world. There are, however, localities in which it prevails to a
remarkable extent, assuming, indeed, the importance of an epidemic
disease. In some portions of Switzerland, as in Savoy and in the Tyrol,
there are villages in which scarcely a single inhabitant escapes. The
disease is very common in Piedmont and in all deep valleys of the Alps,
the Pyrenees, the Apennines, and about the foot-hills of the
Cordilleras. In the valley of the Maurienne, Larrey states, nearly all
the residents were subjects of goitre. According to the government
reports in Piedmont and Savoy, there are 22,371 persons afflicted with
bronchocele. There is a notable prevalence of the disease at
Schlettstadt on the Rhine. In France the districts where the largest
number of cases of goitre is observed are St. Aubin and Rosieux. These
places, with others less noteworthy in the same country, it is
estimated, furnish not less than 500,000 cases of the disease. In the
government of Irkoutsh, which is drained by the sources of the Lena and
its tributaries, there were in 1870, according to Hachine, as many as
3400 persons laboring under goitre. Among the inhabitants of Siberia
antecedent to the conquest by Russia the disease was scarcely known.
Its prevalence after this event was attributed to the habit adopted by
the Russians of living in heated and uncleanly rooms, altogether unlike
the Siberians, who spend most of their time in the open air. {976}
Humboldt speaks of goitre being so common in Honda and Moussa, towns
contiguous to the Magdalena River, that very few of their inhabitants
escaped the disease.
In England the counties of Derbyshire, Surrey, Nottingham, and Norfolk
furnish a large number of cases. In this country New Hampshire,
Connecticut, Vermont, and New York are the States which supply the most
examples of goitre. In Lower Canada goitre is also quite common.
In Switzerland the disease is frequently associated with mental
imbecility (cretinism), though it is not at all established that
between the two there exists any necessary connection, as cretinism is
often met with in persons free from goitre, and the latter in those
whose intellectual powers are unimpaired. Indeed, it has been observed
by Burns, that in some countries where goitre is very prevalent
cretinism is exceptionally rare; nevertheless, the observations of
Lemon and the experiments of Horsley are of a character to leave the
relation between the two still an open question.
CAUSES.--The causes of goitre are quite obscure. The disease is in some
way associated with countries the topographical features of which
consist in high mountains and deep valleys. In illustration of this
fact we have only to cite the great prevalence of the disease in
Switzerland, in the central mountainous parts of Asia, on the Himalayas
and the Andes, as also in the mountains of Brazil. In Europe it may be
said that goitre is much more common in the south and south-west
countries than in the north and north-west. Sea-coasts are generally
exempt from the disease. Bardeleben during the many years in which he
acted as chief of the surgical clinic at Greifswald saw only two cases
of goitre.
The use of glacier- or snow-water has been charged with the production
of this evil, containing as it does large quantities of carbonic acid
and other matters not generally found in pure potable water. In
opposition to this view we are able to present the testimony of Captain
Gerard that in those portions of the Himalayas where the inhabitants
for a number of months in each year drink snow-water goitre is really
less frequently observed than among those who live at the foot-hills of
the same region. This coincides with what Lebert states, that if water
from the regions of ice and snow constitutes a cause of goitre, then we
should expect to find the disease increasing more and more as the
glaciers are approached, when, really, just the reverse is the case,
the subjects of such enlargements being seen in greater numbers at the
bottom of valleys than in the more elevated regions. The Polar
expeditions of Lenstake and Kolleweg, undertaken in the years 1868 and
1870, also contradict the supposed connection between goitre and
ice-water, as not a case of the disease was reported, notwithstanding
the men drank nothing else; and in Sumatra, where snow is never seen,
goitre is quite common. Nor is there any satisfactory evidence that
lime- or magnesia-water, also charged with exerting a determining
influence in the causation of goitre, has anything to do with its
existence. The testimony of Humboldt as to the rareness of the
affection at Mariquita, where the water is strongly impregnated with
lime salts, and my own observation that throughout the Pequea and
Conestoga valleys, both limestone districts, goitre seldom occurs, are
inimical to such a theory. From St. Maurice to Martiny in Wallis,
Lebert speaks of goitre being very common, notwithstanding the absence
of lime formation.
