Chapter XXXIV: Introduction (19)

In some respects the red cells behave as in chlorosis, each carrying a diminished percentage of hemoglobin, resulting in a low color index. Atypical staining reactions and morphology, together with many fractured forms, are the rule. Normoblasts are common throughout the course of the disease, but megaloblasts seldom appear until near fatal termination.

The changes in the white cells are enormous, both as to numbers and character of cells found. The total white count often exceeds 350,000. This, with the accompanying reduction in number of erythrocytes, leads to a reduction of the ratio between reds and whites to as low as 1 to 5 or 3, or occasionally 1 to 1. There is an actual increase in number of all the white cells with the possible exception of the lymphocytes. In the actual increase of polymorphonuclear neutrophiles and eosinophiles is rendered a sharp relative decrease by the enormous production of myelocytes. Basophiles are usually both relatively and absolutely increased. In a white count of 350,000 it is not unusual to have present 325,000 myelocytes, with 25,000 as the actual number of ordinary leucocytes. There is, therefore, a =mild leucocytosis= coupled with a =violent= leukemia. These two are combined with an =anemia= that varies with the course of the disease.

=Treatment.=—The treatment is largely hygienic, including thorough osteopathic attention to the lower dorsal and costal area. Symptomatic treatment is often followed by temporary improvement both clinically and in the blood picture, but complete recovery seldom takes place. Occasionally, roentgen therapy has given a “cure” lasting several years.

=Prognosis= is not good. These patients are frequently carried away quickly by some oftentimes slight intercurrent infection. Even if carefully guarded from such, the course of the process usually leads to death from exhaustion in two or three years.

Lymphatic Leucemia

Clinically, this is a parallel condition to myelogenous leucemia, except that the hyperplasia of cells occurs in lymphoid tissue, and leads to an enormous over-production of lymphocytes rather than myelocytes. It is more readily divided into acute and chronic forms than myelogenous leucemia from differences in symptomatology.

In the =acute form=, adolescents are usually affected, the condition beginning with tumefaction of the lymph glands, first noted in the cervical region, but usually a general involvement. Dyspnea results from pressure upon trachea and bronchi by the enlarged glands of the mediastinum. There is pyrexia of 103 to 105 degrees, intermittent in character.

The pressure upon nerve trunks and plexuses in the thorax leads to variable anginas distributed not only in regions actually imposed upon but over all sorts of possible reflex paths. The blood vessels of the skin are easily broken down so that slight injuries result in great suggillation. The patient rapidly develops anemia, and later goes into a syndrome similar to the cachexia of malignancy. In fact, the rapid termination and clinical course of acute lymphatic leukemia is parallel to the action of malignancy. Probably the condition will eventually be properly classified as a neoplasm of the blood itself.

The =chronic form= occurs in later life, and, instead of being an abrupt rapid process, is slow, progressive and painless. It has the lymph gland hyperplasia, but the enlargement is so gradual that compensation is established to a remarkable degree. It is usually a generalized process, first noted in the cervical and axillary glands because of their accessibility. Usually both the spleen and liver are enlarged, but this also is a slow and later development.

There may be exacerbations of temperature, but they are not constant or usually severe. Hemorrhages into the skin are not common, but pruritus may be very troublesome.

The patient comes to a physician because of symptoms resulting from his secondary anemia, dyspnea, dyspepsia, and palpitation.

The =diagnosis= cannot be made without the aid of a blood study. The blood picture shows a severe anemia with both the number of erythrocytes and the hemoglobin percentage very much lowered. Of the two findings, the hemoglobin percentage is relatively more decreased, so that the color index is markedly lowered.

In the acute form nucleated reds are common. Just before death these may show various forms and sizes as well as the normoblasts. In the chronic form normoblasts do not appear except as the case grows decidedly worse. As compared to myelogenous leucemia the anemia of lymphatic leukemia is of greater severity.

In the leucocyte count there is great increase in numbers, the greater part being composed of the lymphocytes. The lymphocytes may be either of the large or small variety, and occasionally are found in about equal proportions. In contra-distinction to the myelogenous type, the increased type of cells are of the mononuclear nongranular types. It is not very unusual to find a well advanced case of lymphatic leucemia without abnormal cells in the blood count, the expression of pathology being in the shape of disturbance in number and proportion of cells rather than in development of abnormal types. The actual number of leucocytes does not go as high in proportion to the gravity of the condition in lymphatic leukemia as it does in the myelogenous. In other words, a patient with lymphoid leucemia showing a count of 90,000 leucocytes with 90% of these lymphocytes is a much sicker man than the myelogenous case showing a 350,000 leucocyte count.

Usually there is an actual as well as relative decrease of all the granular types of leucocytes with the polymorphonuclear neutrophiles especially decreased.

The =treatment= is systemic and symptomatic. Recovery is not to be expected, but these unfortunates can be made relatively comfortable and given occasional respite by judicious osteopathic care.

Hodgkin’s Disease

(LYMPHADENOMA; PSEUDO-LEUCEMIA)

In a general way, the several conditions which are clinically leucemia, yet do not possess leukemic blood, can be classified as pseudo-leukemias. We do not definitely know the cause of leucemia as yet and can but little more than speculate on the various etiologic factors of the pseudo-leucemias.

Syphilis, malaria, tuberculosis, and malignancy are all considered as factors, and probably certain cases can be definitely associated with these conditions.

All of this group of pseudo-leucemias are characterized by early swelling of cervical lymph glands, followed by general gland enlargement, and by great destruction of the erythrocytes. There may be metastatic-like growths of lymphoid tissue in other organs. The enlargement of cervical glands usually begins on one side near the angle of the jaw, and most commonly in young male adults. These glands progressively increase in size, first are soft, then later become hard through fibrous proliferation. Each gland tends to increase in size by itself, not to coalesce with its neighbors, so that each separate gland can be palpated. This is more readily done as there is little tendency to fibrous adhesion formation to the overlying skin. These glands are painless throughout the course of the disease, and tend neither to caseate nor to suppurate.

