Eclectic Medicine Part 7

8/2/2019 Eclectic Medicine Part 7

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P ART VII .DISEASES OF THE BLOOD AND

THE DUCTLESS GLANDS.

ANEMIA.

Def in i t ion .By the term anemia is understood a change in thequantity or quality of the blood, and represents a variety of affections,deter iora tion of th e blood being cha ra cter istic of each.

There may be a reduction in the volume of blood, without alteration ofits composition, when th e t erm oligemia is a pplied, or a redu ction in t henumber of red corpuscles, is termed oligocythemia, and when theam oun t of hemoglobin is deficient oligoch-romemia is the ter m app lied.

The simplest and perhaps best classification of anemia is into primary,or idiopat hic, an d seconda ry or sympt oma tic.

By primar y, idiopat hic, or essen tial a nem ia, is un derst ood a d istur ban ceof the blood or blood-making organs, or both, the anemia being thedistinctive feature of the lesion, and all the other symptoms areseconda ry or dependen t u pon t hese.

By secondary anemia is understood a disturbance of the blood, due to

some disease acting upon the blood or blood-making organs, the anemiabeing secondary.

Primary anemia is divided into two distinct forms: Chlorosis andprogress ive pern icious an emia.

CHLOROSIS .

S y n o n y m .Green Sickn ess ; Chloremia.

Def in i t ion .A form of primary anemia affecting mostly girls at theperiod of puberty or early womanhood, and characterized by a markeddeficiency of hemoglobin in the red corpuscles.

Et i o l o g y .The disea se is confined a lmost en tir ely to fema les. Noorden,

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Eichorst, Jurgensen, Hayem, Luzet, and Liebermeister hold thatchlorosis n ever occur s in th e ma le; but of one hu ndr ed a nd eight y casesof chlorosis reported in the Leipsic Medical Clinic, eight occurred inma les, th ough some doubt exists a s to th e corr ectn ess of th e diagnosis.

The disease nearly always appears during the second decade, orbetween th e four teenth an d twentieth year.

Un hygienic surr oun dings un doubt edly figur e a s a cau sal factor, for it isquite common in those closely housed, and where the air is bad, andwhere there is little sunshine. Factory girls, clerks, sewing girls, andthose. confined in badly lighted and poorly ventilated quarters, wherethe work is exacting and the hours long, and who eat hastily,impr operly pr epared food, ar e prone t o ch lorosis. While th ese cond itionsfavor this lesion, it must also be recognized that girls reared in luxury

ar e nu mbered am ong its victims.

Heredity is supposed to have some influence in predisposing to thedisease, chlorotic children not infrequently having the history of anemiaru nn ing back two genera tions.

There seems to be a close relationship between tuberculosis andchlorosis, since girls who have a st ru mous t endency a re pr one t o becomechlorotic. Some h ave claimed th at it is du e to men ta l emotion, a nd citecases where chlorosis developed after sudden shock or violent emotion,

homesickn ess, and disa ppointmen t in love.

Sir Andrew dark considered it due to the absorption of toxic productsfrom cons tipa tion.

A change of climate has been considered a cause, and girls who haveemigrated to this country and become chlorotic have been cited asexamples. It is more probable, however, that a change in the manner ofliving h as been m ore r espons ible for chlorosis th an clima te.

We may infer t ha t an y condition t ha t lowers th e vita lity an d impairs t heblood-making function is a factor in producing chlorosis.

P a t h o l o g y .The pat hological cond itions ar e not very well un ders tood,few cases dying of th e disease, and where a ut opsies ha ve been h eld thecondit ions wer e not cons ta nt .

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According to Rokitansky, incurable cases of chlorosis are characterizedby a defect ive form at ion of the blood-vessels a nd genita lia. Virchow a lsofound a congenital hypoplasia of the vascular system in severalau topsies on chlorotic pat ients. In some cases t he ut eru s an d appen dag-

es were imperfectly developed. Fatty degeneration of the intima of thearteries is sometimes noticed, and the heart has been softened, dilated,an d th e left vent ricle hypertr ophied.

There is a marked reduction in the hemoglobin, and though the redcorpuscles are changed in size, there is but a slight reduction innu mber s. The specific gra vity of the blood is redu ced.

S y m p t o m s .The disease usually comes on gradually, the patientlosing color and taking on a greenish-yellow hue; hence the term green

sickness, characteristic of chlorosis. Sometimes the color of the cheeksand lips are retained, when the term chlorosis rubra is applied. Thesubcutaneous fat is retained, and in some cases increased. There islanguor, weakness, with dysp-nea, and palpitation of the heart onexert ion. The pa tient complains mu ch of headache a nd dizziness.

There is usually gastric derangement. The appetite is very poor orperverted, there being a craving for charcoal, chalk, slate-pencils, oreven ea rt h, p ickles, and highly spiced ar ticles of food. Following a mea l,th ere a re a cid eru cta tions, r egurgitat ion of food or vomiting, th e pa tient

complaining of more or less pain. The tongue is usually pale, with adirty coat ing, showing inden ta tion of th e teeth , or it is dry a nd brown.

Constipation is nearly always found, though a diarrhea frequentlyint erven es, owing t o ingestion of some u nwh olesome food.

The pu lse is sm all, frequen t, an d easily compr essed, while the sk in a ndextrem ities ar e cold. In some cases pu lsat ion is visible in t he carotids a ndsuper ficial veins .

Exam inat ion of th e hear t r eveals a soft systolic mu rm ur , hea rd t he mostpronounced over the pulmonary area. Sometimes a systolic murmur isheard over the subclavian artery. A continuous murmur is often heardover the veins of the neck, and is called the venous hum or bruit dediable.



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In some cases there is an absence of horizontal folds in the foreheadwhen t he pat ient is suddenly asked t o look u p with out ra ising th e head.This is kn own a s t he J effrey's sign. Edem a of th e an kles appea rs, a ndis often noticed wher e t he disease is of long st an ding. The ur ine is pa leand of low specific gravity. The conjunctivas become pale, while the

sclerotic coat assumes a pearly or bluish-white color, and is consideredby some as pa thognomonic of ch lorosis.

Neur algic pain s of th e head, ringing in t he ear s, ment al depression, an dgastralgia and hysterical attacks are often present. Menstruation isgener ally ar rest ed or scant y, th ough m enorr ha gia sometimes exists.

D i a g n o s i s .This is usually readily made. When a young girl appearswith a yellowish-green hue, dyspeptic symptoms, capricious appetite,dyspnea an d pa lpita tion on slight exert ion, bluish sclerotic coat , scan ty

menstruation, or amenorrhea, constipation, and with a well-nourishedappearance, headache with dizziness, and more or less hysteria, weha ve a group of symptoms t ha t can not be mistaken.

P r o g n o s i s .This will be favorable in all cases except those whereth ere ar e congenita l anomalies of th e vascular a nd genita l system .

