Diseases of the Endocrine Glands

A dystrophy characterized by increase in size of face and extremities associated with perverted function of the anterior lobe of the pituitary gland. The essence of the disease is a dystrophy of hypophysial origin, which, if it antedates ossification of the epiphyses, leads to gigantism, and in the adult leads to over-growth of the skeleton and other changes which we know as acromegaly [...]. More frequent in women [...]. Trauma, the infections, and emotional shock have preceded the onset of the disease [...].

(a) Regional symptoms—Headache is common, usually frontal, and often very severe. Somnolence has been noted in many cases, and may be the first symptom. Ocular features occur in a large proportion of the cases, bitemporal hemianopia, optic atrophy, and, in the late stages, pressure on the third nerve and the abducens. One eye only may be affected. Exophthalmos may occur. Deafness is not infrequent. Irritability of temper, marked change in the disposition, great depression, and progressive dementia have been noted. Epistaxis and rhinorrhea may be present.

(b) Symptoms due to the perversion of the internal secretion itself form the striking features of the disease. The patient’s friends first notice a gradual increase in the features, which become heavy and thick or the patient himself may notice that he takes a larger size of hat, or with the progressive enlargement of the hands a larger size of gloves. The enlargement of the extremities does not interfere with their free use. The hypertrophy is general, involving all the tissues, and gives a curious spadelike character to the hands, The lines on the palms are much deepend. The wrists may be enlarged, but the arms are rarely affected. The feet are involved like the hands and are uniformly enlarged. The big toe, however, may be much larger in proportion, The nails are usually broad and large, but there is no curving, and the terminal phalanges are not bulbous. The joints may be painful and neuralgia is common, The head increases in volume . . . . [The inferior maxillary bone] in particular increases greatly in size, and often projects below the upper jaw [...]. Late in the disease the spine may be affected and the back bowed—kyphosis [...]. The muscles are sometimes wasted.

Osler, W. (1892). The Principles and Practice of Medicine. New York and London: D. Appleton and Company. Pg. 877-878.

Entered by: Sonia Y. Khan, 7/7/2020

Its onset is, as a rule, insidious. A light yellow or light brown pigmentation of the skin is usually the first symptom to attract attention. It progressively deepens over the entire body and is especially marked over the pigment-bearing areas, the areolas of the nipples, and the genitals. Finally, a marked bronzing of the entire skin surface is observed, with circumscribed, sometimes extensive, areas of a dark brown or black colour. The exposed or irritated skin surfaces are also deeper in colour. Patches of leukoderma are occasionally observed. The mucous membranes ae also pigmented. Addison called attention to the irritability of the stomach in these cases.

Nausea, vomiting, anorexia, abdominal pain, retraction of the abdominal walls, and more or less profuse diarrhea occur, but all vary greatly in severity and frequency. General languor and debility, slight at first but progressively increasing, are symptoms which occur before the discoloration of the skin suggests the true nature of the disease. These increase in severity till asthenia becomes the most character feature of the disease. Lassitude and muscular prostrations are marked even in well-nourished, robust, and muscular persons. The heart’s action becomes remarkably feeble irregular, or paroxysmal. There are accompanying vascular disturbances such as vertigo, syncope, headache, coma, or convulsions; the syncope may even be fatal.

Butler, G. R. (1902). The Diagnostics of internal medicine: a clinical treatise upon the recognised principles of medical diagnosis. New York: Appleton. Pg. 922.

Entered by: Erin Choi, 6/12/2020

The diagnostic feature which distinguishes this disease is an excessive abundance of water in the urine, or hydruria. The affection now generally designated diabetes insipidus exists when there is a persistent, notable increase in the quantity of urine, the specific gravity extremely low (1.001-1.007), albumen and renal casts being absent. The quantity of urine varies much in different cases. It may exceed from ten to twenty times the average amount in healthy persons. Thirst (polydipsia) is always a concomitant symptom, and is proportionate to the increased quantity of urine.

The craving for fluids may be such that, as in two cases observed by Dickinson, patients being prevented from obtaining other liquids, will drink their own urine. In some cases of diabetes insipidus there are no symptoms of disease other than diuresis and thirst. Appetite, digestion, nutrition, muscular strength, together with other functions, are not materially impaired; the patient suffers only from the inconvenience of drinking, and voiding urine so frequently.

Flint, A. (1879). Clinical medicine: a systematic treatise on the diagnosis and treatment of diseases ; designed for the use of students and practitioners of medicine. London: Churchill. Pg. 455-456.