The excised glands show a combined hyperplasia and connective tissue proliferation. In the soft stage of the tumefaction, the lymphoid hyperplasia is in preponderance, while, at the stage of hardening, the fibrous tissue derived from the trabeculae and capsule of the gland is in prominence. There is increase in the size of the spleen, and occasionally of the liver, but these are never as marked as those resulting from leucemia.

The =symptoms= are, first, those due to the glandular enlargement in the order of: dyspnea, hydrothorax, dysphagia, ascites, swelling of the extremities, and jaundice.

The destruction of red cells gives a resulting anemia which goes with and exaggerates the pressure symptoms.

A process of this kind to induce such grave changes over as well protected organs as make up the lymph system, must be virulent enough to set up other symptoms, to be associated with those due to pressure or to anemia. These are usually emaciation (giving greater prominence to glandular tumefaction), cachexia, and the implantation of masses of lymphatic tissue in organs where normally only traces of this tissue exist.

Fever is dependent upon the disturbed thermic metabolism and may be practically absent or subject to wide variations.

The erythrocyte count shows a progressive decrease with a greater proportion of broken down cells and abnormal types as the condition advances. The actual count is usually between 2,000,000 and 3,500,000 per cubic millimeter. The hemoglobin usually reduces in proportion to the erythrocytes, so that there is little change in color index.

The leucocytes are not markedly changed in number (seldom over 10,000), and this is often the =diagnostic= finding between leukemia and the pseudo-leukemias. Hodgkin’s disease usually has a high percentage of lymphocytes, so that there is an actual as well as relative decrease of the granular leucocytes.

The =treatment= is unsatisfactory, and is in the main symptomatic. Roentgen therapy has given temporary improvement, in some cases lasting several years. In general the =prognosis= is hopeless, the end occurring within four years of the time the condition is recognized.

DISEASES OF THE THYROID GLAND

Congestion

Physiological congestions of the thyroid gland are not uncommon during puberty, painful menstruations, pregnancy, and the menopause. The =premenstrual= congestion may persist after the menstrual function has been established, but this is comparatively rare. When the enlargement remains there is more or less hypertrophy, and it should receive appropriate treatment. Upper dorsal and cervical lesions are common. The congestion during =pregnancy= occurs in the majority of cases and seems to be a physiological process, wherein there is more or less hypertrophy and hyperplasia, which probably counteracts the waste products especially caused by this state, or due to the inactivity of the ovary. During =delivery= the gland may rapidly enlarge and remain so for an indefinite time. It seems probable that the straining due to labor may cause lesions of the upper dorsal and neck that will derange the function of the organ. When the enlargement occurs during the =menopause= special care should be taken that the goiter is not malignant.

Other possible causes of congestion are overfatigue, particularly when associated with heavy lifting; tight clothing about the neck; overuse of the voice; and in a few cases it may be discovered in boys at puberty.

The =symptoms= are congestion, the gland being very vascular, either soft or tense, somewhat painful owing to the tension of the capsule, and in persistent cases there may be hypertrophy and hyperplasia. The treatment is the same as given under simple goiter.

Inflammation of the Thyroid

Inflammation of the thyroid is not of frequent occurrence. In the several cases that the authors have seen there was some previous enlargement of the organ, which probably caused a =lowered resistance= of the local tissues. There is almost invariably some infection elsewhere in the body. The exciting causes are usually streptococcus, staphylococcus, or bacillus coli. The inflammation may follow pneumonia, tonsillitis, rheumatism, typhoid, puerpal infections, enteritis, diphtheria, influenza, mumps, etc. Trauma, carrying weights on the head, and cold, may be etiological factors.

Commonly, one lobe is involved, though the entire gland may be affected. There is swelling, the capsule is distended and painful, and small hemorrhages occur which in the case of suppuration form the site of the abscess. The swelling involves the parenchyma and interstitial tissue.

The =onset= is usually sudden with chills, fever, and pain over the glands. The patient keeps the head flexed to release the muscular tension, swallowing is painful, and there is a sense of constriction. A rapid heart may be a prominent symptom. Much depends at this period on the =treatment= given. If the drainage can be freed, by lowering the first ribs and raising the clavicles with attention to the dorsal and cervical innervation, prompt subsidence of the condition commonly takes place. This should be carefully accomplished in order not to bruise the parts.

=Diagnosis= is not difficult as a rule. The symptoms and history of infection will generally suffice. Hemorrhage may occur in a goiter and somewhat simulate inflammation. A possibility of =malignancy= is to be considered.

If the condition does not yield to treatment, surgical interference may be necessary.

=Tuberculosis= and =syphilis= of the thyroid are rare conditions. =Woody thyroiditis= may be mistaken for malignancy. The gland is very fibrous, and when cut has a dry surface. The connective tissue is hardened and crowds upon the parenchyma. This condition is usually found in young men. It develops rapidly, with more or less pain and dyspnea. =Adenocarcinoma=, =carcinoma=, and =sarcoma= are rare diseases[106], still one should be on his guard as to their possibility. They are most apt to occur after forty. A rapid enlargement should be regarded with suspicion.

Simple Goiter

We employ the term simple goiter to designate chronic enlargement of the thyroid gland not due to inflammation, exophthalmic goiter, or malignancy, although the latter conditions are frequently associated with or follow the former. There is usually an enlargement of the gland in cretinism, and occasionally in myxedema, but the functional grade of the gland is far different from that in other diseases of the thyroid.

The disease is very prevalent in certain regions of Europe and Asia, although in the United States it is not so common, except in the environs of the Great Lakes, the District of Columbia, and the Northwest states. The second decade of life, probably owing to adolescent changes, especially in girls, develop the greater number of goiters. It is infrequently congenital, and occasionally a case will develop as early as four or five years of age.