T r e a t m e n t .Dr. Scudder used to say: In t he t rea tm ent of chlorosis weha ve th ree pr ominen t indicat ions to fulfill: First , to remove a ny diseasewhich may exist independently of the chlorotic condition, and which

may, by its continuance, tend to keep it up. Second, to restore the bloodto its normal condition, by the use of tonics and iron, nutritious diet,appropriate exercise, the use of baths, etc. Third, to stimulate theuterine organs to a performance of their natural functions. I amsatisfied if we can correct the first two conditions the third will rightitself.

To restore the blood to its normal condition requires, first, good food,capable of making good blood; an d, second ly, a good digestive a ppa ra tu sto prepa re it for its fina l elaborat ion into hea lthy r ed corpu scles. Takin g

for granted that the patient lias a good food-supply, our first object willbe to restore the digestive organs. Wrongs of the stomach andcons tipa tion of the bowels will receive first a tt ent ion. It is folly for us toexpect to make good blood by the administration of iron, when ourpatient ha s a bad stomach, as shown by the coat ed tongue, bad brea th ,more or less n au sea, an d with th e bowels const ipated.

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First clear the tongue, restore the appetite and overcome theconstipation. Where the tongue is heavily coated, the quickest way toget relief is th e old lobelia em etic, with copious d ra ugh ts of war m wa ter .By it s action th e stoma ch is t horoughly empt ied of a viscid an d offens ive

mucus and put into condition for the digestion of food and theabsorption of medicines. It is, however, unpleasant treatment, and haslargely gone out of use. The more modern method is, to wash out thestomach three or four times a week with the lavage tube. If the tonguehas a dirty, pasty coating, sodium sulphite will accomplish the sameresults. Where the tongue is moist and yellow, with offensive breath,nothing quite equals potassium chlorate and phosphate of hydrastin. Ifth e tongue be slick a nd d irt y, su lphu rous a cid will corr ect t he wr ong. Assoon as the tongue cleans, and the appetite improves, nux andhydrastin can be given with benefit, or drop doses of Howe's acid

solution of iron. Cuprum is a good remedy where the skin is of agreenish-yellow color, and the tongue clean. Of the tincture add ten totwen ty drops to ha lf a glass of wat er, an d give a tea spoonful every th reehours.

For th e const ipation t he sm all Podophyllin a nd h ydrast in pill, with da ilymassage of the bowels, will prove curative. If very obstinate, anoccas iona l fifteen or t went y grain dose of sodium phosph at e will act a s apersu ader . As a tonic, th e old compound tonic mixtur e (tr iple phospha teof quin ine, str ychn ia, an d iron) is one of th e best.

As the patient improves, pulsatilla, viburnum, macrotys, and suchremedies as act upon the reproductive organs may be used, though inmost cases, as the general health improves, the menstrual functiontakes care of itself. The patient should live as much out of doors aspossible, though exercise should never be carried to the extent ofweariness. The diet should consist of broiled steak, lamb-chops, roast-beef, fresh eggs, farinaceous vegetables and ripe fruit.

P ROGR ESSIVE P ER NICIOUS ANEMIA.

S y n o n y m s .Idiopathic Anemia; Essential Anemia; CorpuscularAnemia.

Def in i t ion .A grave blood-disease, characterized by a progressive

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decrease, in the number of red corpuscles and by fatty degeneration ofth e var ious viscera , and a cha ra cter istic, lemon-yellowish decolora tion ofthe skin.

Et i o l o g y .Pernicious anemia depends upon an insufficient and

defective formation of red corpuscles, and is found more frequently inmiddle life than in the young, and among the poor classes rather thanthe well-to-do, though it may be found in children and persons ofwealth.

It is not a common disease, though in Switzerland it prevails morefrequently than in any other country. Addison was the first to clearlydescribe pernicious anemia as an idiopathic disease, and though therehave been many who have doubted that it could exist as a distinctlesion, we will have to admit t ha t t her e ar e cases of an emia, when t her e

is no appreciable cause, cases that have not been preceded bytuberculosis, Bright's disease, malignant growths, renal, hepatic, orsplenic affections, wast ing diseases, hemorr ha ges, or chronic diar rh eas .

Pregnan cy and part ur ition ma y be associated with an emia. The cour seof pregnancy may be attended with so much nausea rind vomiting thatthe function of blood-making is seriously impaired, and anemia of apermanent character develops. Generally, however, the anemiadevelops post partum. Atrophy of the stomach has been regarded as acause of anemia, the two being often associated, though Grawitz

regards t he atr ophy the result , rath er tha n t he cause.

In rare cases, parasites may be the producing cause, by impairingnutrition and establishing toxins that result in cell destruction ; theanchylostoma duodenalis and the bothriocephalus being the ones mostfrequ ent ly respons ible for t he disea se.

Exhausting diseases and profuse hemorrhages may also figure ascontributing causes, but after we exclude these we still find cases ofpernicious anemia that can not as yet be accounted for. Quincke and

Peters t hink t ha t t he increased h emolysis is due t o th e large amoun t ofiron foun d in t he liver at th is time. Hu nt er called at tent ion t o th e ur ineof anemic patients. He found it darker in color and containingpat hological u robilin. His findings na tu ra lly str ength en t he views of th elast-na med writers.



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P a t h o l o g y .The skin p resent s a cha ra cter istic lemon-tint. Ther e is butlittle ema ciat ion. The fat s a re well preser ved an d of a yellow tinge, whilethe muscles may be pale or of a reddish color, resembling horse-flesh.The heart is flabby, and contains but little blood. There is fattydegener at ion of the organ , th e mu scular fibril being replaced by fat . The

spleen is but slightly enlarged, and shows a cloudy swelling or fattydegeneration. The liver and kidneys present the same characteristicchanges, and in addition, there is an excess of iron. In the liver it isdeposited in the outer and middle zones of the lobules while in thekidneys it is foun d in t he convoluted t ubu les. Hem orr ha ges occur in t heretina, skin, and other portions of the body. There is nearly always acha nge in t he bone-ma rr ow, it. becoming r eddish, an d soft in char acter.The stomach is usually diminished in size, with atrophy of the gastrictubules. The intestinal glandula share in the atrophy. Punctatehemorrhages occur in the brain, and the spinal cord, and posterior

sclerosis of th e cord is n ot in frequ ent.

Fatty degeneration of the various viscera, and even the intima of thesmaller vessels, is perhaps the most constant lesion, if we except theblood changes.

The blood shows a marked diminution of the red corpuscles as well asother changes in these cells. It is pale, thinner, and does not coagulatereadily. The red blood-corpuscles are often reduced to 1,000,000 percubic millimeter, and in extreme cases to 500,000, while 143,000 has

been recorded. The blood-disks are found widely separated, and notforming rouleaux.

