Endotracheal Goitre.
—A recent study of Enderlen has shown that small, goitrous growths make their appearance within the trachea more commonly in females than in males, and in patients of middle age. The known duration of growth has varied from a few weeks to fifteen years. He believes the majority of the cases begin to grow at the age of puberty. These growths have been found on the posterior wall of the larynx or in the trachea itself. They have usually rounded bases and broad implantation, with smooth surfaces, covered with intact mucosa. In most instances the thyroid itself is also enlarged. The only recorded symptom is dyspnea, proportionate to the degree of obstruction. They are probably to be explained by the inclusion theory, some thyroidal rest being disintegrated and so entangled as to grow in this direction. The only satisfactory treatment is ablation of the tumor, after tracheotomy, as endolaryngeal operations are more dangerous.
These constitute the ordinary types of goitre. Diagnosis is not difficult, as the resulting tumors are more or less prominent, involve the region of the thyroid, and rise and fall with each act of swallowing. When the entire organ is involved the tumor may have a horseshoe shape. Large veins appear upon the surface, while pressure symptoms will correspond with its size and location. They pursue an irregularly slow course. Many patients attain old age and a considerable size of growth without such discomfort as to require operation. Any goitrous enlargement in which considerable softening occurs, with formation of colloid material, is entitled to the term in frequent use, “colloid goitre.” By accident of location any growth of this kind behind the sternum may cause serious pressure effects before attaining large size. In symmetrical enlargement of both lobes the trachea may be so compressed as to be narrowed and to entitle it to the term scabbard trachea.
Iodine has been used externally and sometimes with benefit. The favored method in India is to use an ointment containing one grain of red iodide of mercury to the ounce. This is daily rubbed over the goitre and then the parts exposed to the bright sunlight for an hour or more. Iodine has also been used by parenchymatous injection. It is mainly used, however, by those who object to operation or do not dare perform it. The iodine treatment, whether externally or internally used, is usually disappointing. So also is that by the Röntgen rays, and, for that matter, all other non-operative measures. Operative relief alone is complete and final. It is described below.
EXOPHTHALMIC GOITRE.
As a clinically distinct type of disease this was first described by Graves, of Dublin, in 1835, and five years later by Basedow, of Magdeburg; hence it is frequently called by their names. Although the thyroid participates in the clinical picture it cannot be stated that it is primarily at fault. Three marked objective features characterize pronounced cases—thyroidal enlargement, more or less pronounced tachycardia, and exophthalmos.
So far as known there is an essentially toxemic feature behind these lesions, which is mysterious, nor is the nature of the toxemia certain. No constant lesions have been found in the nervous system, although the sympathetic nerves are always involved when the heart and the eyes are affected. The three cardinal symptoms or signs above mentioned are nearly always associated; but with pronounced rapidity of the heart’s action there may be but little involvement of the thyroid or slight protrusion of the eyes. Whatever the original toxemia, or its source, a prominent feature of the condition is hyperthyroidism—i. e., hypersecretion of the substance which regulates nutrition—whose overproduction materially disturbs the heart and vasomotor nerves. It stands in strong contrast to myxedema and cachexia strumipriva, which are considered to be due to hypothyroidism or diminished secretion. Consequently it is not to be treated by feeding thyroid extract. A recent view which has much to support it is that at the basis of this condition the parathyroids are so concerned that any operation which includes their extirpation would be a serious menace. At present it may be held that the parathyroids are intermediate factors between the primary toxemia and the hyperthyroidism.
Aside from mere thyroidal enlargement, which is influenced by pressure and shows an increased pulsation, always palpable, sometimes visible, there occur increased heart activity, with a rapid and easily influenced pulse; widening of the palpebral fissures, the upper lid not following the motions of the globe, with defective convergence; rhythmic muscular tremors; increase of general sensibility; insomnia, with disturbed sleep; psychical disturbance, sometimes amounting to melancholia or mania; digestive disturbances, including diarrhea, vomiting, and thirst; cough, with frequent and shallow respiration; loss of hair and nails; sweating, flushing of surface and sometimes leukoderma or pigmentation of the skin. Terminal symptoms consist of all those mentioned above, with acute mania, high temperature, vomiting, profuse sweating, dermatitis, jaundice, and final convulsions with exhaustion, all these resembling those of death in experimental animals after the removal of the parathyroids.
A sign recently described by Teillas, which he considers pathognomonic, consists of deep-brown pigmentation of the outer surface of the eyelids, the color being evenly diffused, bounded above by the eyebrow, below by the margin of the orbit, the conjunctiva being not affected. Its effect is to apparently increase the degree of exophthalmos and to intensify the fixity of gaze observed in these subjects.