=Etiology.=—Disturbed innervation of the gland unquestionably seems to be the predisposing cause of the deranged secretion and vascular changes, which if continued finally lead to hypertrophy and hyperplasia of the tissues. These lesions are found from the fifth dorsal to the occiput and to the corresponding ribs. They probably involve secretory fibers of the sympathetic that emerge from the upper dorsals, first to fifth inclusive, maximum effect second, third and fourth. “Evidence is presented that the impulses pass to outlying neurones whose cell bodies are located close below the superior cervical ganglion and also in the inferior cervical ganglion.”[107]. In both these ganglia impulses to the thyroid pass from preganglionic fibers to the outlying neurones. This also includes the area of vasomotor[108] innervation of the head and neck.

In a number of cases cervical lesions alone will disturb the thyroid innervation, especially from the second to fourth segments. These may involve the superior cervical sympathetic, owing to its relationship to the rectus capitis anticus major muscle. Then there are afferent association fibers that pass down through the lateral horns and whose connecting fibers emerge via the upper dorsal.

The lymphatic drainage of the thyroid should not be neglected. Lesions of the upper ribs and clavicles are very prone to impede its circulation, and thus predispose to secondary infections.

Infection from septic foci are important secondary factors. This is particularly true of focal infections of the upper respiratory tract and buccal cavity, although infections and toxins from various regions may be exciting factors. Toxemia due to intestinal stasis is not rarely an important consideration.

McCarrison insists that infection from certain waters is the cause of goiter. He finds that boiling the water renders it harmless.

=Pathologically=, the first effect upon the gland is to lessen its iodine content. The circulation is increased, with hyperplasia of the epithelial tissue, and a lessened amount of colloid material. If the condition continues, the alveoli will again become distended with the colloid material so that the epithelial tissue cells are almost flattened. This represents the so-termed =colloid goiter=. The gland, commonly the whole organ, though one side may be involved, is fairly uniform in size. In rare instances, the gland may surround the trachea—the so-termed circular goiter. Hemorrhages may occur, and there may be various alterations and degenerations. When the vessels are much dilated, it is often called a vascular goiter, though the colloid changes are present.

The =nodular goiter= is another form characterized by new formation of gland tissue that is not diffuse but circumscribed. These cases are apt to follow persistent involvement of the gland at puberty. The two forms may occur together, and there may be various combinations and changes. In the nodular goiter there is comparatively little colloid. There are many blood-vessels, and small hemorrhages are frequent. This latter point should be remembered by those who treat over the gland, which at best is a doubtful procedure. Various changes may take place, as local points of =necrosis=, =cystic= formation, and =calcification=, are not uncommon.

=Symptoms.=—The essential feature in goiter is distension of the alveoli and formation of new ones, associated with dilated vessels, and usually degeneration of the colloid. Often the function of the gland is not noticeably disturbed. Usually, it is for the pressure symptoms or the unsightliness, due to the distension, that the patient seeks relief. Pressure upon the windpipe, gullet, or blood-vessels is not rare, and may cause more or less difficulty in breathing or swallowing. Coughing and huskiness may be troublesome. The recurrent nerves and vagus may be compressed. Disturbance of the heart, such as palpitation, tachycardia, and hypertrophy may be caused by the effect of pressure upon the blood-vessels, or to changes in the secretory function of the gland.

=Treatment.=—Adjustment of the upper dorsal and cervical lesions will be followed by recovery in the majority of cases. Dr. Still emphasized the point that the vertebral ends of the first ribs are frequently displaced upward and outward. This lesion is often found in cases following confinement. The effect of the change here is probably to the stellate ganglion, or to the lymphatic drainage of the gland. Treatment over the gland should be cautiously given, if at all. Definite correction of the lesioned vertebræ and ribs will be sufficient, but muscular manipulation and halfway measures are practically useless.

Lesions of the lower spine may be the primary source of a compensatory lesion of the upper dorsal, or they may derange the pelvic organs, or be the predisposing factor of intestinal stasis. Attention to possible focal infections, and thorough elimination, are to be considered. In goitrous regions boiling the water is of value. In obstinate cases the X-ray may be of service, and as a final resort surgery may be employed.

“Marine observed that the amount of iodine is inversely proportional to the degree of hyperplasia of the gland, and when the hyperplastic condition becomes fully developed, scarcely a trace of iodine is contained in the gland. Later, when the hyperplasia gives place to colloid goiter, the iodine increases again, both absolutely and relatively. Moreover, it has been found that if iodine be administered to an animal suffering from hyperplasia, the hyperplastic condition very quickly disappears and the animal becomes normal.”[109]. His viewpoint of the hyperplasia is that an effort is being made to compensate for an “insufficiency due to inability to absorb or assimilate sufficient iodine”, and thus the effect of the administered iodine is to normalize the gland by stimulation.

No one can question that this may be effective under certain conditions, particularly where there is deficient iodide in the water, but it is an essential element of the body. But it does not necessarily follow that because in thyroid disturbance the relationship between thyroid functioning and the substance containing iodine is upset that recovery depends upon furnishing more iodine to the body economy. It may be somewhat parallel to giving iron in anemia, when often the real difficulty is one of assimilation, and not insufficient iron in the alimentary canal. Moreover, case after case of goiter has recovered through osteopathic measures following a most thorough trial of the iodine treatment. It is very obvious that the cause of the goiter rested elsewhere. Dogs are susceptible to thyroid enlargement. Lesioning of the cervical region has resulted in goiter formation, and recovery has followed adjustment of the lesion. And dogs having goiter without experimental lesions have frequently been normalized by adjusting an abnormal cervical spine.