These blood-cells are of various sizes and shapes, the giant cellspredominating, though there is a wide range between the megalocytesand the microcytes. In form they may be spherical, oblong, dumb-bellshaped, or of other irregular shapes. There is also a reduction ofhemoglobin. The leukocytes are diminished in number, but do notassume t he peculiar sh apes noticed in th e red blood-corpu scles.

S y m p t o m s .The disease comes on so insidiously that the patient isun able to refer to th e day th at t he disease arrested his att ention. He,perhaps, has noticed for some time that his strength was failing, andthat he was getting pale; that his appetite was poor, and that he tiredreadily on exertion. Among the earlier symptoms are shortness ofbreath, slight palpitation of the heart, dizziness, ringing in the ears,



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and headache. Dyspeptic symptoms are common, and nausea andvomiting, with diarrhea, are often present. The patient takes on alemon-color tint, and the skin is waxy in appearance, and, thoughema ciation does n ot ta ke place, th e tissu es lose th eir tonicity an d becomeflabby.

Respiration is sh ort an d hu rried on t he slightest exertion, an d th ere issometimes pain, more often a sense of constriction of the chest. Thepu lse ma y be full, but is soft a nd eas ily compressed; gener ally, however,it is small and feeble. Hem orr ha ge ma y occur in th e retina , giving riseto disturbed vision. There also may be bleeding from the nose, lungs,ur eth ra , an d ut eru s. As th e disease pr ogresses, th e an kles swell, debilityincreases, and t he pat ient ta kes to his bed.

In advanced cases there may be an irregular fever, anemic fever,

though the temperature range is usually low. The lips and gums arepale and bloodless. The mind wanders, and he sinks into a half-torpidstate. If we examine the heart during this stage we find tlie cardiacsounds feeble and hemic murmurs common, especially over tlie base ofthe hear t .

Treatment may give rise to some encouragement, but a relapse occurssooner or lat er, and th e pat ient dies from exhau stion.

D i a g n o s i s .This is usually not very difficult, though it may be

mistaken for malignant growths, kidney lesions, and various gravediseases. The a ge of th e pat ient a nd t he slow, insidious ma nn er in wh ichthe disease begins, should arouse our suspicions. The increasing pallorcha nging to a lemon-tint, with waxy skin, th e inelast ic, doughy t issues,the absence of emaciation, the tired, wearied condition of the patient onthe slightest exertion, the quick and hurried breathing, would suggestanemia. If retinal hemorrhages are found, they confirm the diagnosis.Micro-scopial examination of the blood not only reveals a markeddecrea se in t he r ed blood-disks , 1,000,000 or less per millimetr e, but a lsoreveals large nucleated led blood-corpuscles, megalocytes and various

sized an d shaped corpu scles.

Can cer is a pt to occur late in life; th ere is great er em aciat ion, more pa in,an d a local t um or can usu ally be out lined.

P r o g n o s i s .All writers agree that pernicious anemia is a very grave

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disease, and that very few cases recover. Under the administration ofarsenic, some cures are recorded, though a patient, seemingly cured, isapt to have a relapse within five years and die. A few permanentrecoveries are recorded.

T r e a t m e n t .All schools of medicine agree that arsenic is the oneremedy that promises greater relief than any yet tried. Whileadministering this agent, we are stimulating the blood making organs,with the hope of getting a better elaboration of blood. Pure air, outdoorexercise, and an easily digested diet will assist materially in bringingabout th e desired result. If the pa tient complains of great weariness, restin bed sh ould be en joined. Daily or t riweekly injections of norm al sa linesolution may prove of some value. Should recovery take place, thepat ient should, at th e first indicat ion of its r etur n, resort t o arsenic.

SECONDARY ANEMIA.

S y n o n y m .Sympt oma tic Anem ia.

Et i o l o g y .All cases of anemia occurring in the course of otheraffections; or d ue t o hemorr ha ge, ar e classed a s seconda ry a nem ias, th evar ious cau ses being included in th e following clas sificat ion :

Hemorrhage.The loss of blood may be rapid and in large quantity,

giving rise to an acute anemia, as where the hemorrhage is due toinjury of the blood-vessel, either from serious wounds or from therupture of an aneurism, or from flooding during parturition. In thesecases, t her e is loss of all th e const ituen ts of the blood. When sudden an din large quantities there is danger of fatal syncope. Severe hemorrhagema y arise from gast ric or du odena l ulcers.

The patient may lose considerable blood in hei nophilia, scurvy, andpur pur a, th ough in t hese cases t he loss is not so rapid.

The loss of blood may be small in quantity each day, but whencont inued for severa l days or weeks, gives rise t o severe a nem ia; thu s inepistaxis, bleeding piles, uterine hemorrhage, or cirrhosis of the liver,we have examples of a large loss of blood, extending over a period ofdays or weeks, and which ma y be considered a s chronic an emia.



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Inanition .This m ay be due to insu fficient food, or t he qu an tit y ma y besufficient, but lack the constituents necessary for the elaboration of anormal blood supply, or, having a sufficient quantity and quality offood, there may be wrongs of the digestive apparatus whereby digestionan d assimilat ion a re impa ired, th us cancer of th e esopha gus or st oma ch,

or at rophy of the gast ric mu cous follicles, or cirr hosis of th e liver, wouldresu lt in a failure t o man ufactu re good m at erial into blood.

Wrongs of the sympathetic nerve, as seen in lesions of the rectum,uterus, and urethra, may so impair the blood-making organs as to giverise to anemia.

Albuminous Waste.A long, continuous drain upon the albuminousmaterial of the blood, as in chronic nephritis, long-continuedsuppuration, chronic diarrheas, profuse leucorrhea, and prolonged

lacta tion gives rise to an emia.

Toxic anemia results from certain organic and inorganic agents; thus,arsenic, lead, phosphorus, and mercury are well-known blooddestr oyers, and t he poison from venomous sn ak es acts in th e sam e way.Of th e chr onic infections, syphilis, tu berculosis, and ma laria ar e ma rk edexamples, and, not infrequently, typhoid fever, pyemia, septicemia,diphtheria, and kindred diseases give rise to anemia. Various intestinalpar asites a lso play some pa rt in producing anemia.

P a t h o l o g y .The condition of the blood varies from the slightestimpairm ent to the gra vest form of an emia, depending upon t he severityand duration of the producing cause, and upon the power of bloodrenewal. The number of red corpuscles and the percentage ofhemoglobin are proportionately diminished, while the red corpusclesremaining, vary in size and shape, some being unnaturally small(microcytes) and others unduly large (macrocytes), while still others areof irregular sizes (poikilocytes). Nucleated red cells are also found, andusually there is an increase in the leukocytes, the exceptions being intuberculosis, enteric fever, measles, influenza, and malaria. The

alkalinity of the blood is generally slightly diminished, the specificgravity reduced, and the watery elements increased, rendering theblood more fluid, and the color of the entire fluid being more pale thannorm al blood.

The fluid and albuminous principles of the blood are quickly restored,

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the corpuscular elements following next in order, and the hemoglobinlast, in some cases the last constituent requiring months before itreaches the norma l sta ndar d.

