The practice of osteopathy

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.