Exophthalmic Goiter

In exophthalmic goiter there is an excess of the thyroid secretion or thyroid autacoid which passes into the circulation, due to hypertrophy or hyperplasia of the secreting cells. The disease is characterized clinically by nervousness and irritability, rapid pulse, flushed and moist skin, tremor, and increased nitrogenous metabolism. A goiter is usually present, but not always noticeable. There is apt to be protrusion of the eyes, especially after the disorder is established, though it may never appear. A disturbed coordination of the muscles of the eyelid, eyeball, and orbit are frequent characteristic symptoms.

=Etiology.=—The essential factor in the cause of this disease is probably osteopathic lesions that irritate the secretory fibers of the thyroid tissue. These lesions are almost invariably found in the upper dorsal, first to fifth, and most often localized at the second-third or third-fourth segments. They are definite interosseous changes, combined rotation and lateral flexion, and are generally very sensitive upon palpation. The constant stimulus thus produced passes through the sympathetic fibers to the cervical ganglia, and thence to thyroid secreting tissue, which through vascular changes and hypertrophy and hyperplasia increases the output of the thyroid hormone.

The sensitiveness of the lesions is probably of more than passing interest. For this actual tenderness is not to be confused with a neurasthenic state, which may be associated with the disease, or even be a source of confusion in the diagnosis. The lesion is of such a distinct character that there is considerable local irritation and congestion. This constant stimulus is a cause of the increased number of impulses carried to the sympathetic, and results in not only an excess of thyroid secretion and the concomitant hypertrophic changes, but also in the rapid removal of the colloid into the circulating blood. This seems to be a very important link in the pathologic chain.

Other underlying lesions may be present, as outlined under simple goiter, and do not require repetition here.

The mechanism of the thyroid gland may be further upset or deranged by various exciting causes, such as focal infections, toxic states, intestinal stasis, and occasionally an enlarged thymus is an important factor. An inherited neuropathic tendency, excessive strain, worry, and mental shocks may have more or less influence in either predisposing or exciting the disorder.

The particular points for the practitioner to remember are that exophthalmic goiter is due to a toxic state, of which there are many gradations, from the excessive secretion of the thyroid gland; that the normal resistance of the gland is lowered through definite lesions of its innervation or circulatory channels, or occasionally of lesions of the other organs of internal secretion which are closely associated; that infections and toxins are often important considerations; and that direct manipulation of the organ may increase the disorder.

=Pathology.=—The enlargement of the thyroid gland is commonly an early symptom, occurring before the nervous, cardiac and exophthalmic manifestations. There are instances where it follows a simple goiter, although Graves’ disease does not seem to be any more prevalent in regions where simple goiter is endemic than elsewhere. In these particular instances intestinal toxemia is often present. There are cases where the gland is very slightly enlarged, containing only small areas of hyperplasia. There is usually very little colloid, though there may be marked exceptions. It should be emphasized that there are various degrees of changes found in the gland though fundamentally of the same order. The blood supply is extensive, and the veins especially are fragile. The alveoli are distorted, due to the increase of epithelial cells. Lymphoid nodules are frequently noted through the glandular tissue.

Research work of unusual interest to the osteopathic physician pertaining to the etiology and pathology of exophthalmic goiter has been carried out at the Mayo Clinic. An examination of cervical sympathetic ganglia removed at operation from such cases and certain animal experimentation has given definite results. The following is a summary of their principal findings:

“Degree of hyperpigmentation, granular degeneration, and reduction in the number of cells was in direct ratio to the continuance of symptoms of hyperthyroidism. The increased amount of perivascular connective tissue generally throughout the gland was similarly in direct ratio to the time during which symptoms of hyperthyroidism had continued.

“Increase of connective tissue in the ganglia from the chronic cases may be interpreted as due to the irritation from inflammation, or as merely a replacement following the destruction of the ganglionic nerve cells.

“Ganglia were intimately connected by firm adhesions to the surrounding tissue.

“There were changes in the outer and middle coats of vessels, and in the nerve fibers. There was an increase of connective tissue throughout the ganglion.

“It appears that definite histologic changes do occur as (a) hyper-chromatization, (b) hyperpigmentation, (c) chromatolysis, and (d) atrophy, or (e) granular degeneration of the nerve cells. All of these are but successive steps in degeneration which, if uninterrupted, proceed to complete destruction of the ganglion cells affected. Not all of the ganglion cells in any of the ganglia examined were so completely destroyed as to render improbable their return to normal under favorable conditions. There is some evidence that in ganglia from cases clinically improved some of the cells have partially or wholly recovered.”[110] They are inclined to the view that local infection in the cervical sympathetic ganglia plays an important part in the etiology.

The above pathologic changes of nerve fibers and ganglia support in many ways the findings noted at the A. T. Still Research Institute, not alone in the cervical region but in other regions of the body, that is, they are changes common to interosseous lesion pathology of various areas of the spine, and thus are predisposing factors that establish lowered resistance of tissue and derangement of function.

An important feature of the pathology is hyperplasia of the thymus. Simmonds finds it enlarged in three out of four cases. MacCallum[111] has found it enlarged in all autopsies that he has seen. The lymphoid structures of the spleen, liver, kidneys, intestines, and bone marrow is increased, while the lymphatic glands of various regions of the body may be enlarged, especially the cervical, bronchial, and axillary. This is probably due to a toxic condition.

Dilatation and hypertrophy of the heart is common, and in advanced cases myocardial degeneration is apt to take place.

=Symptoms.=—The outstanding feature of hyperthyroidism is the excessive secretion of the gland. The symptoms seem to be largely dependent upon the amount thrown into the blood stream; still there is a possibility that there may be a certain perversion of the secretion, though if such exists it has not been discovered. It should be kept in view that in certain instances where the secreting activity of the gland has been markedly curtailed, by surgical means, for instance, even to hypo-functioning there may still exist some of the symptoms of exophthalmic goiter, which goes to show that other factors may be of decided importance. The thymus and other related organs, as well as the sympathetic nerves, are not to be neglected.