Females can lose a much larger quantity of blood and recover quicker

than males, though infants of both sexes do not bear the loss of muchblood.

S y m p t o m s .Pallor of the skin, colorless appearance of the ears, andparticularly of the mucous membranes. are among the early symptomsof anemia, though we must remember that not all pale people arean emic, nor th at all an emic people are pa le.

Cardiac Symptoms.The pulse is usually small and rapid, of lowtension, though a high-tension pulse is sometimes encountered.

Palpitation and attacks of syncope are not uncommon. The heart, beingpoorly nourished, is apt to lose its muscular tone, attended by slightdilatations; as a result, a systolic hemic murmur may be heard over thepulmona ry ar ea, and t ra nsmitt ed to th e axilla. The mur mu rs a rise fromdilatation of the left ventricle, which gives rise to relative mitralinsufficiency.

Dyspeptic symptoms are nearly always present; the tongue is pale,broad, and flabby, the appetite poor, some headache, and generallyth ere is const ipation.

Pulm onary sym ptom s ar e present when t he a nem ia is well developed. Aslight hacking cough is common, and dyspnea, on slight exertion,usu ally att ends, a nd occasiona l sighing m ay be n oticed.

Cerebral S ym ptom s .Cerebral anemia is indicated by spots appearingbefore the eyes, ringing in the ears, and vertigo. Mental apathy andinability to concentrate the mind is not an uncommon symptom. Thepat ient complains of a pa in in t he t op of th e hea d.

Nervous symptoms are not infrequently present, the patient beingirritable and restless at night, though drowsy and passive during theday. The patient may complain of hot or cold flashes, crawling orcreeping sensation of the skin, and vague pains in different portions ofth e body. Menstru at ion is distu rbed; at first t here m ay be menorrha gia,but later, the flow becomes pale, scanty, and finally ceases. Generally



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debility is noticed, and in extrem e cases a low tempera tu re is noted.

Edema of the ankles and legs are common, and where tuberculosis orcan cer ar e present, emaciat ion is a ma rked feat ur e.

D i a g n o s i s .A grouping of the above symptoms are so characteristicthat the diagnosis is rendered comparatively easy, but a positivediagnosis is only made by examina tion of th e blood.

P r o g n o s i s .This depends upon the primary lesion that gives rise toth e disease, an d our ability to overcome it .

T r e a t m e n t .The treatment depends upon the cause. If due totraumatic hemorrhages, and they have been arrested, rest, goodnutritious food, and plenty of fresh air and sunshine, will be all that is

required. If due to hemorrhoids, they should be removed; or frommenorrh agia, suitable trea tm ent should be inst itut ed to overcome it.

The pa tient should be exam ined very car efully as to th e cau se or cau sesgiving rise to it, an d th e tr eat men t directed to removing it. The idea t ha tiron and arsenic are to be given whenever anemia is present, is afallacious one.

Wrongs of digestion ar e to be corr ected, cons tipa tion m us t be overcome,and the nervous system built up. Bach case will need a special study,

and special remedies required for individual cases. Copper, iron, andarsenic will be useful agents in connection with the specially indicatedremedy; but, above all, do not forget to give the patient fresh air, plentyof sunshine, n our ishing food, sponge-bat hs, a nd moderat e exercise.

LEUKEMIA.

S y n o n y m .Luekocythemia.

Def in i t ion .A constitutional disease, of unknown causation, andcha ra cter ized an at omically by cha nges in t he spleen, lymph at ic glan ds,singly or combined, an d a ccompa nied by a m ar ked increase in th e whitecorpu scles a nd a decrease in th e red.

H i s t o r y .This rare, but peculiarly interesting disease, was first



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described by Dr. Hughes Bennett in 1845, and a few weeks later,though independently, by Virchow. Bennett, in holding an autopsyupon a man who died with a very much enlarged spleen and liver,foun d t he blood filled with corpuscles resem bling pu s-cells, an d yet th erewas no evidence of phlebitis, nor any reason to suggest pyemia, there

being no local suppurative process. He therefore came to the conclusionthat he was dealing with new pathological conditions in which pus-corpuscles were generated within the blood. He did not undertake tosay, however, what relation, if any, the spleen and liver bore to thediseased condition.

A little later Virchow, independently, described a similar case, butdeclared that the corpuscles in question were not pus-cells, but whitecells of the blood in very greatly increased quantities, and that therewas a direct relation between the enlarged spleen and the increase of

white corpu scles, an d suggested th e na me leukem ia. Bennet t chimedpriority of discovery, and named the lesion leukocythemia. Since then,mu ch a tt ent ion h as been given to tlie disease, though but litt le light h asbeen t hr own upon th e cau sat ion.

Var ie t i e s .The older writers recognized two forms of leukemiathesplenic, in which the spleen was enormously enlarged, and thelymph at ic, in wh ich, while th e spleen wa s somewha t involved, th e chiefcha ra cter istic was t he enla rgement of th e lymph at ic glan ds. These werefor a time r egarded a s distinct pa th ological t ypes, but since Neum an n's

discovery tha t th e bone-mar row is t he pr incipal seat of th e origin of th eblood, especially of the leukocytes, and since it has been demonstratedthat in both splenic and lymphatic leukemia the marrovv-cells areinvolved, and tliat the spleen is enlarged to some extent even in thelymphatic form, the old division lias been discarded, and that of Ehrlichand Lazarus has been generally accepted; namely, (1) Myelogenousleukemia (a growth of myeloid tissue); (2) Lymphatic leukemia (agrowth of lymphoid tissue).

MYELOGE NOUS LE UKEMIA.

S y n o n y m s .Myeloid Leukemia; Splenic Myelogenous Leukemia;Splenic Leukemia ; Leukocytic Leukemia .

Et i o l o g y .This is a very ra re disease, an d but litt le is kn own a s t o its

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determ ining cau se. It occur s more frequen tly in m ales th an fema les, an dbetween the ages of' twenty and fifty, though no age is exempt. It isfound in all parts of the world, and among all races, though, accordingto Eichorst, the Jews are the most likely to suffer. Heredity seems toplay an important part, while syphilis, malaria, unhygienic conditions,

an d injur ies to the bone or spleen ha ve been considered a s pr edisposing,th ough th ey ma y be only coincident factors. Wheth er it be du e to au to-infection or to bacteria is yet to be determined, though, whatever thecau se, it a ffects directly th e blood-ma king organ s.

P a t h o l o g y .The Blood.This is generally of a pale or creamy color,an d cont ain s Cha rcot-Leyden cryst als. When leukocytosis is extr eme, itresembles lymph or is m ilk-like or pur iform , while at oth er t imes it m aybe of chocolat e color .

