Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

Clinical Features.—Both sexes, above the age of fifty, are affected in about equal proportion. The characteristic features are that the tumour undergoes a progressive increase in size, that it becomes fixed to its surroundings, that its surface tends to be uneven and nodular, and its consistence densely hard. The voice often becomes hoarse from abductor paralysis due to infiltration by the growth, usually of the left recurrent nerve. The effects upon the trachea are more decided and more progressive than in parenchymatous goitre; it displaces and compresses the trachea and frequently overlaps it, so as to bury the air-passage completely. If the tumour tissue has actually penetrated the trachea, the expectoration is tinged with blood. Dysphagia is rarely a prominent symptom. The lymph glands become enlarged after the tumour bursts through the capsule; and metastases to the lungs and bones, particularly the skull, sternum, and mandible, are common. When the goitre extends behind the sternum—the malignant form of retro-sternal goitre—the pressure symptoms are due to the encroachment upon the limited accommodation of the upper opening of the thorax; the trachea especially suffers, and the pressure on the veins causes distension of the anterior and external jugulars and their tributaries. The patient is unable to lie down; there are violent paroxysms of coughing, and an abundant frothy expectoration. Death may take place suddenly from asphyxia, from heart failure, or from displacement of a thrombus from one of the veins in the neck.

Treatment.—It is only in the earliest stages that a malignant goitre can be successfully removed. In the later stages complete extirpation is not to be attempted, as it usually involves the removal of a portion of the trachea or œsophagus, and the operation is attended with grave risk to life.

Operative interference is often called for, however, for the relief of respiratory embarrassment. Tracheotomy may prove a difficult and dangerous procedure, owing to the trachea being buried under the goitre and displaced or narrowed by it, so that it is not easy to reach it or to introduce an efficient tube beyond the point of obstruction. A more certain method consists in exposing the goitre by an incision as for thyreoidectomy, rapidly removing sufficient of the growth to expose the trachea and admit of a tube being introduced. If there is a retro-sternal prolongation compressing the trachea within the thorax, a long flexible tube may have to be passed beyond the site of the compression before the dyspnœa is relieved. The benefit is immediate and decided; the accumulated secretion is coughed up, and after a few deep breaths the patient is able to lie down, and usually falls asleep. The stridor disappears. Unfortunately the relief is only temporary, and the patient soon succumbs to a broncho-pneumonia, or to secondary hæmorrhage from the trachea.

Toxic Goitre—Exophthalmic Goitre—Graves' or Basedow's Disease.—These terms are applied to a variety of goitre in which the symptoms due to absorption of thyreoid secretion—thyreotoxicosis—predominate. The name “exophthalmic goitre” is misleading, as in some cases the enlargement of the thyreoid, and in others the eye symptoms, are scarcely appreciable, while the general symptoms are well marked. The term toxic goitre or hyperthyreoidism, suggested by C. H. Mayo, is preferable, as the manifestations of the disease depend upon excessive or abnormal action of the thyreoid tissue.

Fig. 282.—Exophthalmic Goitre.

The condition is chiefly met with in young adult women, and may develop suddenly after a shock to the nervous system. The intoxication affects the higher cerebral functions and causes nervousness, irritability, and tremor; the cardiac and vaso-motor centres, causing tachycardia and pallor of the skin; the sympathetic fibres to the eye, causing protrusion of the eyeballs, staring of the eyes without winking, narrowing of the palpebral fissure, dilatation of the pupil, and lagging behind of the upper lid, and sometimes also of the lower lid—von Graefe's symptom. There may be diarrhœa and vomiting, loss of weight, and in the worst cases there is delirium at night. In course of time there develops cardiac insufficiency with fibroid degeneration of the myocardium. Coagulation of the blood is retarded, and there is a marked diminution in the number of leucocytes, especially the neutrophils, and an increase in the lymphocytes (Kocher).

In the early stages the thyreoid is enlarged and pulsatile, and bruits may be heard over it; later, these vascular symptoms disappear, and only a firm, diffuse, uniform swelling implicating all parts of the gland remains.

Prognosis.—The tenure of life is uncertain as the patient offers little resistance to intercurrent affections such as influenza and pneumonia. If the average course of the disease is represented by a curve, the greatest height is reached during the second half of the first year and then descends. For the next two to four years it fluctuates with occasional exacerbations of symptoms due to fright or worry.