucaemia. Tonics such as iron, strychnine



STATUS LYMPHATICUS. 519

and codliver oil are often very useful. Bone-marrow may be prescribed.
Arsenic, however, seems to be the most effective drug at our disposal. Under
its administration the glandular swellings often diminish, the condition of
the patient is markedly changed for the better and the course of the disease
is retarded even if recovery does not ensue. It may be given in the form of
Fowler's solution of potassium arsenate — in increasing doses, beginning with
3 or 4 minims (0.2 to 0.25) 3 times daily after eating. It should be well diluted.
The dose is increased each week by i minim (0.065) ^^til the patient is taking
20 to 30 minims (1.33 to 2.0) 3 times a day. Upon the appearance of gastric
disturbance the drug should be stopped and later resumed. In the mean-
time we may inject the Fowler's solution directly into the glandular tumor.
The proper amount is slightly less than that to be given by mouth, diluted
with an equal amount of sterile water. Arsenic administered in this way
is said to be very effective. Sodium dimethyl arsenate and disodium methyl
arsenate may also be employed as suggested in the section upon the treatment
of pernicious anaemia.

Inunctions of 10 percent, iodine in vasogen or of potassium iodide may
have some influence upon the glandular enlargements and the administration
of phosphorus has been suggested. Berberine siilphate is advised upon the
ground that it betters the general condition, increases the appetite and lessens
the tendency to increase in size of the spleen. Its dose is from 7^ to 15 grains
(0.5 to i.o). It may be prescribed in powder mixed with milk sugar or in
piUs each containing 3 grains (0.2) of berberine sulphate and 2 grains (0.13)
of extract of gentian. Of these three should be taken 3 times daily.

Symptomatic cures have been reported as resulting from Rontgen ray
treatment and improvement is said to take place in many instances. A
relatively hard tube should be used and is so excited as to give a light pene-
trating enough to reach the diseased tissues. The ray is applied to the enlarged
glands, the spleen, the chest, elbows and knees, care being taken to avoid
burns, and the organs of generation being protected by an opaque screen.
The number, intervals and duration of the treatment are to be regulated
in accordance with the effect produced.

When the lymphoid enlargement involves the neck only, particularly if
the glands of only one side are affected, excision of the tumors is considered
advisable and may delay the progress of the disease.

STATUS LYMPHATICUS.

Synonym. Lymphatism.

Definition. A rare affection characterized by a hyperplasia of the various
lymphoid structures and tissues of the body, including the lymph nodes, the
spleen, the thymus gland and the lymphoid marrow of the bones.



520 DISEASES OF THE DUCTLESS GLANDS.

etiology. The condition is chiefly observed in children and adolescents;
nothing definite is known of its causation.

Pathology. The lymphoid tissues of the pharynx and the lymph glands
of the chest and abdomen are most frequently involved; the superficial lymph
nodes are seldom aft'ected. Enlarged tonsils and adenoid growths are common
and the solitary and agminated glands of the intestine are often greatly increased
in size. The splenic h}^erplasia is not particularly marked, the consistenc}-
of the organ is soft and the Malpighian corpuscles are distinct. Enlarge-
ment of the thymus gland is the rule, the structure is soft and upon its
cut siirface a milky fluid may appear. The marrow of the long bones
may be in a condition of hyperplasia and red marrow may replace the
yellow.

Associated lesions in certain instances are cardiac and aortic hypoplasia
and rickets.

The chief point of interest concerning the status lymphaticus is its tendency
to association with sudden death from apparently inadequate causes such as
short chloroform or aether anaesthesia, or the injection of a dose of diphtheria
antitoxin. Instances of sudden death while bathing, or upon faUing into
the water although immediate rescue has taken place have also been attributed
to lymphatism. The so-called "Thymus Death" of the Germans has been
considered a result of this condition and persons who have died suddenly
during the convalescent period of the acute infections have sometimes been
thought to have possessed this affection.