It is less alkaline than normal blood, is of lower specific gravity,undergoes decomposition more rapidly, and does not coagulate sorea dily. The m ost cha ra cter istic factor of th e disease is th e great increa sein the number of the leukocytes, there being 100,000 to 200,000 whitecorpuscles per cubic millimeter in a case of moderate severity, and acorresponding increase in the more severe cases, the relation of thewhite corpuscles to the red being as 1 to 2 or 1 to 1, and Robin statesth at th e leukocytes ma y even double th ose of th e red.

The Bone-Marrow .Cha nges in th e bone-mar row occur in both th e long

and spongy bones, the characteristic lesion being the pyoidtransformation. The light appearance of the normal marrow is replacedby a yellowish or pu riform color; th is ma y be un iform , or scat ter ed ar easmay be seen. In the early stage it may be firm in consistency, but asfur th er chan ges ta ke place, th ere is a ten dency for it to liquify.

There is a marked increase in the colorless marrow-cells, and roundhemoglobin free cells, with large pale nuclei and many fine granulespossessing neu tr ophilic properties.

Spleen .The sp leen in t he ea rly sta ge is hyperem ic, of a da rk color, andvery much enlarged, not infrequently extending downward to the spineof the ilium and forward to the median line. Infiltration andproliferation of lymphoid cells take place, the spleen becomes hard, andon section it presents a variegated appearance, due to small areas offatty degeneration or necrosis, which are scattered throughout the

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organ , an d which ar e du e to pressu re from th e excessive infiltr at ion; orthere may be fibroid degeneration. In some cases there is hyperplasticth ickening of th e capsu le with adh esions t o th e sur rounding str uctur es.

The Lymphatic Glands.Though they are usually somewhat enlarged,

th ey ar e seconda ry t o myeloid leukemia, a nd ma y not be n oticeable. It issimply an infiltration of the gland with leukocytes, and not ahypertrophy of lymphoid tissue. Similar infiltrations of leukocytes arefound in m ost of th e orga ns of the body.

The Liver.In most of the cases examined the liver is found enlarged;but how much of this is due to hyperplasia of the liver tissue, and howmu ch t o a lymphomat ous developmen t, ha s not been determ ined.

Heart and Vessels.Infiltrations are found in the heart and sometimes

in t he walls of th e blood-vessels, but a re due to secondar y cond itions .

Leukemic Retinal Changes.With the ophthalmoscope, smallinfiltrations may be seen in the retina as small whitish spots, while theretinal veins a re greatly enlarged, th ough t he ar teries remain n orm al.

S y m p t o m s .It is somewhat astonishing how well nourished many ofthese patients are, even after the alterations of the blood andenlargement of the spleen; many times the discovery of the disease ismade when examining the patient for some intercurrent affection. In

the advanced stage the patient complains of feeling weak andprost ra t ed, bodily effort being difficult . The pa tien t complains of pa in inthe side, there is hurried and oppressed breathing, more or lesspalpitation of the heart, loss of appetite and gastric disturbance,hemorrhage from the nose or gums; in fact, there may be hemorrhageinto the various organs; pain and tenderness in the sternum and longbones, pallor of skin and mucous membranes, and marked anemia arethe most characteristic symptoms. The temperature is quite erratic, insome cases being normal, subnormal in others, while a third class willshow fever.

D i a g n o s i s .The diagnosis can only be made by the aid of themicroscope, and, according to Lazarus, must show the following fourconditions:

1. The granular mononuclear leukocytes (Ehrlich's myelocytes) must

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constitute a considerable number of all the white blood-cells. Theirappearance in the blood is always somewhat abnormal; yet innonleukemic cases, even when their percentage is moderately high,their absolute number is small, in fact far below the smallest numbersever observed in myeloid leukem ia.

2. The eosinophilia mononuclear and polynuclear cells must beconsiderably increased. Their percentage may not be greater than ahigh norma l (th ree-qua rt ers per cent ), yet their a ctu al nu mber per cubicmillimeter is incomparably greater than in the most marked cases ofpur e eosinophilia yet observed.

3. The ma st cells mus t sh ow a great absolut e increa se.

4. Nucleated red blood-corpuscles of especially normo-blastic type must

be readily found. All of these characteristics must be presentsimultaneously.

P r o g n o s i s .Medication has thus far proven of but little benefit, thepat ient dying sooner or later.

T r e a t m e n t .As a lready st at ed, medicines h ave ha d but litt le influen ceon the disease. Rest in bed, a nutritious and easily digested diet.Fowler's solution of arsenic, iron in some form, bone-marrow andoxygen inha lation, ha ve been r ecomm ended. Polymnia deserves a tr ial.

LYMP HATIC LEU KEMIA.

S y n o n y m .Lymphemia.

Def in i t ion .A leukemia characterized by an increase in thelymph ocytes an d enlar gement s of th e lymph at ic str uctur es.

Et i o l o g y .As in mvelogenous leukemia, various theories have been

suggested, but none sa tisfactorily proven.

P a t h o l o g y .Hemorrhages occur in the skin, the retina, the mucousmembrane of the intestinal tract, the pleura, pericardium andperitoneum , the pelvis of th e kidney, an d somet imes into the bra in, and,if in t he m otor r egion, give r ise to par alysis.



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The lymph glands are universally enlarged, hard and firm inconsistency, marrow-like and white, unless hemorrhage occurs, whenth ey ar e pink.

The spleen ma y be norm al in size, th ough u sua lly slight ly enlar ged, an din children it occas iona lly is of enorm ous size. It is soft, confluent , an d ofa brownish red or chocolat e color .

The Bone-MarrowThe changes in the marrow are constant andcharacteristic, usually affecting the tubular bones throughout theirent ire exten t; th e ma rr ow is red in color, a nd th e cons isten cy of jelly.

The characteristic change produced in the blood by lymphatic leukemiais the tremendous increase in the absolute number of circulating

lymph ocytes. While in h ealth y blood t hese const itut e less th an th irty percent of the whole nu mber of whit e cells, in th is cond ition th ey form overninety per cent of a total leukocyte count, which is many times thenormal.

S y m p t o m s . Acute Lymphatic Leukemia.The onset is sudden andthe course rapid, the disease terminating in a few days or weeks. Thesymptoms a re t hose of an in fectious disease, th ere being fever, n au sea,vomiting, an d diar rh ea. Hemorrha ges into th e skin an d mucoussur faces ar e cha ra cter istic, at ten ded by an emia. The enlar gement of th e

lymphatic glands is never so marked as in chronic lymphatic leukemia,in fact, may not be noticeable till near the close of the disease. As thedisease progresses, it a ssum es a typhoid type, with delirium , coma , andfinally deat h. A painful an d somewha t cha ra cter istic symptom is severeulceration of the mouth and gastro-intestinal tract. Acute nephritis issometimes present .

Chronic Lymphatic Leukemia.This form comes on slowly andinsidiously, the enlargement of the lymphatic glands being the firstsymptom, many times, to call attention to the disease. The first to be

noticed are the cervical, to be followed in turn by the axillary, inguinal,etc., till all the glands of the body become affected. Thev graduallyincrease in size, are usually soft, though they rarely suppurate.Occasiona lly th ey are qu ite firm. The sp leen is enlar ged, but not t o theexten t as seen in t he m yeloid form .

