is most effective when begun early. Iodothyrin is said to be less apt to cause
unpleasant manifestations than the glandular substance or extract, and to be
quite as productive of good results.
532 DISEASES OF THE DUCTLESS GLANDS.
Cachexia strumipriva necessitates the thyroid treatment just as do the
other types of myxoedema and its continuance for the remainder of the patient's
life is usually essential; periods of intermission, however, are often advisable,
the reappearance of symptoms being the signal for the resumption of the
thyroid preparation chosen.
The glycerin extract of the thyroid gland may be made by separating the
connective tissue from the substance of several dozen thyroids of calves or
young sheep; these are divided into small pieces and covered with pure gly-
cerinj* about 30 minims (2.0) of the latter substance being allowed for each
lobe used. The mixture is allowed to stand for thirty hours and is then
pressed through a cloth, so as to obtain as much liquid as possible. Of this
about 30 minims (2.0) constitute a dose. The fluid may be given hypoder-
matically by adding to it i percent, aqueous solution of phenol (carbolic acid)
in the proportion of 60 minims (4.0) to 30 minims (2.0), the dose of the mixture
being from 10 to 15 minims (0.66 to i.o) three or fom* times weekly.
The gland substance itself may be given raw or slightly cooked. When
prescribed thus it may be finely divided and spread on bread, the daily quan-
tity being from one-fourth to one-haK a gland daily.
Th}Toid grafting has been employed in cretinism and myxoedema, the
fresh gland of the sheep being implanted in the peritonaeal cavity of the patient.
Previous to the operation, thyroid extract should be given until the symptoms
of the disease have been at least partially relieved. By means of this procedure
a temporary disappearance of the affection has been effected; ultimately, how-
ever, the symptoms have usually reappeared and a second operation or the
administration of thyroid preparations has become necessary.
NEOPLASMS OF THE THYROID GLAND.
Various new growths may involve the th)Toid gland; of these the most
common are:
1. Adenoma. This type of tumor is usually encapsulated and may be
either single or multiple. The malignant adenomata may be associated with
metastases in different parts of the body.
2. Sarcoma of the thyroid may occur.
3. Tuberculoma of the gland has been noted in association with tuber-
culosis of other structures, but is rare.
4. Gummatous tumors of syphilitic origin.
5. Hydatid cysts.
All these are of little medical interest and their treatment, with the excep-
tion of the tuberculous and syphilitic growths, is surgical.
Accessory and aberrant thyroid glands; these are not of very unusual occur-
DISEASES OF THE THYMUS GLAND. 533
rence. They may be found anywhere between the base of the tongue and the
aortic arch. Tumors of thyroid tissue of considerable size have been found
in the mediastinum and pleura. The lingual thyroid may grow to the size
of a pea and is usually situated in the substance of the lingual muscles or is
attached to the hyoid bone. A goitrous condition, characterized by moderate
enlargement of this structure, has been observed and, in the absence of the
normal thyroid, its excision has resulted in myxoedema.
DISEASES OF THE THYMUS GLAND.
The functions of this structure are not definitely known. The organ
increases in size up to the end of the second year, weighing at this time in the
neighborhood of one ounce (30.0) ; from the age of two years, it gradually shrinks,
until at puberty it has become a mere bit of fatty tissue.
The thymus gland is subject to various pathological changes.
Hypertrophy of the gland is sometimes observed and one of the chief points
of interest in this condition is its influence in the production of thymic asthma
which is a result of pressure. Laryngismus stridulus has also been attributed
to enlargement of the gland; certain clinicians, however, beUeve that the
latter is a convulsive affection and in no way due to thymic hj^ertrophy.
Thymus Death. Instances of sudden death in children have been observed
which are associated with hypertrophy of the gland and sometimes with a
hyperplastic condition of the entire lymphatic system (see the section upon
Status Lymphaticus). Where the thymus only has been found enlarged, death
has been thought to be due to pressmre upon the trachea or upon the pneu-
mogastric nerve. Epilepsy is sometimes accompanied by a persistently enlarged
thymus gland and hyperplasia of the other lymphatic tissues.
Enlargement of the gland has been found in exophthalmic goitre.
Atrophy of the thymus gland is occasionally observed both in primary
and secondary types. The former is believed to have some association with
marasmatic conditions and the latter is found in chronic wasting diseases
such as tuberculosis.
