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.