That water, however, does become the medium for certain materials
which, taken into the system, produce enlargements of the thyroid, is
unquestionably true. In corroboration of this statement we have two
notable facts recorded by Frank, who says that at Rheims, where goitre
was very common, quite one-half of the tumors disappeared after the
source of the old water-supply was abandoned and the town supplied by a
branch from the river Verle. {977} And again at Stenseifen, near
Schmideberg, where goitre prevailed as an endemic, the disease
disappeared on the closing of a fountain which furnished water to the
inhabitants of the place.
Atmospheric causes have also been invoked in order to shed light on the
production of goitre. Thus it is said that the common occurrence of the
latter in very deep valleys, so overshadowed by the dense foliage of
timber as to prevent a proper interchange or circulation of air, is
favorable to this theory; yet as against this view we have the
statement of Humboldt, who says that on the plateaus of Bogota, which
are swept by constant currents of air and are quite sterile in
vegetation, goitre is common.
That local or geological conditions do exist which are directly
concerned in the development of endemic goitre cannot be gainsaid, and
these of so active a nature that persons coming from remote districts
into such goitrous centres and entirely free from all enlargements of
the gland, are liable to suffer in common with the native born. Not
only so, but, as has been observed by Virchow, even domestic animals in
such localities become subjects of the disease.
The very careful study of this subject by Labour of Newcastle, England,
furnishes strong evidence that water passing through calcareous soils
alone had little if anything to do with goitre, but when such soils
were impregnated with ferruginous and earthy salts the geological
conditions were present for developing the disease.
Enlargement of the thyroid body is occasionally seen as one of the late
manifestations of syphilis, usually bilateral and attaining in some
instances a great size.
Gestation is another and not an uncommon cause of goitre, the tumor
appearing in the last months of pregnancy or immediately after
parturition. Three cases clearly traceable to the above cause are under
the writer's care while penning this article. It is in such cases that
the tumors sometimes grow with frightful rapidity. Roberts reports
three cases in primiparæ, all of which ran an acute course and
terminated fatally by asphyxia.
In Graves' or Basedow's disease goitre forms one of the elements in the
morbid circle, and when thus associated may be regarded as a neurosis.
VARIETIES.--Goitre appears under different forms, and not unfrequently
one variety is transformed into another. The following classification,
resting on a pathological basis, will be adopted, namely--Follicular;
Gelatinous; Cystic; Fibrous; Vascular.
In follicular goitre there is a proliferation, both in the
cell-elements of the follicles and in the connective tissue
constituting their walls. This general hyperplasia of the normal
histological components of the gland constitutes a tumor which, for a
time at least, remains quite soft and compressible, even communicating
to the touch the sensation of fluctuation. The tendency, however, of
the growth is not to remain long in this condition, but to become more
firm and even hard to the feel.
The fibrous is often a transformation from the follicular goitre, an
advanced stage in the life-history of the latter. There occurs a new
formation of interstitial connective tissue, which by its accumulation
and encroachment upon the follicles lessens, and finally obliterates,
them to a degree which converts the gland into a fibroma. It is rare,
however, to find this metamorphosis general. Generally the change is
limited to portions of the thyroid, and accordingly the tumor in this
variety of the disease is found hard, knotty, and incompressible at
different points corresponding to the sclerosed portions. The
vascularity of the fibrous variety is quite insignificant in those
portions of the gland which have been the subject of this morbid
change, though in other parts there is a liberal supply of
blood-vessels.
Vascular goitre may also be a transformation from the follicular
variety, in {978} which, with an increased hyperplasia of the
follicular elements of the gland, there is a new formation of
blood-vessels taking the place of the connective tissue present in the
fibrous form of goitre. When the arterial element predominates, the
vessels will be found to be very much dilated and anastamosing freely.