Haemorrhages into the thymus gland occur in the various haemorrhagic
diseases and have been noted in children after death from asphyxia.
Abscess of the gland has been found and is said to be chiefly associated
with instances of congenital syphilis.
Neoplasms such as sarcomata, gummata and dermoid cysts are not very
uncommon and mediastinal tumors not infrequently develop from the remnant
of the gland.
Tuberculous inflammation, characterized by the production of miliary
tubercles, has been described.
534 DISEASES OF THE DUCTLESS GLANDS.
DISEASES OF THE SUPRARENAL CAPSULES.
ADDISON'S DISEASE.
Definition. A chronic affection probably the result of non-function of
the suprarenal bodies and characterized by progressive weakness, pigmen-
tation of the skin and digestive irritability.
Etiology. The disease is more frequent in men than in women and it
usually appears during young adult life or in early middle age. One con-
genital instance has been reported. The onset of symptoms may be subse-
quent to traumatism of the abdomen or back or to spinal caries.
Pathology. The most common post mortem lesion is tuberculosis of
the suprarenal capsules with fibro-caseous and calcareous degeneration.
Other conditions which have been observed are cystic and fatty degeneration,
atrophy, simple or preceded by a chronic interstitial inflammation, carci-
noma, sarcoma, haemorrhage and embolism. In some instances the supra-
renal bodies have been found normal and here the symptoms have been
accounted for by inflammation of or pressure upon the sympathetic ganglia.
Degeneration and pigmentation of the semilunar ganglia and sclerosis of
the nerves have been noted. Cicatricial tissue about the suprarenals may
siirround the ganglia. An enlargement of the spleen and of the thymus
gland may exist as associated lesions.
The two chief theories of the pathogenesis of Addison's are (i) that it is
due to non-function of the adrenals just as myxoedema is the result of a similar
condition of the th3n:oid gland; (2) that it follows some interference with
the proper working of the abdominal sympathetic system usually caused by
disease of the suprarenal capsules and by other affections of the solar plexus.
Symptoms. The onset of the disease is usually slow, with gradually increas-
ing asthenia followed by cutaneous pigmentation. An acute type of the
affection has been described in which a rapid evolution of the symptoms has
taken place after severe shock or depression.
The discoloration of the skin is, as a rule, the first symptom noticed; this
varies from light yellow to dark brown or even black. It is most apparent
upon the exposed parts such as the face and hands, in other situations where
pigment is normally most abundant and where the skin is irritated by the
clothing. Rarely the pigmentation may be general and at times it is wholly
absent. It is often found upon the mucous membranes of the mouth, con-
junctiva and vagina. At times there are patches of leucoderma, the normal
pigment being entirely absent. Very infrequently there may be deposits
of pigment in the serous membranes and upon the discolored skin there may
be small spots of deeper pigmentation.
The digestive symptoms consist of nausea and vomiting, particularly
Addison's disease. 535
marked at the inception of the disease; diarrhoea may be present from time
to time and anorexia is not infrequent. In the late stages abdominal pain
with retraction may appear.
Progressive weakness is a constant and characteristic symptom and may
become so extreme that the patient is unable to leave his bed. With the muscu-
lar weakness there is accompanying cardiac asthenia with feeble heart action,
smaU and rapid pulse, dyspnoea, dizziness and even fatal syncope. Head-
ache and pain in the back are common. Convulsions may occur.
The condition of the blood is usually normal; the same is true of the urine
but increase in the contained pigment has been observed. Polyuria may
occur.
The diagnosis should not be made upon the presence of cutaneous pig-
mentation alone for there are many conditions of which this is an accom-
paniment. Of these may be mentioned peritonseal tuberculosis, abdominal
malignant growths, melanotic cancer, pregnancy, hepatic disease, bronzed
diabetes, vagabondism with marked filthiness, the prolonged administration
of arsenic, exophthalmic goitre and cardiac and arterial disease. All these
should be excluded before Addison's disease is diagnosticated and even then
associated symptoms — weakness and gastro-intestinal disorders — should be
sought before arriving at a definite conclusion. The employment of the
tuberculin test may clear up doubtful instances if due to tuberculosis of the
adrenals.
The prognosis is unfavorable although treatment may prolong life and
make the patient comfortable. Marked pigmentation augurs a protracted
course and patients in whom this manifestation is slight or absent usually
fail rapidly. There are cases in which the evolution of the affection is acute,
and the symptoms marked, in which death takes place within a few weeks.