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As the glands enlarge, the patient becomes anemic; there is failingstr ength , an d emaciat ion more or less mar ked, are th e danger-signals ofan incur able ma lady. Hem orr ha ges may occur late in t lie disease.

The disease runs its course to a fatal issue in from one to three years,

though occasionally it terminates in a few months, through someintercurr ent disease, like pn eumonia, tuberculosis, and k indred diseases.

The treatment of all forms of leukemia is unsatisfactory; the most wecan do is to retard, to some extent, the progressive changes bysymptomatic treatment. Outdoor life in a suitable climate, a nutritiousdiet, an d a rsenic, the bitter tonics, an d iron, ma y accomplish some good.

HODGKIN'S DISEASE.

S y n o n y m s . Pseudo-leukemia; Lymphadenoma; AnemiaLymph at ica; Lymph asa rcoma ; Maligna nt Lymphoma , etc.

Def in i t ion .A chronic disease characterized by enlargement of thelymph glands, a progressive anemia, and often attended by secondarygrowths of lymphoid tissue in the liver, spleen, kidneys, bone-marrow,aliment ar y tra ct, an d other organs.

Et i o l o g y .The causes of this disease are as obscure as those of

leukemia. About seventy-five per cent of all cases occur in males, andthe majority of cases occur under forty years of age. Syphilis, malaria,tu berculosis, rickets , chr onic diar rh ea, a nd oth er affections ar e given bysome writers as predisposing causes, but just how far these diseaseshave been coincident factors and how far they have really influencedthe disease, it is impossible to say. Unhygienic conditions seem to favorth e a ffection, since th e majorit y of cases occur am ong t he lower classes .

The course of the disease in some cases, especially the occurrence offever of an irregular type, but a recurring type, and the rapidity with

which some of the cases run a fatal course, strongly points to aninfectious nature. Recent studies in bacteriology suggest micro-organisms as a probable cause, though nothing specific has yet beendiscovered.

P a t h o l o g y .The pathological changes found will depend upon the



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stage of the disease. Generally the first changes are noticed in thecervical glan ds, and th ese in t ur n by th e axillary glan ds, and fina lly theinguinal glands become involved. The affected glands are first isolated,and freely movable, and are about the size of almonds, but as thedisease progresses, they become adherent, forming a tumor mass from

the size of an orange to that of a cocoanut. These cervical lymphaticsmay form a chain extending down the trachea and large blood-vesselsto the a xillar y glands.

The mediastinal glands, enlarging, may encroach upon the blood-vessels, and occasionally perforate the sternum and appear as externaltumors.

Any of the glands of the body may become involved. When themesenteric and retroperitoneal glands are the seat of the trouble, the

diagnosis becomes somewhat difficult, laparotomy having beenperform ed for a bdomin al tu mors, only to find m asses of enla rged lymph-glands.

As t he disease progresses, lymphoid deposits t ak e place in oth er organ s,especially the spleen, thymus gland, and sometimes the liver andkidneys. More rarely the skin becomes the seat of lymphomatousgrowths . The cons isten cy of the glan ds va ry, being soft and jelly-like orfirm, ha rd, an d dr y. The ear ly sta ge genera lly reveals th em t o be of firmconsistency; but as the disease advances, there is a proliferation of the

connective tissue-cells, which may change the soft gland into one ofalmost st ony ha rdness.

A cut section reveals this varied condition, and if made of the spleen,shows a dark-reddish, pulpy mass, interspersed by lighter sections ofconn ective tissue. This gland ra rely casea tes, a nd when th is does occur ,it is p robably due t o seconda ry condit ions , nota bly tuber culosis.

According to Stengel, the blood of pseudo-leukemia is distinguished bythe absence rather than the presence of alterations from the normal.

The reduction of red corpuscles is usually slight, except in severe cases,where they may be reduced to 2,000,000 or even 1,000,000 per cubicmillimeter, with a ltera tions in t heir size and sh ape. The white corpu sclesare about normal in number, though they may be slightly increased ordiminished.

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S y m p t o m s .The disease comes on so insidiously that the earliersymptoms are negative. If the superficial glands are the first to beinvolved, and this is the rule, the patient will notice a bilateralenlargement of a chain of cervical lymphatics; even before this,however, he has noticed a progressive loss of weight and strength. As

the disease advances, his attention is called to the enlargement of theaxillar y glan ds, an d finally to th e inguina l glan ds.

There is generally loss of appetite, furred tongue, and dyspepticsymptoms; especially is this marked where there is. atrophy of thegastro-intestinal mucosa. There is more or less dyspnea, which mayarise either from the anemia present, or from pressure from theenlarged mediastinal glands, or from the bronchial glands, and in somecases from pressure upon the trachea by an enlarged tumor mass ofcervical glands.

Edema of the ankles is not uncommon in the late stages of the disease.The presen ce of album in in th e urine is not infrequen t. Hemic mu rm ur sare present, and palpitation is a common symptom. Fever is present atsome st age of th e disease in nea rly all cases; in some it is of an irregulartype, while in others it will assume a remittent form. Where the skin isaffected, ulcera t ion is a pt t o occur.

D i a g n o s i s .In the early stage, Hodgkin's disease is, not readilyrecognized, but when well advanced, the diagnosis is comparatively

easy. A few characteristic points, if kept in mind, will enable us todistinguish tills from tu berculosis, th us: in pseudo-leukern ia t he cervicalenlargement is usually bilateral, and involves the anterior or posteriorchain of lymphatics, and there is no tendency to suppurate, while intuberculosis the enlargement is usually confined to one side, involvesth e subma xillar y cha in. an d th e tendency is to suppur at ion. In theformer, there is splenic enlargement and more pronounced anemia. Todifferen tia te from leuk emia , a blood examin at ion is n ecessa ry.

P r o g n o s i s .The prognosis is grave, but few cases recovering. The

disease usu ally ends fata lly in from one to th ree years, th ough a n a cut ecase ma y ter mina te fat ally in thr ee month s.

T r e a t m e n t .Before there is an involvement of the general lymphaticsystem, th e removal of local tu mor ma sses in th e neck m ay help sta y theprogress of th e disease.

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A good nourishing diet, plenty of air and sunshine, will be importantfactors in pr olongin g life.

Arsenic in the form of Fowler's solution has perhaps been more

su ccessfully used th an a ny oth er one rem edy. Ph ytolacca , iris vers icolor,an d like remedies deserve a th orough tr ial..

ADDISON'S DISE ASE.

S y n o n y m s .Bronzed Skin Disease; Melasma Supr ar enale.

Def in i t ion .A chr onic disease cha ra cter ized by progressive ast hen ia. Abronzed pigmentation of the skin, irritability of the gastro-intestinal

tract, feebleness of the heart's action, with degeneration of thesuprarenal capsules.