Kendall and Plummer (Mayo Clinic) “believe that the location of the active constituent of the thyroid, when it functions, is within the cells not of any particular set of organs or portion of the body, but that it is a constituent of cellular life and activity. Plummer states that the active constituent of the thyroid determines the rate at which any particular cell can produce energy, that is, it establishes the quantum energy which any cell can produce when it is stimulated, either from within itself or from without, so that the thyroid is directly related to the production of energy within the body. He has shown that one-third of one milligram of the active constituent of the thyroid increases the basal metabolic rate one per cent in an adult weighing approximately 150 pounds.” This shows how important the secretion is not only to all related glands but to every cell of the body, and assists in establishing a physiological basis in the correlation of the symptoms of both hyper- and hypo-functioning of the organ.

As a rule the =thyroid= is not greatly =enlarged=. The size, shape, and consistency varies. It may follow a simple goiter. Many of them are soft and yielding, or cystic; others are hard, of a fibrous resistance, or nodular. Probably in the instances where hypertrophy is not discoverable there is hyperplastic tissue scattered through the gland. Or it is possible there may be an intrathoracic thyroid, or =accessory= tissue in other regions, varying from the root of the tongue to the aortic arch, which has become diseased. Generally, both lobes are enlarged, though the derangement may be confined to a portion. Often there is pulsation and a thrill over the gland. Systolic murmurs are frequent. In the early stage of goiter, tenderness is noticeable due to the distension of the capsule.

The =eye symptoms= are: widened palpebral fissure or Dalrymple’s sign; failure of the upper lid to follow the downward movement of the eyeball or V. Graefe’s sign; insufficiency of convergence of the two eyes or Moebius’ sign; exophthalmos, which may be unilateral (in about seventy five percent of the cases); and rareness of involuntary winking, are the principal eye signs.

=Rapid heart= action is an early and important symptom. This is given by all observers as the most constant of all symptoms. Palpitation is often disturbing. The pulse is forcible, especially in the vessels of the neck. There is generally a low blood pressure. The heart is apt to be dilated, and in chronic cases hypertrophy and degeneration are often found.

A =fine tremor=, eight to ten times a second, is an important symptom. This is usually present and is considered one of the cardinal diagnostic points.

Profuse sweating, emaciation, muscular weakness, especially of the legs, vomiting, diarrhea, a feeling of dyspnea, and polyuria are frequent symptoms. Anxiety, apprehension, headache, irritability, and fatigue are often early symptoms, but care should be taken that they are not entirely dependent upon a neurasthenic state.

Pruritus may be a distressing symptom. There may be abnormal pigmentation. Menstrual derangements are common, especially amenorrhea, owing to the anemia. And there may be various sexual disturbances. Exophthalmic goiter occurs oftener in women than in men.

The disease is commonly a chronic one lasting several years, unless the morbid cycle can be broken; still there are cases where it appears very suddenly and runs a rapid course.

McCarrison[112] says: “Our consideration of the morbid changes met with in Graves’ disease will have brought into prominence the fact that they are indicative of toxic action. The lymphocytosis, the lymphatic hyperplasia, the lymphocytic infiltration of the thyroid, the liver and other organs; the chronic toxic inflammatory changes in the thyroid, liver and pancreas; the changes in the muscles, in the nervous system and in the adrenals; all these point to a condition of chronic irritation as the underlying factor in their production, and to the gastro-intestinal tract as the most common source of the toxic irritant.”

=Diagnosis.=—The diagnosis as a rule is not difficult. Difficulty may arise where there is incomplete development of the disorder. Irritation of the sympathetic nerves is of the greatest significance, for the characteristic symptoms are dependent upon this condition. Neurasthenia, hysteria, paralysis agitans, and tobacco poisoning and alcoholism may mislead one. The enlarged and active gland, with murmur in the majority of cases, loss of weight, excessive sweating, diarrhea, tremor, and tachycardia, even without the eye symptoms, are specially significant. The tenderness of the osteopathic lesions is very often noticeable.

=Prognosis.=—A great deal depends upon the cooperation of the patient. Rest and diet are such important features of the treatment, that if the patient is not willing to follow instructions, great difficulty will be encountered in securing satisfactory results. Adjustment of the lesions and elimination of toxins are highly essential, but only in a certain number of cases will this suffice. This, however, will usually lessen the severity of the condition, and the patient gets along fairly well, but this may be far from securing the possible maximum results. The duration of the disease is often from five to twenty years, or even longer. And the patient frequently dies from some intercurrent disease, particularly pneumonia and tuberculosis. Weakness of the heart is the most important cause of death. Severe vomiting and diarrhea may so exhaust the patient that a fatal termination takes place. Surgical interference should not be too long delayed if there is no indication of improvement by other means.

=Treatment.=—Every case requires individual study, owing to the many possible exciting causes, especially those where infections and toxins play so important a role. The four cardinal features of treatment are: adjustment of the osteopathic lesions, rest, diet, and elimination of infectious and metabolic poisons.

=Specific adjustment= of the upper dorsal spine is primarily essential. The work should be definitely and quickly accomplished. Soft tissue manipulations amount to but little except as a preparation for the interosseous adjustment. Do not tire the patient. Often, following exact adjustment a definite lessening of the severe symptoms will be noticed. The activity of the thyroid will be appreciably decreased; the heart’s action slowed; the eye symptoms less noticeable; the tremor lessened; and the strength of the patient improved. Do not treat too often. Once a week is far better than every day. But usually twice a week in the majority of cases will secure the best results. Then later once in two weeks will be the best course to pursue. The tissues are irritable, and require time to establish a physiological balance, that if kept constantly excited by too frequent or too severe manipulation will increase rather than lessen the condition. This, however, does not apply to those cases where a certain amount of general treatment is demanded to improve systemic tone and overcome intestinal stasis, but even here do not unduly tire the patient, and keep away from the thyroid innervation except at stated intervals. There is nothing more important in osteopathic therapy, except definite adjustment, than not over-treating.

