Goitre

Goitre (from Lat. guttur, the throat; synonyms, Bronchocele, Derbyshire Neck), a term applied to a swelling in the front of the neck caused by enlargement of the thyroid gland. This structure, which lies between the skin and the anterior surface of the windpipe, and in health is not large enough to give rise to any external prominence (except in the pictures of certain artists), is liable to variations in size, more especially in females, a temporary enlargement of the gland being not uncommon at the catamenial periods, as well as during pregnancy. In goitre the swelling is conspicuous and is not only unsightly but may occasion much discomfort from its pressure upon the windpipe and other important parts of the neck. J. L. Alibert recorded cases of goitre where the tumour hung down over the breast, or reached as low as the middle of the thigh.

Goitre usually appears in early life, often from the eighth to the twelfth year; its growth is at first slow, but after several years of comparative quiescence a sudden increase is apt to occur. In the earlier stages the condition of the gland is simply an enlargement of its constituent parts, which retain their normal soft consistence; but in the course of time other changes supervene, and it may become cystic, or acquire hardness from increase of fibrous tissue or from calcareous deposits. Occasionally the enlargement is uniform, but more commonly one of the lobes, generally the right, is the larger. In rare instances the disease is limited to the isthmus which connects the two lobes of the gland. The growth is unattended with pain, and is not inconsistent with good health.

Goitre is a marked example of an endemic disease. There are few parts of the world where it is not found prevailing in certain localities, these being for the most part valleys and elevated plains in mountainous districts (see Cretinism). The malady is generally ascribed to the use of drinking water impregnated with the salts of lime and magnesia, in which ingredients the water of goitrous districts abounds. But in localities not far removed from those in which goitre prevails, and where the water is of the same chemical composition, the disease may be entirely unknown. The disease may be the result of a combination of causes, among which local telluric or malarial influences concur with those of the drinking water. Goitre is sometimes cured by removal of the individual from the district where it prevails, and it is apt to be acquired by previously healthy persons who settle in goitrous localities; and it is only in such places that the disease exhibits hereditary tendencies.

In the early stages, change of air, especially to the seaside, is desirable, and small doses of iron and of iodine should be given; if this fails small doses of thyroid extract should be tried. If palliative measures prove unsuccessful, operation must be undertaken for the removal of one lateral lobe and the isthmus of the tumour. This may be done under chloroform or after the subcutaneous injection of cocaine. If chloroform is used, it must be given very sparingly, as the breathing is apt to become seriously embarrassed during the operation. After the successful performance of the operation great improvement takes place, the remaining part of the gland slowly decreasing in size. The whole of the gland must not be removed during the operation, lest the strange disease known as Myxoedema should be produced (see Metabolic Diseases).

In exophthalmic goitre the bronchocele is but one of three phenomena, which together constitute the disease, viz. palpitation of the heart, enlargement of the thyroid gland, and protrusion of the eyeballs. This group of symptoms is known by the name of “Graves’s disease” or “Von Basedow’s disease”—the physicians by whom the malady was originally described. Although occasionally observed in men, this affection occurs chiefly in females, and in comparatively early life. It is generally preceded by impoverishment of blood, and by nervous or hysterical disorders, and it is occasionally seen in cases of organic heart disease. It has been suddenly developed as the effect of fright or of violent emotion. The first symptom is usually the palpitation of the heart, which is aggravated by slight exertion, and may be so severe as not only to shake the whole frame but even to be audible at some distance. A throbbing is felt throughout the body, and many of the larger blood-vessels are, like the heart, seen to pulsate strongly. The enlargement of the thyroid is gradual, and rarely increases to any great size, thus differing from the commoner form of goitre. The enlarged gland is of soft consistence, and communicates a thrill to the touch from its dilated and pulsating blood-vessels. Accompanying the goitre a remarkable change is observed in the eyes, which attract attention by their prominence, and by the startled expression thus given to the countenance. In extreme cases the eyes protrude from their sockets to such a degree that the eyelids cannot be closed, and injury may thus arise to the constantly exposed eyeballs. Apart from such risk, however, the vision is rarely affected. It occasionally happens that in undoubted cases of the disease one or other of the three above-named phenomena is absent, generally either the goitre or the exophthalmos. The palpitation of the heart is the most constant symptom. Sleeplessness, irritability, disorders of digestion, diarrhoea and uterine derangements, are frequent accompaniments. It is a serious disease and, if unchecked, may end fatally. Some cases are improved by general hygienic measures, others by electric treatment, or by the administration of animal extracts or of sera. Some cases, on the other hand, may be considered suitable for operative treatment.