Et i o l o g y .The disease occurs most frequently between the ages oftwenty and forty, and affects males more frequently than females.Blows and injuries to the back would suggest traumatism as apredisposing cause; the lesion is almost constantly associated withtuberculosis of the suprarenal capsules. A rare disease and one ofun kn own etiology.

P a t h o l o g y .Both capsules are usually involved, though occasionallybut one is found affected, and in still rarer cases neither appear to bethe seat of the disease, the disturbance being confined to thesympath etic plexus a roun d t he organ s.

The glan ds ar e usu ally enlar ged, firm, an d nodulated, irregular in form ,showing the cha ra cter istic caseous ma sses of th e tu berculosis. In ra recases the tubercular lesion seems to be primary and confined to thecapsules, though generally associated with tuberculosis of the lungs,bones, an d viscera in genera l.

In some cases, owing to interstitial changes, fibrous tissuepreponderates, or the glands may atrophy, becoming sclerotic, or theyma y be replaced by fat ty deposits. Maligna nt growth s m ay destr oy th eirfunction.



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In a few cases the pathological changes seem to be confined to thesympat het ic, an d consist of degenera tion, congestion, h emorrh ages, an dinfiltration by leukocytcs, or new connective tissue in tlie ganglia andner ve fibers. Pa ren chyma tous or fat ty degenera tion is sometimes foun din heart, liver, and kidneys. The spleen, in some cases, is enlarged,

showing more or less degeneration of its tissue. The blood shows thesam e cha nges that ar e foun d in anemia.

S y m p t o m s .Asthenia .Prostration comes on gradually, butsomet imes quite ra pidly, an d is shown by genera l lass itude. The pat ientcomplains of always being tired, and is unrefreshed by his night's rest.He becomes weak, listless, takes but little interest in his surroundings,an d grows peevish or desponden t. The prost ra tion is progressive.

Cardiac feebleness is manifested by occasional attacks of syncope, any

one of which ma y prove fat al. The pu lse shows char acteristic weak ness,though it may be quite rapid. The heart-sounds are quite feeble. As thedisease advances, there is palpitation of the heart, and dyspnea of adistressing character upon slight exertion. Disturbance of vision,dizziness, ringing in the ears, headache, and various other cerebralsymptoms appear. In the last stages, stupor, delirium, and coma mayfollow one another in quick succession, terminating in convulsions anddeath.

Gastro-intestinal symptoms are nearly always present. Nausea and

vomiting ar e am ong th e early sympt oms, an d ma y persist to the end. Attimes it is violent, coming on in paroxysms, and does not appear to bedue to any wrongs of the stomach, as the tongue may be clean anddigestion fair, but to irritation of the sympathetic. Diarrhea is the rule,and accompanies the gastric disturbance. Pain in the epigastric,hypochondriac, and lumba r regions is not u ncomm on.

Pigmentation of the skin gradually appears in the form of a bronze orcopper color, after the constitutional symptoms become well marked,th ough it m ay be am ong th e first symptoms observed. It usu ally begins

upon the exposed parts of the body, as the face, neck, and hands, andwhere nat ur al pigmenta tion is most m ar ked, as a roun d th e areola of th enipple, in th e axilla, and a round t he genital organs an d in t he groin.

The color varies from a yellowish-brown to an olive or bronze color, thepatient assuming sometimes the hue of a mulatto. The mucous

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membrane of the mouth and vagina may show bluish or purplishpa tches of discolora tion.

Renal symptoms may or may not be present; thus polyuria is seen insome cases, while in others the quantity is but little affected. There is

but litt le emaciat ion, th ough general evidence of an emia is pr esent . Thetempera tu re is normal or subnorma l.

D i a g n o s i s .In typical cases, the diagnosis is comparatively easy. Themarked asthenia, feebleness of heart and circulation, gastro-intestinalirritation, anemia without emaciation, and the bronze or browndiscolora tion, ar e a group of symptoms t ha t can ha rdly be mistak en. Inatypical cases, where the constitutional symptoms are slight, thediagnosis becomes more difficult. It may be mistaken for malignant ortuberculous lesions of the abdomen, or cirrhosis of the liver, for

pregnancy and uterine diseases, protracted cases of jaundice, chronicmalaria, nitrate of silver discolorations, arsenic pigmentation,vagabond's disease, and other lesions that are attended by more or lesspigment at ion of the skin.

P r o g n o s i s .The prognosis is unfavorable, the disease usuallyterminating fatally in from one to two years, though in rare cases thepat ient m ay live five or even ten years.

T r e a t m e n t .The t rea tm ent will be along th e sam e line a s su ggested in

leukemia, and will consist of hygienic, dietetic, and medicinal measures.The pa tient should avoid overexert ion, either men ta l or p hysical, lead aquiet life in the open air and sunshine, take light, easily digested, andnutritious food.

Var ious dru gs, such as iron, a rsen ic, th e iodids, gua iacol car bona te, an dmany others, have been used, but are of doubtful value. The stomachmay be quieted with small doses of ipecac, peach-tree infusion, bismuth,and rhus tox., and cactus may have some influence in strengtheningthe heart, but we are not to expect too much from medication. The

administration of the extract of suprarenal capsules has manyadvocat es, and a few cases ha ve been r eport ed benefited from th eir use,though the remedy has not been tried sufficiently long to warrant us inha iling it a s a specific.

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MYXEDEMA.

S y n o n y m s .Sporadic Cret inism; Ath yria.

Def in i t ion .A chronic constitutional disorder, due to functional

derangement of the thyroid gland, and characterized by infiltration(myxedema ) of mu cin in t he su bcut an eous tissu es.

Var ie t i e s .Three varieties are given: (a) True myxedema, or adultmyxedema ; (b) Spora dic cret inism ; (c) Opera tive m yxedema, or cachexiastrumipriva.

The removal of the thyroid gland in lower animals demonstrates thatth e myxedema of adult s, cret inism , and t he cachectic cond ition followingthe removal of the thyroid gland for goitre, represent the same morbid

condition th ough un der different circum sta nces.

Et i o l o g y .The secretions from the ductless glands possess variousconstituents that are necessary to normal metabolism, and when theirfunction is impaired, and these constituents are absent or perverted,disorders of nut rit ion follow.

The thyroid secretion contains such a constituent, which has beennamed thyroidin, and when this is absent, myxedema results. Morecases have been found in England and Switzerland than from all other

coun tr ies. Women suffer m ore frequent ly th an men , the r at io being 6 to1.

It occurs most frequently between the ages of thirty-five and fifty.Pregnancy seems to predispose to it; at least married women who haveborn e children su ffer more often t ha n t he un ma rr ied.

Her edity may play some pa rt as a predisposing factor, an d exopht ha lmicgoitre may bear some rela tion to th e disease.