The status lymphaticus has been considered to be associated with a condi-
tion of intermittent lymphotoxaemia or due to excessive production of the secre-
tion of the thymus gland and it has been supposed that the sudden death is
probably the result of such toxaemia or occurs as a result of toxic, physical or
psychic injuries which are predisposed to by the already existing lymphotoxaemia.

The recognition of the condition is often difficult but in general it may be
stated that it is characterized by a pale and pasty skin, a considerable amount
of subcutaneous fatty tissue, hypertrophy of the superficial lymph glands,
especially those of the cervical and axillary groups, enlargement of the tonsils,
and the presence of pharyngeal adenoids. The patient is often rickety and
there may be enlargement of the spleen and of the thymus gland. H}^er-
trophy of the deep lymph nodes is less frequent than that of the superficial
groups and cardio-vascular hypoplasia is very inconstant, although the state-
ment has been made by Quincke that dilatation of the left ventricle and a
shrunken condition of the peripheral arteries may be observed.

Treatment. This is based upon the underlying conditions. Individuals
in whom the condition is suspected should not be subjected to general anaes-
thesia. If surgical operations are necessary they should be done under the
influence of cocaine or some analogous drug.



DISEASES OF THE THYROID GLAND. 52 1

DISEASES OF THE THYROID GLAND.

SIMPLE GOITRE.

Synonyms. Bronchocele; Struma.

Definition. A non-inflammatory enlargement of the thyroid gland occur-
ring sporadically or endemically.

etiology. The cause of simple goitre is unknown but it has been thought
that the endemic type of the affection may be due to some constituent of the
drinking water. Goitre is much more common in women than in men both
in its sporadic and endemic forms and the most common time for its develop-
ment is shortly after the onset of puberty. In some instances the swelling does
not appear until the incidence of the menopause. Heredity may have some
influence in its production and congenital instances have been observed.

In the United States endemic goitre is infrequent but the condition is not rare
in regions about the eastern shore of Lake Ontario, Michigan and certain
mountainous districts in Pennsylvania. It is very common in certain parts
of Switzerland, France and Italy and may occur in connection with cretinism.
In Derbyshire, England, it is observed and a large proportion of the inhabi-
tants of some portions of central Asia are affected with the disease.

An acute epidemic form of goitre has been described as breaking out in
schools and garrisons, persisting for a few months and then subsiding.

Patients afflicted with sporadic goitre are quite frequently seen.

Pathology. Simple goitre begins as a hypertrophy of the parenchyma of
the gland but as the enlargement develops certain peculiarities appear result-
ing in goitres of various types: a. Parenchymatous ^oz7re in which the increase
in size affects all the elements of the gland uniformly, h. Vascular goitre
in which the enlargement is chiefly the result of dilatation of the blood-vessels.
c. Cystic goitre in which the foUicles become enlarged and contain fluid and in
which calcareous degeneration of the walls is frequent; d. Fibrous goitre
which is characterized by increased growth of connective tissue, e. Colloidal
goitre in which the enlarged foUicles are distended with coUoid substance.
Combinations of these varieties are not uncommon.

Symptoms. When smaU, goitrous enlargements usually cause no symp-
toms; large goitres cause symptoms which are chiefly the result of pressure
upon neighboring structures. Pressure upon the trachea causes difl&culty
in breathing, upon the oesophagus interference with deglutition. Extension
of the tumor behind the sternum may compress the veins draining the head
and neck, and cause swelling of these parts, with vertigo or headache. Rarely
there may be pressure upon the vagus resulting in paralyses of the vocal chords
or glottic spasm. Sudden death has been observed in rare instances and
has been attributed to pressiire upon the pneumogastric nerve or hemor-
rhage.



522 DISEASES OF THE DUCTLESS GLANDS.

Examination reveals a tumor of varying size which rises with deglutition
and involves either the entire th}Toid gland, one or both lateral lobes or the
isthmus alone. In cystic goitre, fluctuation of the fluid contents of the cysts
may be detected and in the vascular type pulsation may be present.