The average duration of the disease is from two to three years. Death occurs
as a result of the increasing weakness, in syncope or from associated tuberculous
lesions.
Treatment. The management of this disease should be so carried out as
to conserve the patient's strength as much as possible and to sustain the proper
functions of the various organs. The patient should live a quiet life and all
physical and mental excitation should be avoided on account of the danger
of sjmcope. In the later stages it is best to confine the patient to bed. The
diet should be plentiful, nourishing and easily digestible; during the periods
of gastric and intestinal disturbance, a strictly fluid regimen, consisting of
milk, broths, etc., should be enjoined. Iron may be given as a tonic but,
as ansemia is seldom a prominent feature of the disease, is usually less
efficient than strychnine, arsenic, codliver oil, phosphorus and the bitters.
Acute vomiting and diarrhoea necessitate a diet of fluids such as milk, kou-
myss, matzoon, peptonized milk, albumin water, etc., and the administration
536 DISEASES OF THE DUCTLESS GLANDS.
of antiemetic drugs such as cerium oxalate, of which 10 grains (0.66) may be
combined with 20 grains (1.33) of sodium bicarbonate and added to each
glass of milk; in this connection cracked ice, iced champagne, dilute hydro-
cyanic acid, creosote and tincture of iodine are useful. The diarrhoea may
be controlled by the ordinary means, such intestinal disinfectants as phenyl
salicylate and bismuth naphtholate being especially useful; other bismuth salts
are also effective. The muscular weakness may be combated by the use of
electricity, massage and hydrotherapeutic measures.
T-iie extraordinary results achieved in myxoedema by the administration
of the thyroid gland would give ground for hope that in the analogous con-
dition present in Addison's disease equally good results might follow the
use of the suprarenal extract. Unfortunately treatment by this means as yet
has proven of little benefit but it is quite possible that the resulis of future
experimentation may be more favorable than those achieved up to the present
time. Instances have been cited in which the administration of a glycerin
extract, made from the suprarenals of the pig just as the thyroid extract
(see p. 530) is made, given in doses of about 4 ounces (120.0) three times daily,
was followed by marked improvement; the pigmentation, however, persisted.
The suprarenal gland may be taken raw or slightly cooked or the gland sub-
stance may be prescribed in the form of tablets of the dried extract. The
dose of desiccated suprarenal glands is 4 grains (0.25). The usual daily
dosage of the suprarenal preparations is about the equivalent of two glands.
While no curative effect should be promised from this treatment, a trial of it
should never be omitted as no evil sequelae result and much benefit may
follow.
DISEASES OF THE PERICARDIUM. 537
CHAPTER VII.
DISEASES OF THE HEART AND BLOOD-VESSELS.
DISEASES OF THE PERICARDIUM.
ACUTE PERICARDITIS.
Definition. An acute inflammation of the serous membrane surrounding
the heart.
.Etiology. This affection may occur primarily as a result of tuberculous
infection, as a resiilt of traumatism either external or internal, from the migra-
tion of a foreign body from the oesophagus, or perhaps as a result of rheu-
matic infection which manifests itself in the pericardium instead of in the
articulations. Idiopathic cases may be observed.
Secondary pericardial inflammations are far more common than primary.
They may occur as a complication of acute rheumatism, accompanying joint
inflammation or tonsillitis; as a complication of the acute infectious diseases,
particularly scarlatina and acute infectious pneumonia; in septicaemia and
pyaemia; in tuberculosis; wiih chorea; and in the later stages of various
chronic dyscrasiae such as gout, nephritis, diabetes and the haemorrhagic
diseases.
Pericarditis also occurs as an extension of affections of neighboring organs
or tissues, e.g., in chronic endocarditis, pleurisy, pneumonia, aneurysm, etc.
Inflamma:ory processes and neoplasms in the ribs, oesophagus, vertebrae,
mediastinal glands and even of structures beneath the diaphragm may cause
pericarditis by extension.
The disease in the majority of instances is rheumatic in origin; it is common
to all ages but seems to attack males more frequently than females.