The cervical region should be normalized, and the upper ribs and clavicles carefully adjusted. But leave the gland alone, for manipulation over it further stimulates its function and there is a possibility of rupturing its fragile vessels. Normalization of the entire spine is important, owing to its bearing upon interdependent relationship, mechanically and physiologically, and the necessity of correcting all metabolic irregularities.

Both =physical= and =mental rest= are essential. This tends to lessen the excitability of the nerves, conserves the strength, increases the metabolism, improves muscle tone, and rests the heart. At least several extra hours in bed is always best. Lying down two or three hours during the middle of the day will accomplish considerable. In severe cases absolute rest in bed until the disorder is under control is imperative. In mild and moderate cases all excessive fatigue should be avoided. Unless such measures are followed the treatment otherwise may not accomplish anything. Stopping short of fatigue is the rule that must be followed.

The =diet= is important in order that the strength may be increased and harmful foods eliminated. If the carbohydrates in the small intestine are not sufficient, they may decompose into toxic substances that are harmful when absorbed into the circulation. An abundance of green vegetables and fresh fruit is best. Milk, fermented milk, butter milk, butter and cream are allowable. The patient should drink freely of water. Meat should be used sparingly, and avoid tea, coffee, and condiments.

Free elimination and fresh air are also important. It is the aggregate of details that counts so much, particularly in such a toxic and excitable disease as exophthalmic goiter. The neutral bath (95 to 96 degrees) is better than either hot or cold baths. In such a nervous disease as this, suggestion is unquestionably a valuable measure in quieting the nerves and improving the mental viewpoint.

All focal =infections=, such as often found in the throat, nose, and buccal cavity, in the appendix region, gall-bladder, etc., should be eradicated.

If under carefully controlled treatment the patient does not definitely respond within from two weeks to a month, surgical measures should be seriously considered.

Myxedema

Myxedema is a chronic disease due to loss of thyroid function, and characterized by markedly decreased metabolism, trophic disturbances of the skin and subcutaneous tissues, and a cessation of mental development corresponding to the time of the injury of the thyroid.

McCarrison restricts the term “cretinism” to those cases where there is congenital thyroid deficiency. “After the first year of life, when ossification has proceeded to the extent of closure of the fontanelles, the case is only distinguishable from one of cretinism by this fact.” In the =child=, all the functions are depressed, there is a low temperature, the bones do not develop, and the child may become stout. The mental development is retarded, and also the sex organs.

In the =adult= cases there is the same depressed metabolism. The skin is sallow, dry, and increased in thickness. The tongue is enlarged, the lips thick, and the feet and hands considerably changed in size. The nails may be thickened, and the hair falls out. The abdomen is apt to be pendulous. Heavy pads occur below the clavicles and on the chest, neck, abdomen, and sexual organs. Usually the thyroid cannot be palpated. In a few, the gland may be goitrous.

The =mental= faculties are sluggish. The speech is slow, and the voice more or less changed. Physical exertion is an effort, and the patient may have some difficulty in walking. And there is anemia, loss of appetite, and poor digestion. The number and character of symptoms are innumerable, depending upon the extent of thyroid insufficiency, and often upon predisposing and associated disorders. But the essential symptoms are those pertaining to the skin, and the mental apathy. In children the retarded physical and mental growth is the outstanding condition. Development of the disorder is slow.

=Etiology.=—Lesions of the thyroid innervation may cause a lessened function of the gland, for correction of the lesions has been followed by markedly definite improvement in a number of cases. The disorder has followed operation on the gland. In other cases some form of infection, primary or secondary, is probably the cause of the injury and subsequent atrophy. In some instances there is evidently a family tendency. It occurs more frequently in women, and in cold than in hot climates. The menopause seems to be a predisposing factor. Overwork, anxiety, poor nutrition, and conditions that lower tissue resistance, are among the etiological considerations.

In well marked cases the =diagnosis= is easy. In others the disease may be mistaken for nephritis or jaundice. X-ray examination of the ossification centers is of decided value. The =prognosis=, in untreated cases, is considered hopeless, the duration being from four to seven years. The treatment with thyroid extract, or alpha-iodine, has resulted in marked improvement, though in severe cases it must be kept up continuously in order to supply the deficiency.

=Treatment.=—There have been several well marked cases that have responded to the osteopathic treatment. Adjustment of the lesions affecting the gland, and attention to the general health have been the methods administered. The response in a number of children has been most notable. In fact, to such an extent that all faculties and functions were completely recovered. Even in cases where thyroid extract had been administered with comparatively little results, the adjustment of the upper dorsal and cervical lesions, with attention to the diet, elimination, and general hygiene, was followed by normalization.

That the thyroid function when deranged, hyperthyroidism, hypothyroidism, or otherwise, can often be recovered through osteopathic treatment, adds a very important therapeutic measure in the treatment of this gland. But in view of the brilliant results secured in hypothyroidism, through the administration of the thyroid extract, one should not hesitate to use it if improvement is not otherwise forthcoming. Nevertheless, the very important point remains that thyroid extract is only supplying a necessary substance, however essential, to the bodily metabolism, and does not strike at the essential etiology of the disorder.

Cretinism

It should be kept in mind that there are many gradations and alterations in both hyperthyroidism and hypothyroidism, and that a “goiter” may present either picture, partly or wholly, or on the other hand may be normally functioning.

MacCallum says: “Unlike the myxedema cases which occur anywhere and everywhere, regardless of environment or hereditary taint, these people, known as cretins, are found in regions where the condition seems to be endemic or inherent in the environment, and we can usually trace in their parents or ancestors some similar thyroid defect.”

This disease is found in various countries, particularly in certain parts of Switzerland, Austria, and Italy. McCarrison presents an interesting study of 203 cases of Endemic Cretinism found in Himalayan India. He thinks it is due to infection. There are a few cases in North America, probably mostly due to immigration. It is frequently confused with myxedema.