These goitres are compressible, have a soft, spongy feel, sometimes
pulsate, and on auscultation disclose a distinct bruit, hence the term
aneurismal goitre often applied to such. In other instances the venous
element predominates, when the swelling will, as in the arterial
variety, be compressible and communicate to the ear a well-marked
blowing sound or murmur. As the superficial veins, in common with the
deep ones, are enlarged and tortuous, the surface of the tumor will
often exhibit at different points a bluish appearance. In two
instances, and in females of a highly-wrought nervous temperament, I
have known the vascular goitre to enlarge in a few minutes to wellnigh
twice its usual size, threatening the patient with suffocation for the
time, and almost as quickly subside after a free emesis.
In gelatinoid goitre the follicles of the gland are distended so as to
form large cavities filled with a gelatinoid- or colloid-looking
substance, the product of the enclosed cells. As the distension of the
follicles progresses the vascularity of the gland becomes notably less,
the vessels being obliterated by the pressure. This tumor may attain a
very great size, is much firmer than the vascular goitre, and to the
touch has a doughy feel.
Cystic goitre is rarely such in the beginning of its history, being
often an advanced stage of the follicular variety. In the transition
the compartments of the latter undergo enlargement, their normal
cell-contents being replaced by an albuminoid transudation from the
vessels of the follicles. This process continuing, the interfollicular
connective tissue disappears--a mechanical result caused by pressure.
Still later, and from this cause, the walls of the adjoining follicles
suffer a similar fate, and as these melt away larger cavities are
formed, until at length the whole interior of the gland is converted
into a number of loculi, and in some rare instances into one great sac.
The gelatinoid or colloid goitre may undergo a similar transformation,
and much in the same way. The fluid contents of cystic goitre vary in
their physical properties as also in their chemical constitution.
Generally the substance contained in the cysts is rich in albumen, has
a ropy appearance resembling somewhat the white of an egg, and to the
feel is viscous or unctuous, similar to that of the synovial secretion.
Sometimes it is dark, resembling coffee-grounds--a condition due to the
decomposition of extravasated blood derived from ruptured blood-vessels
belonging to the gland. Crystals of cholesterin are also present,
formed by fatty degeneration of the cells of the follicles, and mingled
with a variable amount of sodium chloride. The cystic goitre is soft
and fluctuating, and often grows to a large size.
* * * * *
The blood-vessels of goitre are not exempt from pathological changes,
but frequently become the subjects of atheromatous and amyloid changes.
Carcinoma and Sarcoma of the Thyroid Gland.
Malignant growths of the thyroid body are comparatively rare, and when
present are accompanied by symptoms sufficiently significant to
differentiate them from those which are benign. In both carcinoma and
sarcoma the increase of the tumor is rapid; the surface veins become
very distinct, and the enlargement is general, affecting the entire
gland. In addition to the above phenomena, the evil effect resulting
from pressure is sooner realized and more pronounced than in goitre,
and in a short time the generalization of the disease becomes apparent
in the loss of flesh and strength. Should {979} the tumor be a
carcinoma, there will likely follow the infection of those lymph-glands
in nearest relation to the neoplasm.
EVIL EFFECTS OF GOITRE.--In this country, though goitre may grow to a
large size, it is not common for patients to suffer any inconvenience
other than that which results from the unsightly appearance of the
tumor; hence life is not seriously imperilled by the disease.
Occasionally, however, there are exceptional instances in which
unpleasant and even troublesome symptoms are developed. Among these may
be mentioned alteration of voice or a slight aphonia in consequence of
pressure by the tumor on the recurrent laryngeal nerve. An irritating
cough may also exist, and when no evidence of pulmonary trouble is
present it must be referred to pressure upon the pneumogastric nerve.
Dyspnoea when present results usually from pressure upon the trachea.
It has been observed that when this pressure is long continued,
particularly in cases of vascular goitre, some of the rings of the
trachea gradually disappear, leaving only a membranous tube, which may
collapse and cause the sudden death of the patient.