Pathology. The disease may be considered to occur in three stages. First,
the membrane is congested and reddened, it becomes roughened and an
exudation of fibrin involving more or less of its surface, takes place, the latter
assuming a ridged or fringe-like appearance. The heart muscle may be in-
volved in the inflammation to a slight degree, if the pericardium is markedly
affected, as evidenced by an anaemic appearance. In tuberculous cases the
miliary tubercles may be detected by close scrutiny. In simple fibrinous
pericarditis the exudation softens and is absorbed, leaving behind a normal
or adherent pericardium, but more often the affection passes on to the serous
stage. Here there is added to the plastic exudate an effusion of serum, which
538 DISEASES OF THE HEART AND BLOOD-\^SSELS.
distends the pericardial sac to a greater or less extent. This fluid is amber-
colored and clear, although in it there may occur floating particles of fibrin.
This effusion may be absorbed, the pericardial surfaces being left adherent in
many instances, or it may become purulent. The adhesions may render the
two layers of the pericardial sac almost like a single thickened membrane or,
\dllous adhesions resulting, the two pericardial layers are permitted to move
one upon the other with the impulse of the heart. These villous adhesions
are composed of vascular connective tissue which is produced by a proliferation
of tbe normal connective tissue of the membrane and resemble the papillae
of a sheep's tongue or buttered surfaces of bread which have been sepa-
rated.
Suppuration may be priman^ or secondar}^ the effusion being purulent
from the first, or, in the latter instance, pyogenic infection of the serous fluid
may take place later. In tuberculous pericarditis the exudate may undergo
caseous degeneration.
The pathogenic bacteria most usually found in acute pericardial inflam-
mations are the ordinary germs of suppuration, the tubercle bacillus and the
pneumococcus.
Symptoms. These differ with the pathological condition; while pericar-
ditis may begin with a chill or pain referred to the heart, the fibrinous tj-pe
often exists without subjective symptoms. The pain may be merely a sense
of cardiac discomfort or it may be referred to the ensiform cartilage or to the
epigastrium. The temperature usually is dependent upon the primary
affection; in primary- pericarditis it seldom exceeds 102° F. (38.9° C). The
pulse is increased in rapidity and dyspnoea may be present. Precordial
tenderness may be observed.
Pericardial effusions by pressure interfere with the heart's action causing a
rapid and perhaps irregular piflse. With inspiration the pulse beat may
become much weakened or even imperceptible {pulsus paradoxus). Inter-
ference with cardiac action also results in dyspnoea, with cyanosis, and the
patient may prefer to lie upon the left side or may be unable to breathe com-
fortably unless he sits up. Large collections of fluid encroach upon the left
lung, press upon the oesophagus causing dysphagia, or upon the left recurrent
larv'ngeal nerve causing aphonia. The patient is restless and sleepless, and
cerebral symptoms, even delirium and coma, may be present, especially in
the rheumatic cases with high temperature. In suppurative pericarditis
the constitutional symptoms are usuaUy more marked and the fever is of
septic t}'pe. The invasion of the pyogenic micro-organisms may be evidenced
by a chiU.
Physical Signs, a. 0} -fibrinous pericarditis. Pressure over the pre-
cordium or over the ensiform may elicit tenderness and upon palpation a
rough fremitus corresponding to the pericardial friction sound may be
ACUTE PERICARDITIS. 539
detected. Auscultation reveals the presence of the pericardial friction sound;
this is heard with greatest intensity over the left half of the sternum at the
level of the foiurth and fifth intercostal spaces and in these spaces close to the
sternum, i.e., where the heart most closely approximates the chest wall; it is
usually a to-and-fro murmiir but may be single or even triple. In quality
it is rasping, grating, or, more rarely, creaking; the sound is close to the ear
and may be increased in intensity by the pressure of the stethoscope. It is
not constant and may at intervals be inaudible or change in its quality or
intensity from time to time or with the position of the patient. Its trans-
mission varies; it may be localized to a small area, or transmitted in various
directions; there is no fixed rule.
b. 0} pericarditis with the effusion of â– fluid. Here the physical signs
vary with the quantity of the fluid. If this is large, and especially in children,
there may be a fulness or bvdging of the precordium and the apical impulse
is wavy or perhaps absent; pressiire upon the left lung may diminish its
expansion and downward pressure may displace the left lobe of the liver and
cause an epigastric prominence. Palpation reveals a diminished or absent
impulse and, as the effusion increases, the friction thrill diminishes; it may
be palpable at the base only and then only when the patient is sitting up. In
the recumbent position it is likely to be absent. Upon percussion an increased
area of dulness is made out, this is irregularly triangular, the base being directed
downward and the apex upward toward the sterno-clavicular articulation.