Entered by: Erin Choi, 6/16/2020

“The onset of the disease is gradual, and either frequent micturition or inordinate thirst first attracts attention. […] When fully established the disease is characterized by great thirst, the passage of large quantities of saccharine urine, a voracious appetite, and as a rule, progressive emaciation. Among the general symptoms of the disease thirst is one of the most distressing. Large quantities of water are required to keep the sugar in solution and for its excretion in the urine. […] In spite of the enormous amount of food consumed a patient may become rapidly emaciated. […] General pruritus or pruritus pudenda may be very distressing, and occasionally is one of the earliest symptoms. […] The amount [of urine] varies from 3 to 4 liters in mild cases to 15 to 20 liters in very severe cases. […] The urine is pale in color, almost like water, and has a sweetish odor and a distinctly sweetish taste. […] Sugar is present in varying amounts. […] Of other ingredients in the urine, the urea is increased, the uric acid does not show special changes, and the phosphates may be greatly in excess. The calcium salts are markedly increased. The same holds true for the ammonia in all severe cases, and particularly in diabetic coma. […] Acetone and acetone-forming substances are not infrequently present. […] In true diabetes hyperglycaemia is constant. […] As coma supervenes, B-oxybutyric acid occurs.”

Osler, W. (1909). The Principles and Practice of Medicine (7th ed.). London: Appleton and Co. Pg. 415-416.

Entered by: Erin Choi, 7/3/2020

Edited by: Bernardo Galvan, 9/7/2020

A chronic enlargement of the thyroid gland [...] occurring sporadically or endemically [...]. The disease is rarely congenital [...]. Women are much more frequently attacked [...]. Usually the whole gland is involved, but one lobe only may be attacked [...]. When small a goitre is not inconvenient, but when large pressure symptoms may cause the patient to seek relief. The windpipe may be flattened from pressure, usually of an enlarged isthmus, or it is narrowed by circular compression. The symptoms are more or less marked stridor and cough, which may persist for years without special aggravation. They may be present with very large glands, or with the small encirculating goitre, or with the goitre which passes deeply beneath the sternum. Pressure on the recurrent nerves may cause attacks of dyspnea, particularly at night, and the voice may be altered. Pressure on the vagus is not uncommon. Sometimes there is difficulty in swallowing, and the veins of the neck may be compressed. The heart is often involved, either from pressure on the vagi, or there is dilation associated with dyspnea. This is sometimes spoken of as the “goitre heart” in contra-distinction to the cardiac condition in Graves’ disease [...]. Simple goitre can be prevented by small doses of iodine.

Osler, W. (1892). The Principles and Practice of Medicine. New York and London: D. Appleton and Company. Pg. 864-865.

Entered by: Sonia Y. Khan, 7/3/2020

A disease defined by goitre, exophthalmos, tachycardia, and tremor, associated with a perverted or hyperactive state of thyroid gland [...]. Acute and chronic forms may be recognized. In the acute form the disease may arise with great rapidity [...]. The acute cases show marked toxaemia but are not always associated with delirium. More frequently the onset is gradual and the disease is chronic. There are four characteristic symptoms—tachycardia, exophthalmos, enlargement of the thyroid, and tremor [...]. Other features are anaemia, emaciation, and slight fever. The blood shows lymphocytosis. Attacks of vomiting and diarrhoea may occur. The latter may be very severe and distressing, recurring at intervals. The greatest complaint is the forcible throbbing in the arteries, often accompanied with unpleasant flushes if heat and profuse perspirations [...]. Pruritus may be a severe and persistent symptoms [...]. Irritability of temper, change is disposition, and great mental depression occur [...]. The emaciation may be extreme. Glycosuria and albuminuria are not infrequent and true diabetes may occur. The basal metabolism shows a marked increase and this is an important aid in diagnosis [...]. The course is usually chronic, lasting several years. After persisting for six months or a year the symptoms may disappear.

Osler, W. (1892). The Principles and Practice of Medicine. New York and London: D. Appleton and Company. Pg. 869-871.

Entered by: Sonia Y. Khan, 7/6/2020

Cretinism—Two forms are recognized—the sporadic and the endemic. In the sporadic form the gland may be congenitally absent, or is atrophied after one of the specific fevers, or the condition develops with goitre . . . . In the congenital cases . . . . it is noticed that the child does not grow so rapidly and is not bright mentally. The tongue looks large and hangs out of the mouth. The hair may be thin and the skin very dry. Usually by the end of the first year and during the second year the signs become very marked. The face is large, looks bloated, the eyelids are puffy and swollen; the alae nasi are thick, the nose looks depressed and flat. Dentition is delayed, and the teeth which appear decay early. The abdomen is swollen, the legs are thick and short, and the hands and feet are underdeveloped and pudgy. The face is pale and sometimes has a waxy, sallow tint. The fontanelles remain open; there is muscular weakness, and the child cannot support itself. In the supraclavicular regions there are large pads of fat. The child itself does not develop mentally and may lapse into imbecility. In cases in which the atrophy of the gland follows a fever the condition may not come on until the fourth or fifth year, or later. This is really . . . a juvenile myxoedema. In a few of the sporadic forms cretinism develops with an existing goitre. It may retard development, bodily and mental, without ever progressing to complete imbecility.