Hiccough and diaphragmatic spasms have also occurred when the
enlargement of the gland extended laterally, in consequence of pressure
on the phrenic nerve. In addition to the above phenomena there is often
experienced in goitre severe neuralgic pains on the side of the neck,
in the ear, and over the back of the head, and indeed in the course of
any of the branches of the cervical plexus of nerves.
Occasionally I have seen a red blush of the integument on the side of
the neck, answering to the largest portion of tumor, accompanied by
increased heat, doubtless from the growth encroaching on the
sympathetic nerve.
TREATMENT.--The treatment of goitre may be divided into constitutional
and local. Too often the management of the disease is conducted in an
empirical manner, every variety being subjected to the same routine of
remedies. No greater mistake can be made. To attain any satisfactory
success it is absolutely necessary that a correct diagnosis of the
composition of the tumor shall be known. In follicular and in fibrous
goitre much may be anticipated from constitutional and local measures.
Those remedies which possess the property of inducing retrograde
changes of structure and their subsequent absorption are the ones to be
selected for administration, and among these iodine and its
combinations rank highest. The compound solution of iodine, the iodide
of potash, and the iodide of iron, all have their therapeutical
adaptiveness. The earlier treatment is commenced the more hopeful will
be the prognosis. If the patient is in all other respects in good
health, and especially is somewhat fleshy or given to obesity, the
compound solution of iodine should of preference be selected. At first
the dose should be small, in order to test the tolerance of the
stomach, not exceeding five or six drops three times a day, taken in
some sweetened water, orange syrup, or curaçoa, and always about one
hour after meals. Every two or three days the dose may be increased one
or two drops until eighteen or twenty are taken, beyond which it is not
desirable to go. It is in these forms of goitre that the burned sponge
(spongia usta) was at one time very generally used as an internal
remedy, half a drachm to a drachm being taken twice or thrice daily. As
the virtue of the article was due to the iodine it contained, it must
necessarily be inferior to the solution of the same substance.
In addition to the constitutional treatment the local use of alterative
ointments will be indicated, the best of these being iodoform, iodide
of lead, and iodide of mercury. Iodoform will be found most efficient
employed in the following formula:
Rx. Iodoform, drachm iss;
Benzoated lard, ounce j.
This ointment is to be rubbed into the goitre for fifteen or twenty
minutes {980} morning and evening, after which a piece of lint smeared
with the same should be laid over the tumor, covered with oiled silk,
and retained in position by a strip of muslin. If the officinal
iodide-of-lead ointment be used, it will be desirable to lessen its
strength by the addition of a little simple cerate, as it is liable to
cause severe irritation of the skin when thoroughly applied, thus
neutralizing in a great measure the value of the application. Whatever
unguent is selected, the application will be best made before an open
fire.
There are several natural waters which can at the same time with the
other treatment be taken with advantage, their efficiency being due to
the iodine which they contain. The most valuable of these are
Adelheid's Quelle and Wildegger. A glass of either can be drank morning
and evening. If after two or three months' continuous treatment under
the plan described no impression is made on the disease, or in the
event of the iodine acting unpleasantly by causing symptoms of iodism,
the iodide of potash should be substituted, administering three times a
day from five to twenty grains of the salt dissolved in water and
syrup, and well diluted.
Boinet has proposed the mixture of iodine with the food as a very
satisfactory mode of introducing the drug into the system; and I
suppose that it was on the strength of this suggestion that Michaud,
with a view to protect the garrison of Étiennes against the prevailing
goitre, ordered iodine to be baked in the soldiers' bread. In cases of
goitre associated with a pale, anæmic state of the system it will often
be found necessary to alternate, for a time, the remedies already
directed with iodide of iron and cod-liver oil.
