Goitre.
Synonyms:—Broncocele; struma; thyrocele.
Definition:—The name goitre is a general one, including all forms of enlargement of the thyroid gland, whether it be all or part of a gland. Hare recognizes also an inflammation, an "infectious" and "parasitic" form, a "simple" or "benign" form, which includes the hyperplastic or "parenchymatous" form of some writers, as well as the cystic, the amyloid and colloid forms of other writers; also the "neoplastic" or "malignant" form. I rather favor this simple classification, but it does not bring out the pathologic characteristics as a classification should. It has more reference to the cause than to the pathology. Murray's classification recognizes the pathology to a larger degree. He gives the "hypertrophic" or "parenchymatous" goitre, a "fibrous," and a "cystic" goitre, and adenoid of the thyroid gland. When all the conditions found in enlargement of this gland are considered, this classification does not seem to be all inclusive, as there are goitres in which there is an amyloid or colloid development of the thyroid or a deposit of earthy or calcareous matter in the substance of the gland.
Etiology:—This disorder seems in many cases to result directly from the use of drinking water which contains a large proportion of calcareous salts. This seems to be confirmed by the fact that the disease is common in localities where the water is positively from limestone formation. This is the case in mountainous regions (Iodine deficiency; no iodine, as a rule, in the mountains. -Henriette), as in Switzerland, in the Pyrenees, in the Himalayas, in the Andes, and in some parts of the Rocky Mountains of North America, especially in Mexico, as well also as in the mountainous regions of New England and Pennsylvania. There are undoubtedly other causes, as it does not occur either endemically or epidemically in various localities where the drinking water contains lime. I have observed it in a number of cases in women of coarse fiber, who from early life lived the life of a drudge, and were constantly forced to do the heaviest of manual labor, with poor, coarse food and with but little care, living in an unhygienic and filthy manner and having none of the refinements of life.
It is more common among women than men. A simple form of enlargement is quite common among American girls during the first three or four years following puberty or during early womanhood. Treated at once, at this time, it is quite amenable to simple measures and may entirely disappear. It seems to depend upon menstrual irregularities. If there is any thyroid enlargement at the beginning of the pregnant state, it may increase greatly in size during that period. In other cases it is first observed during pregnancy. It occurs in the children of goitrous parents, but in many cases the children are subject to the same conditions to which the parents are subject, and the disorder develops directly from these causes. In malignant goitre the cause is evident.
Symptomatology:—There are no evidences of this disorder which precede the discovery of some swelling of the throat, most frequently appearing first in the right lateral lobe and upon the right side. This slowly increases, with no pain or tenderness and no discomfort, except the slight upward movement of the mass in swallowing. There are no attachments; the mass is readily movable, and later, as its size increases, it presses on the adjacent structures and interferes with the breathing, as well as with the swallowing; it compresses the vagus. It may become very large, extending widely on either side and involving both lobes and the isthmus, and resting upon the walls of the throat; it interferes to a marked degree with the movements of the head. The condition does not interfere to any great degree with the general health, unless it suspends the functional action of the gland or unless inflammation and suppuration should occur.
Compression of the nerves and of the blood vessels produces sympathetic difficulties and cerebral hyperemia. There is sleeplessness and hyperemic headache, and in rare cases convulsions. If there is interference with the functional action of the gland, marked heart symptoms may occur from a form of septic infection. I had at one time under observation a patient with a very large goitre; a large and apparently strong man, about thirty-five years of age, a Norwegian, who insisted upon the rapid reduction of the gland. He consulted an electrician, who used a strong current and iodine externally. Two-thirds of the bulk of the enlargement was reduced in three weeks. The patient was then taken very sick, tachycardia was pronounced, the heart's action was feeble and fluttering, there was a temperature of from 101° to 103.5° F.; he lost strength rapidly, and died four weeks later, with evidences of profound toxemia.
Diagnosis:—A movable enlargement in the location of the thyroid gland, the absence of pain, and the absence of constitutional symptoms, its more common occurrence in young females, are diagnostic points.
Prognosis:—The prognosis may be said to be always favorable, as to life. It runs a chronic course.
Treatment:—In the treatment of the simple forms of thyroid enlargement the results are very good in the early stages, and often quite satisfactory in the later stages. In the treatment of the chronic forms and those of complicated or mixed character, or which contain calcareous deposits, and the neoplastic form, the treatment is much less satisfactory, and may be devoid of benefit. I have made it a rule to give these patients iron, in conjunction or alternation with phytolacca decandra, at the same time paying the most strict attention to the condition of the general health. The compound tincture of iodin may be applied externally at times, and in the intervals it is a good plan to apply a paste of which the extract of phytolacca, in full quantity, is a constituent. I am convinced that when efforts are made to reduce the gland, alterative eliminatives, well selected, and heart tonics will be indicated, and should be selected early, in anticipation of constitutional symptoms or of heart complications. Iris, lycopus and cactus may each have a place in the treatment of this disorder at some time during its progress. In administering phytolacca it must be given in increasing doses to the point of toleration. The same is true of iodin in any form. I have used electricity, both in the form of the galvanic and faradic currents, in the reduction of these glands, and have found it in many cases a remedy to be depended upon. In early cases the measures should be persistent, and where the gland is very large the reduction should be extended over considerable period of time, and free elimination should be sustained without reduction of the patient's strength.