Actinomycosis has been reported as destroying the gland in a reportedcase of myxedema .

P a t h o l o g y .Lesions of the thyroid are constant, there either beingatrophy or degeneration. The gland may be congenitally absent, as incretinism. Occasionally it is larger than normal, the secreting structure



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being- repla ced by int erst itial fibrous tissu e. Myxoma tous cha nges in t lieblood-vessels an d kidn eys ha ve been recorded.

S y m p t o m s .The disease comes on insidiously, the first symptomsappearing in the face, which loses its expression and takes on a coarse

or bloat ed appea ra nce. There is pu ffiness of th e eyes, an d th e pat ient isdull an d st upid. The tongue is broad, th ick, an d m ore or less coat ed. Thenose increases in breadth, becomes flattened, and is inclined to turn upat the end. The lips become thick, the lower sometimes being slightlyeverted; the ears are enlarged, and the hair becomes coarse and isinclined to drop out. The skin becomes dry and harsh; the teeth decay,an d the na ils ar e dry and brittle.

The extremities become large and clumsy, and the hands and feet areswollen and become less flexible, and the body generally increases in

bulk. The movements of the patient are slow. The heart's action isfeeble, though the pulse may be rapid. The temperature is normal orsubnormal. There m ay be tra ces of albumin a nd su gar in t he u rine.

The mental faculties become dulled, the patient reasoning withdifficulty, ta king on more a nd more t he appea ra nce of imbecility as th edisease progresses.

Headache is often present, and the special senses, smell, taste, sight,hea ring, an d t ouch, become impa ired.

D i a g n o s i s .The general swollen or bloated appearance, yet absence ofpitting on pressure, the dry, harsh skin, the dull besotted appearance,the clumsy movements, are symptoms not likely to be mistaken for anyoth er lesion.

P r o g n o s i s .The disease is one of marked chronicity, lasting five, ten,or fifteen years. Since the introduction of the thyroid-gland treatment,ma ny favora ble report s h ave been r eceived as to its cur at ive action.

The thyroids of sheep and calves are used, and may be given raw orcooked, or in t he form of glycerin extr act, or the dry powdered extr act.

Ail form s of myxedema seem t o respond t o this t rea tm ent , if reports ar eto be relied upon. If th e glan d be destr oyed or r emoved, th e tr eat men t isto be cont inued a t inter vals dur ing life.



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CRETINISM.

This form of myxedema follows either a congenital absence of the gland

or loss of its function during the first few years of life. The chiefsymptoms are those that arise from lack of development, the childretaining an infantile appearance, both in its physical and mentalmake-up.

The firs t ph ysical or a bnormal cond itions m ay not a ppear for six or eightmonths after birth, at which time it is noticed that the child'sdevelopment seems to be arrested. The awful dread arises in themother's mind that the baby is not bright,, which becomes verified asth e mont hs pa ss. The physical developmen t is also rem ar ka bly ret ar ded.

The anterior fontanels remain open, and the head becomes enlarged,narrow in front, but large posteriorly. The face becomes large andbloat ed, th e nose broad, flat, an d slightly tur ned u p at th e end, the eyesappear to be widely separated, the cars are large, the tongue is broadand thick, and often protrudes from a large mouth. The complexion iswaxy or of a dull, chalky color. The hair is coarse, and usually thin.Dentition .is delayed, an d t he t eeth ear ly decay.

The neck is short and the clavicular foss are filled with fatty tumors.The body is short and stunted, the skin dry and harsh, the arms and

legs are short, and the hands and feet puffy and enlarged. Theabdomen is bloated and prominent, and the child is unable to standalone. The whole appeara nce of th e child is repu lsive. The cond ition m aynot a rise un til th ree or four years after birt h, a nd follow some one of th einfectious fevers, which in some way impairs the function of the thyroidgland. There is arrest of mental development in either case, and thechild becomes an imbecile.

P r o g n o s i s .Congenital cases usually live but a few weeks or months,while th ose developing ea rly in childhood m ay live for year s.

T r e a t m e n t .The treatment is along the same lines as for myxedemain t he adult .

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OP E RATIVE MYXE DE MA.

Removal of the thyroid gland for surgical reasons has resulted in thegradual production of the same conditions that are found in myxedemaof the adult or cretinism. These results are not apt to follow if a portion

of the gland remains; hence the surgeon should be careful never toremove the entire gland, unless due to malignant growths. We are notto understand, however, that myxedema strumipriva always follows acomplete thyroidectomy, for accessary glands elsewhere may preventsuch a r esult.

G O I TRE.

S y n o n y m .Bronchocele.

Def in i t ion .This is a hypert rophy of a par t or t he wh ole of th e th yroidglan d, an d occur s spora dically or endem ically.

Et i o l o g y .The exciting cause is unknown. Goitre occurs sporadicallyor endemically, and Sievere speaks of an epidemic occurring atSerdobal, Finland, where a teacher and fifteen children were suddenlyattacked. Locality seems to favor the disease, for while it occurs in allcoun tr ies, in cert ain distr icts, wh ich ha ve ma ny point s of resem blance, itoccurs in far greater numbers, and is thus said to be endemic in suchlocalities. Moun ta inous districts seem t o favor its pr opaga tion. Th us it is

common in Switzerland and. Italy, in the Himalayas, and in the hillydistr icts of China.

In On ta rio, Can ada , man y cases a re seen. It is foun d more frequen tly inwomen th an men , especially in th is coun tr y, an d is accoun ted for on t hegrounds that women drink more water than men, while in India bothsexes drink the same amount of water, and are equally affected withgoitre.

The disease usually appears shortly after puberty, especially in girls,

where th ere is some dera ngement in th e menst ru al flow.

There seems to be some constituent of the water-supply in certainsections t ha t favor t he form at ion of goitre, th ough wh at th at const ituen tis, no one has been able to determine. A change in the water-supply,where goitre h as prevailed, ha s led to a disappear an ce of th e disease



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Heredity .In some families her edity seems to play an import an t r ole.

P a t h o l o g y .The gland undergoes various degenerative changes, andhas been divided by Murray into four varieties: (a) Hypertrophic or

parenchymatous goitre; (b) Adenoma of the thyroid gland; (c) Fibrousgoitre; (d) Cystic goitre. Besides these types there may be variouscombinations.

In parenchymatous or hypertrophic goitre there is a hyperplasia of allthe original tissue-elements. It may be confined to one lobe or involvethe whole gland. Adenoma of the thyroid occurs as an encapsuledgrowth, there being one or more nodules in one or both glands; thestr ucture r esembles th at of th e glan d itself.

In a fibrous goitre we have, in addition to overgrowth of the glandularsubstance, a large increase in the fibrous tissue, which may occur asbands running through the substance of the goitre or as fibrousnodules.

Cystic goitre occurs, either as a result of expansion and coalescence ofth e follicles of an a lrea dy enla rged glan d, or a s the r esu l

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Eclectic Medicine Part 7