In follicular and fibrous goitres which prove rebellious to the plan of
treatment detailed a resort may be had to injections. From eight to
twenty drops of the tincture of iodine should be introduced deep into
the substance of the gland by the hypodermic syringe. This procedure
can be repeated every three or four days, selecting at each operation a
different section of the gland, at the same time carefully watching the
effect produced. Any marked elevation of temperature, local or general,
accompanied by pain or stiffness of the neck, is the signal for
suspending temporarily this form of medication. The favorable signs
following injections are the shrinking and increasing hardness of the
tumor; and so long as these processes continue progressive no
repetition of injections will be necessary.
Electrolysis constitutes another therapeutic resource, applicable not
only to the treatment of follicular and fibrous, but also to the
vascular, goitre. This agent has been favorably employed by Chvostek of
Vienna, and to some extent in this country by Baird and others. The
current used by Chvostek was one from a Siemens battery of thirteen
elements and strong enough to cause a moderate degree of burning. The
time consumed at each sitting is not to exceed five minutes, during
which the points of application must be frequently changed.
In vascular goitre, iodine, either internally or locally, effects
little good. Ergot is to be preferred. From ten to twenty drops of the
fluid extract should be given internally three times a day, with
injections of the same amount and used in the same general manner as
has been directed for the iodine.
Recently I have been using injections of carbolic acid in vascular
goitre, and thus far with the most promising results. Four or five
drops of a solution of the crystals of the acid dissolved in glycerin,
using no more of the latter than will be barely sufficient to liquefy
the crystals, should be deposited by means of the hypodermic syringe
deep into different portions of the gland at intervals of four or five
days. On the withdrawal of the instrument the puncture can be covered
with a strip of rubber adhesive plaster. The acid when thus employed
causes the tumor to shrink and become hard.
{981} Gelatinous and cystic goitres are quite intractable to
constitutional remedies. They require to be attacked locally. Bonnet
has tried caustic potash and chloride of zinc. The applications were
made over the front wall of the tumor, and in some instances to the
inner surface of the sac. The results were not of a kind to make the
method a popular one. Iodine and alcohol have also been thrown into the
parenchyma of the gland, and with a like unsatisfactory effect. Setons
have had numerous trials. The method is an old one, having been used by
Celsus, and revived from time to time by Quadi of Naples, Hutchinson,
Kennedy, and Stanton. The object in using the seton is to develop in
the tumor a destructive inflammation and suppuration. Any one who has
witnessed a case of acute suppuration in the thyroid gland will not be
anxious to repeat the experience. The purulent products are profuse,
highly offensive, and tax severely the powers of the general system;
and to these disadvantages may be added the risks of sloughing,
hemorrhage, and septic poisoning.
The treatment which promises most in gelatinous and cystic goitre is
either that practised by Gosselin or that by Morrell Mackenzie of
London. The plan of Gosselin is to make a very small incision in the
skin over the front of the tumor, in order to lessen the resistance to
the introduction of a small trocar and canula, through the latter of
which, after evacuating the cyst and washing it out with tepid water,
he injects the tincture of iodine (fluidrachm j). This injection is
allowed to remain about five minutes. Should its discharge be followed
by a flow of blood, a second and even a third injection is made before
withdrawing the canula. This operation does not materially differ from
that practised by V. Dumreicher, except that this practitioner emptied
the cyst with an aspirator previous to washing out the sac and
injecting the iodine. The method of Mackenzie, however, has succeeded
so well in practice that it is to be preferred both for efficiency and
safety. In this plan perchloride of iron is substituted for iodine. One
part of the iron is mixed with four parts of water, and after partially
emptying the cyst with a trocar and canula at its most dependent part
the fluid (fluidrachm j-fluidrachm ij) is thrown into the sac by a
syringe. The canula is now plugged with a stopper that the injection
may be retained. After three days the stopper is removed and the
contents of the sac are allowed to flow out. In case the discharge
proves to be bloody or serous, the injection is repeated; if, on the
contrary, it exhibits signs of pus the iron solution is withheld, but
the canula is permitted to remain, that free drainage may be maintained
until the goitre has been destroyed by suppuration. During the presence
of the instrument the affected part of the neck is covered by a
flaxseed-meal poultice.