            Endemic Cretinism—This occurs wherever goitre is very prevalent . . . . The clinical features are the same as in the sporadic form; stunted growth and feeble mind, plus goitre . . . . Infants a year or so old sometimes become flabby, lose their vivacity, or show a protuberant abdomen, and lax skin with slight cretinoid appearance. These milder forms, as they have been termed, are probably due to transient functional disturbance in the gland.

            Myxoedema [severe hypothyroidism] of adults (Gull’s Disease)—Women are much more frequently affected than men . . . . The disease may affect several members of a family, and it may be transmitted through the mother. In some instances there has been first the appearance of exophthalmic goitre . . . . The symptoms . . . are marked increase in the general bulk of the body, a firm, inelastic swelling of the skin, which does not pit on pressure; dryness and roughness, which tend with the swelling to obliterate in the face the lines of expression; imperfect nutrition of the hair; local tumefaction of the skin and subcutaneous tissues, particularly in the supraclavicular region. Perspiration is often much decreased. The physiognomy is altered in a remarkable way: the features are coarse and broad, the lips thick, the nostrils broad and thick, and the mouth is enlarged. Over the cheeks, sometimes the nose, there is a reddish patch. There is a striking slowness of thought and of movement. The memory becomes defective, the patients grow irritable and suspicious, and there may be headache. In some instances there are delusions and hallucinations, leading to a final condition of dementia. The gait is heavy and slow. The temperature may be below normal . . . . Death is usually due to some intercurrent disease, most frequently tuberculosis . . . .  In one case a young man became bloated and increased in weight enormously during three months, then had tachycardia with tremor and active delirium . . . .

            The diagnosis of myxoedema is easy, as a rule. The general aspect of the patient—the subcutaneous swelling and the pallor—suggests nephritis, which may be strengthened by the discovery of tube casts and of albumin in the urine; but the solid character of the swelling, the exceeding dryness of the skin, the yellowish white color, the low temperature, the loss of hair, and the dull, listless mental state should suffice to differentiate the conditions . . . . Hypothyroidism should be considered in children who are dull and backward, in women who have symptoms suggesting a premature menopause, in obesity, and in those with constipation for which is obscure.

Osler, W. (1892). The Principles and Practice of Medicine. New York and London: D. Appleton and Company. Pg. 866-868.

Entered by: Sonia Y. Khan, 7/3/2020

The disease is extraordinarily chronic [...]. Usually the first feature to attract attention is:

Splenomegaly—The enlargement is uniform, smooth, painless, usually reaches to the navel, very often to the anterior superior spine, and the organ may occupy the whole of the left abdomen. It may exist for years without any symptoms other than the inconvenience caused by the distension of the abdomen. Following an infarct pain may be present.

Anaemia—Sooner or later the patients become anaemic. The attack may develop with rapidity, and in children a severe and even fatal form may follow in a few weeks. More commonly the pallor is gradual and the patient may come under observation for the first time with swelling of the feet, shortness of breath, and all the signs of advanced anaemia. The blood picture is that of a secondary anaemia with a very low color index and a marked leucopenia [...].

Haemorrhage—Bleeding, usually haematemisis, may be a special feature of the disease and occur at intervals for many years [...]. In such cases the diagnosis of ulcer of the stomach may be made. The bleeding may be of great severity [...]. The bleeding comes, as a rule, from aesophageal varices. Malaena may be present. Hematuria and purpura may occur.

Ascities—Usually a terminal event, it may be due to the enlarged spleen itself or to secondary cirrhosis of the liver. When due to the liver, it is associated with slight jaundice.

Jaundice—Icterus has been a rare symptom in our cases. Enlargement of the spleen may persist for many years without any consecutive change in the liver . . . . Slight jaundice may persist for years, sometimes with enlargement of the liver, in others with distinct reduction in its volume, and in either case with a progressive cirrhosis [....].

Osler, W. (1892). The Principles and Practice of Medicine. New York and London: D. Appleton and Company. Pg. 883-884.

Entered by: Sonia Y. Khan, 7/6/2020