Cretins are of short stature, flat-chested and pot-bellied. The face is broad, low forehead, broad nose, prominent cheeks, thick lips, and large nose. The development of the bones is retarded; the skin is thickened and edematous; the hair is thin, and the nails brittle; the sexual organs as a rule do not develop; and in most cases a goiter, sometimes of huge size, is present. Most of them are stupid and apathetic; others are distinct idiots. Deafness is common.

There are sporadic and endemic cases, but the same underlying cause is probably present. It is claimed that most cases of the former should be classed as congenital myxedema.

Early diagnosis is essential. Removal of the patient from the goiter region, and thyroid substance is the treatment given, though results are not so marked as in myxedema.

FOOTNOTES:

[106] Ewing, Neoplastic Diseases; Grotti, Thyroid and Thymus.

[107] Cannon and Cattell, The Secretory ennervation of the Thyroid Gland, Am. Journal of Physiology, July, 1916.

[108] Gaskell, Involuntary Nervous System.

[109] Macleod, Physiology and Biochemistry in Modern Medicine.

[110] Collected Papers of the Mayo Clinic, 1916, ’17, ’18.

[111] MacCallum, A Text Book of Pathology.

[112] McCarrison, The Thyroid Gland.

DISEASES OF THE PARATHYROID GLANDS

Tetany

The clinical manifestations of the insufficiency of function of the parathyroid glands is well understood. This came about through the study of endemic tetany, and, especially, noting that tetany followed operations when the entire thyroid gland was removed. Considerable experimental work on animals was next in order, until the discovery was made that the thyroid gland and parathyroids are anatomically independent, and that tetany is entirely dependent upon the loss of function of the parathyroid glands. =Operative tetany= is now comparatively rare, since the surgeon is particularly careful not to injure the parathyroids in his operations on goiters, though mild forms may occur through damage of the tissues or extension of inflammatory processes.

There are =other forms= of tetany aside from operative, that occur in both adults and children, but instability and insufficiency of the function of the glands are basic to all cases. This is the common factor, which may be modified by tissue resistance and various hygienic factors.

In tetany there are paroxysmal, and often painful, contractions of the muscles of the extremities. Both sides are affected, and occasionally the spasms may extend to other muscles of the body. This is due to an abnormal excitability of the nervous system. Probably the secretion of the parathyroids have normally a restraining effect upon the nervous impulses, which when removed, or insufficient, or possibly perverted, results in the tonic spasms.

Thus the =predisposing condition= of tetany may be either =acquired= or =congenital=. Children may be born with defective parathyroids. In such instances there is probably a hypoplasia of tissue, which may markedly vary in a series of cases, and give rise to different degrees of tetany. Other factors, nutritional and toxic, would, very likely, be important exciting causes. Hemorrhages and fibrosis have been noted in some cases, that add to the injury of the tissues.

The blood and nerve tissues in tetany show a decreased amount of =calcium=. It is claimed by some that the abnormal excitability of the nervous system is due to the lack of calcium. Noel Paton[113] believes that, though this may bear some relationship, the parathyroids control the metabolism of =guanidine=, and that guanidine intoxication is the cause of the symptoms. Guanidine seems to regulate the tone of the skeletal muscles, and is closely related to urea.

Tetany may occur under many conditions: during pregnancy and nursing, the infectious and nutritional diseases, the diseases of the thyroid and very often gastro-intestinal disorders. There are various exciting causes, such as cold, worry, overfatigue, etc. Alcohol, ergot, morphine, chloroform, and other poisoning may precipitate an attack. But in all these cases the parathyroids are previously damaged.

The blood supply to the glands is from branches supplying the thyroid organ. This intimacy implies that the same sympathetic nerves to the thyroid vessels are in control. Probably there are distinct secretory nerves, as well as vasomotors, that are connected with the upper dorsal and cervical sympathetics. =Lesions= related to the corresponding spinal areas probably affect the integrity of the parathyroid function.

Schafer says: “The parathyroids are amongst the most vascular organs in the body. They are supplied each by a special branch of the inferior thyroid artery. The sinus-like capillaries come into close relationship with the epithelial cells of the gland. The nerves of the parathyroids, like those of the thyroids, pass both to the vessels and to the secreting cells. Some evidence has been adduced which seems to show that the cell-activity is controlled by the nervous system.”

Hence it would seem that in many cases of tetany, aside from those cases due to operative injury and possibly certain congenital instances, =osteopathic lesions= affecting the nerve and vascular supply of the organs may so lessen, or pervert, the secreting cells that tetanic states may supervene, especially where lowered nutrition, toxins, and infections are inciting factors.

=Symptoms.=—The tonic contraction of the muscles may last a few minutes or may persist for several hours, and are usually confined to the hands and feet. The fingers and toes are first affected by the spasm, which extends upward toward elbows and knees. This is commonly preceded by numbness and more or less pain in the parts. Occasionally there is a general ill-feeling, depression, and headache. There may be rise of temperature, and some edema of the affected parts. There are no mental symptoms.

The fingers are partly flexed at the metacarpo-phalangeal joints and rigidly extended at the inter-phalangeal joints, the thumb is markedly adducted and the fingers drawn close together. The wrist may be flexed, and in severe cases the elbows flexed and adducted. When the feet are contracted the toes are drawn together, flexed, and may overlap, and the feet are arched.

=Trousseau’s phenomenon.=—The spasm is increased by pressure over the median or ulnar nerves, or blood-vessels supplying the parts. This may also excite an attack. =Chvostek’s phenomenon.=—Percussion over the facial nerve will cause quick contraction of the muscles innervated. =Erb’s phenomenon.=—The electrical excitability of the motor nerves is markedly increased.