Treatment. In goitrous regions only boiled water should be drunk and, if
possible, a change of climate shoiild be advised; even after the appearance
of the tumor recovery has been observed upon removal to a non-goitrous
district.

Iodine externally and internally seems to have more influence upon the
size of the tumor than any other drug. It is given by inunction into the tumor
in the form of the ofi&cial iodine ointment, as the ointment of red mercury
iodide or in an ointment consisting of i part of iodine, lo parts of potassium
iodide to loo parts of lanolin or lard; lo percent, iodine in vasogen is also
suggested as an inunction. Internally the tincture of iodine in doses of from
3 to 10 minims (0.2 to 0.66) may be prescribed; it should be taken twice a
day after eating and diluted with simple syrup. Potassium iodide in doses
of from 10 to 20 grains (0.66 to 1.33) or the syrup of hydriodic acid in doses
of I drachm (4.0) in a wine glass of water before meals may prove useful.

The injection of iodine, 15 to 30 minims (i.o to 2.0) of a 10 percent, alcoholic
solution, into the substance of the gland has been suggested. The procediure
may be carried out two or three times per week. Iodoform injections have been
practised and are particularly indicated in the cystic type of the affection;
the cyst contents having been drawn off by means of an aspirating needle,
30 minims (2.0) of a solution containing 15 grains (i.o) of iodoform, if
drachms (7.5) each of gether and sterile olive oil are injected at intervals of
from one to two weeks.

In vascular goitre, ergot in increasing doses may be administered and
belladonna has also been suggested.

The organotherapy of goitre has been advocated with enthusiasm and
has proved beneficial in some instances. The extract of the thyroid gland
may be given in doses of from 3 to 5 grains (0.2 to 0.33) 3 times a day or the
fresh thyroid of the sheep chopped and spread upon bread may be prescribed;
75 to 150 grains (5.0 to lo.o) of the gland being given twice weekly.

The use of electricity may be tried in recent goitrous swellings of the hyper-
plastic type, A needle attached to the negative pole is inserted into the gland,,
the positive pole, to which a sponge electrode is fitted, being applied to the
skin of the adjacent parts. The galvanic current is employed and the result-
ing electrolysis may diminish the size of the tumor.

Surgical treatment is indicated when the tumor has become so large as
to cause distress by its pressiire or disfigurement. The entire gland may be
excised if desired but there is always the possibility of resulting myxoedema
or cachexia strumipriva. In vascular goitre particularly, the ligation of the



CONGESTION OF THE THYROID GLANDS. 523

thyroid arteries has been advised. Other surgical procedures which may be
undertaken are partial thyroidectomy, incision of the isthmus, and evacua-
tion of the contents of cysts followed by the injection into their cavities of
iodine or iron chloride solutions.



CONGESTION OF THE THYROID GLAND.

Congestion of the thyroid gland is often observed in girls at puberty and
there is frequently a temporary enlargement coincident with the menstrual
period. Such enlargement is extremely rarely permanent. Increase in the
size of the organ has also been observed as a result of violent and prolonged
weeping, wearing too tight collars and the over-use of the voice.

ACUTE THYROIDITIS.

Acute thyroiditis, general or confined to one lobe of the gland, is evidenced
by acute swelling, tenderness and redness. Rarely suppuration may follow
with destruction of the organ and resulting myxoedema.

This affection is seldom primary but is a not very infrequent complication
of the acute infectious diseases, especially enteric fever, scarlatina, diphtheria
and pneumonia. Exophthalmic goitre has been observed as a sequela.

EXOPHTHALMIC GOITRE.

Synonyms. Graves' Disease; Basedow's Disease; Parry's Disease.

Definition. An affection characterized by enlargement of the thyroid
gland, protrusion of the eyeballs, rapid pulse and tremors.

.Etiology. The disease is much more frequent in women than in men and
is most often observed in young and middle-aged adults. Instances have