Rotch's sign, an absence of resonance in the fifth right space, may be present
and there may be an area of dulness or flatness posteriorly below the angle
of the left scapula. Auscultation. The friction sound may disappear on
account of the separation of the layers of the pericardium by the effusion or
it may remain audible over the base of the heart. The heart sounds are
indistinct and muffled or even almost inaudible. The rate of the cardiac
contractions is increased and may become arrhythmic. A systolic murmur at
the base and an accentuation of the pulmonic second sound may be present.
There may be an area of broncho-vesicular or bronchial breathing posteriorly
below the angle of the left scapula or between this point and the vertebral
coliunn.
As the fluid gradually is absorbed the physical signs return to normal,
either with or without the reappearance of the friction murmur, or, if per-
manent pericardial adhesions are formed, the physical signs of this condition
may be apparent.
The diagnosis of pericarditis is often overlooked, consequently in all instances
of acute articular rheumatism daily examination of the heart should be made.
In cases in which the typical to-and-fro murmur, heard close under the ear,
is present the diagnosis is simple, but unfortunately the characteristic physical
signs are often absent; here the direction of transmission of the murmur is
540 DISEASES OF THE HEART AND BLOOD-VESSELS.
of aid, there being no rule for the transmission of a pericardial murmur,
as also is the fact that the sound becomes louder upon pressure wich the
stethoscope. The so-called "pleuroparicardial" friction sound may be dis-
tinguished from the pericardial murmur by the facts that it is more usually
heard over the lefi border of the heart and is louder during expiration, ofcen
being absent during inspiration; also it may cease upon holding the breath,
but not always since it is due to the motion of the heart. The differen-
tiation of pericarditis with eifusion from acute cardiac dilatation : in the
lat^r, if the patient is thin, the apical impulse is diffuse and undula.ory, while
it is usually indefinite or even absent in pericarditis. In dilatation the apex
beat is more distinctly palpable; percussion reveals the t)'pical triangular
area of dulness in pericardias, the upper limit of which may change with the
position of the patient; in dilatation the dull area is not triangular nor does
it extend so high or so low. On auscultation the heart sounds in pericarditis
are mufiled and indistinct while in dilatation they are much less so and may
be sharp and definite. Dulness and changes in the breath sounds below the
angle of the left scapula and tympany in the axilla, due to pressure upon the
lung by the effusion, are absent in dilatation. Large pericardial effusions
have been mistaken for localized pleural exudates. The character of the
fluid cannot be certainly determined without paracentesis, but it is usually
serous in rheumatic, while in pysemic and tuberculous cases it is likely to be
purulent; bloody fluid may occtir in tuberculous pericarditis or that seen as a
terminal inflammation of nephritis, etc.
The prognosis is variable, the sero-fibrinous rheumatic cases usually going
on to recovery in two or three weeks; relapses may, however, occur, or the
condition pass on to a chronic adhesive pericarditis. Recovery from septic
and tuberculous pericarditis is rare.
Treatment. The patient should be at once put to bed and kept at rest.
If he is more comfortable in this position his back may be supported by
pillows or a rest. The over-action of the heart should be relieved by the
application of an ice coil or bag to the precordium. In the rheumaiic cases
sodium salicylate in doses of i to ij drachms (4.0 to 6.0), or aspirin 45
grains (3.0) daily, may be given internally. Usually, however, the inunction
of an ointment containing i part each of salicylic acid, oil of turpentine and
lanolin to 5 parts of simple ointment is to be preferred; of this a drachm (4.0)
should be thoroughly rubbed into the precordium three times a day. The
excitability of the heart is best relieved as above stated by the applica-
tion of cold in connection with the adminis ration of glyceryl nitrate
in considerable doses — gr. -j-^j- (0.0012) — 'hree or four times a day in order
to render the heart's work more easy by lessening the peripheral resistance.
Venesection may be employed in plethoric individuals with the same object in
view. These means are preferable to the administration of digitalis and
ACUTE PERICARDITIS. 541
aconite. If pain is very severe we may give morphine hypodermatically with
atropine — ^ of a grain (0.022) of the former to y-^^ of a grain (0.0006) of
the latter; these drugs, however, should not be employed unless absolutely
necessary.