=Diagnosis.=—The characteristic attitude, and the irritability of the motor and sensory nerves, make diagnosis easy. It may be confused with =meningitis=, but in tetany there are no brain symptoms, while in meningitis there are no characteristic signs of tetany. Generally, there is little probability of confusing the disease with =tetanus=, or =hysteria=.

=Treatment.=—Most cases are of a mild type, and recovery is the rule. A great deal depends upon the underlying cause. Malnutrition, if long continued, is a very important factor that may readily predispose to the disorder. Rickets in children is often a basic consideration.

Rest, warm baths, and careful inhibitory relaxation of the tissues materially assist in controlling the spasms. Attention to the thyroid innervation should not be neglected. In indicated cases thyroid feeding may be of assistance. The diet is of special importance, for many cases present some disorder of the gastro-intestinal tract. Meat should not be given. Milk is of great value, owing to its calcium content. The administration of calcium is highly recommended, for reasons stated under etiology.

Diseases of the Thymus

There is little known relative to the functions of the thymus. It is most active during the growth of the body, attaining its greatest weight from the eleventh to fifteenth years, after which it gradually atrophies, though a certain amount of the tissue remains throughout life. There is usually a gradual atrophy of the organ after puberty, associated with increase of connective and adipose tissues. In cases where it does not atrophy, there is often hyperplasia of the entire lymphatic system in the body.

There is some relationship between the thymus and sexual organs, and in experiments where the organ has been removed, ossification is delayed, muscular weakness and tremor occur, there is hyperplasia of the thyroid, parathyroids, and adrenals, and general cachexia, acidosis, and mental deterioration take place.

The inferior thyroid and internal mammary arteries from above, and the pericardiophrenic from below, comprise its arterial supply. The nerve supply is from the sympathetic, vagus, and possibly the phrenic. In cases of exophthalmic goiter there is frequently an associated enlargement of the thymus, which may be shown by the X-ray, due to failure of normal involution or a renewal of growth, that may be definitely influenced by adjustment of the osteopathic lesions.

In some of the acute infections as pneumonia the thymus may atrophy with some fatty degeneration and increase of connective tissue. This also occurs in starvation. If the condition is not of long standing recovery will take place.

In =status lymphaticus= there is hyperplasia of the thymus and enlargement of the lymphoid tissue of the body, and hypoplasia of the cardiovascular system. This is a constitutional defect, so that slight injuries or infections may prove fatal. It is found in some cases that there is hypoplasia of the chromaffin system. Whether this latter condition is primary or secondary has not been settled.

In males the secondary sexual characteristics are not fully developed. The figure resembles the feminine type. The skin is pasty, and the beard is lacking or but little developed. In females the distribution of the hair may be somewhat similar to the male sex, slender limbs and chest, and disturbances of the menstrual function are noticeable.

The thyroid, thymus and lymphatic tissues are usually enlarged, while there is hypoplasia of the adrenals and chromaffin system.

The condition is met with in children who have a weak muscular system, increased adipose tissue, pasty complexion, enlarged tonsils and adenoids, and frequently are anemic. In children where the thymus is enlarged there may be excessive lymphocytosis.

The enlarged thymus may compress the trachea, interfering with breathing so that cyanosis and temporary loss of consciousness occur. Young children may die in the attack, probably due to compression of the trachea or to heart shock. Death in adults has occurred from trifling injuries, shocks, infections, and anesthesia. The underlying cause is probably a constitutional weakness.

=Diagnosis= is made from the clinical signs, percussion of the thymus and the X-ray picture, although these may not be positive. An excessive lymphocytosis is suggestive.

=Treatment= should consist of good general care of the patient, avoidance of injuries and shocks as far as possible, and careful attention to all lesions, especially of the upper chest and neck. By following this plan the child may overcome the condition. X-ray treatment is being employed with success in some cases. Operations have been successful in thymic hyperplasia where it has complicated exophthalmic goiter, and also in serious mechanical pressure in children.

Diseases of the Adrenal Glands

Experimental work supports the view that the cortex and the medulla have separate functions. The =medulla= of the adrenals is part of the chromaffin system, which includes tissue of the same character in the ganglia of the sympathetic, the carotid gland, and the accessory gland called Zuckerkand’s organ. This system is derived from the same cells as the sympathetic nerves. The medulla receives a richer blood supply than any tissue in the body. The secretion of the chromaffin tissue is called adrenalin or epinephrin. The blood receives a continuous supply of the secretion, which acts upon the small blood-vessels and assists in maintaining blood pressure. It also stimulates glandular tissue, and has some effect upon voluntary muscle which tends to counteract fatigue.

The =cortex= of the adrenal glands is of epithelial origin, and is part of the so-called interrenal system, which comprises very small masses of tissue in the sympathetic ganglia. These are located in the hilus of the kidney, broad ligament, inguinal canal, prostate, epididymis, and along the spermatic veins (Baker). The cortex is the chief glandular tissue of the interrenal system. The amount of tissue is not so great after puberty as before. The blood supply of the cortex is not so rich as that of the medulla. Abnormal activity is claimed to be the cause of certain sexual derangements, particularly sexual precocity.

Schafer states that the adrenals are very richly supplied with nerves. Each receives no less than thirty-three nervous filaments (Kolliker), derived in part directly from the splanchnic, in part from the suprarenal plexus, which is itself constituted by branches from the celiac, phrenic, and renal plexuses.

We have noted that in lesions (experimental) of the splanchnics a few cases presented acute pathological changes, congestion with some degeneration of cells, in the adrenals.

Macleod states that of the many functions of the adrenals that which is most directly associated with epinephrin is the production of glucose from glycogen. “When the nervous system is stimulated in such a way as to excite the glycogenolytic process, two effects both operating in the same direction with regard to the glycogenic function are developed: the one, a hypersecretion of epinephrin, which activates the sympathetic nerve endings, the other, the transmission of the nerve impulse to the liver cell.”

Addison’s Disease