The practice of osteopathy

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

This is a rare, chronic disease, more often occurring in men, that is characterized by muscular and vascular weakness, digestive disturbances, and pigmentation. Tuberculosis of the adrenals has been the most constant lesion found. In others, syphilis and atrophy have been noted, while in a few the condition seemed to be functional. It should be remembered that it is possible that lesions elsewhere in the chromaffin system may be the cause in some cases, for all the chromaffin tissues secrete adrenalin.

It is quite likely that in most cases there is some constitutional defect of the chromaffin system which underlies a certain tendency to the disorder. Infections, injuries, physical and mental strains may lower resistance and predispose to the condition.

Osteopathic lesions of the splanchnics may congest the organs, or derange the secretions, or be of such a character that hemorrhages result, or fibrous changes follow, that would definitely incapacitate the cells and lower resistance.

Pathologically, the most common change is tuberculosis. Next in importance are atrophy and interstitial inflammation. Cancer of the organs has been noted in a few. The adrenal ganglia, the semilunar ganglia, and the solar plexus are often involved. The thyroid gland may be altered, which, when affected, is usually decreased in size. Brown atrophy of the heart is common.

Symptoms.—An insidious onset with muscular weakness, languor, and weak action of the heart are generally the first symptoms. Digestive derangements, such as nausea, hyperacidity, loss of appetite, may occur at the same time, or shortly succeed the general debility. Headache, insomnia, and depression frequently take place. Pigmentation, usually, shortly follows, though there are cases where it is only slightly noted. The disease is very chronic, of several years duration, with periods of intermission. Occasionally, a case runs a very rapid course.

The general weakness is most noticeable. There is low blood pressure. The derangement of the stomach and intestines is characteristic. And the pigmentation, which at first is light yellow later assumes a dark brown color. The pigmentation may be more or less general, but the axillæ, nipples, genitals, the palms of the hands, and the neck, waist or wherever the clothing presses upon the skin, are most pigmented. And pigmentation of the mucous membrane may be noted.

Diagnosis.—In typical cases, where there is esthenia, pigmentation, and gastro-intestinal disturbances, the diagnosis is not difficult. Where the clinical picture is incomplete, the diagnosis may be very difficult.

Pigmentation may occur in several other disorders, notably: in bronzed diabetes, abdominal malignancy, tuberculosis of the peritoneum, exophthalmic goiter, pellagra, marked intestinal stasis, stomach ulcer, pernicious anemia, certain skin diseases, etc., so great care has to be taken in atypical cases.

Treatment.—General treatment, with special attention to the adrenal innervation, diet, rest, and fresh air will accomplish something. In functional derangements, which are very few, recovery may follow. But owing to the often constitutional defect, the probability of tubercular, syphilitic, and other serious lesions, the prognosis is unfavorable.