A system of practical medicine. By American authors. Vol. 3

by Unknown

Hypertrophy of the gland may be either general or partial; when general—that is to say, involving the entire body—the term symmetrical or bilateral is employed to designate the enlargement; when confined to a single lobe, it is said to be asymmetrical or unilateral. Not unfrequently limited portions or small areas of one lobe only are affected, causing irregularities or nodosities which may be readily detected by the eye or the touch.

SYMPTOMS.—The earliest evidence of bilateral goitre is the appearance of an unusual fulness and breadth of the lower part of the neck or that part between the sternum and the larynx. This fulness extends laterally under the sterno-cleido-mastoid muscles, partially effacing the suprasternal fossa, and is entirely unattended by pain, heat, redness, or other sign of inflammation. When the disease is unilateral, the swelling is seen to extend from the side of the trachea and larynx outward under the sterno-cleido muscle. The tumor, in consequence of its attachment to the trachea, follows the movements of the latter, and hence will be seen to rise and fall during the act of swallowing or of deglutition.

The progress of the enlargement varies greatly in different cases. After its first appearance it may remain quiescent for years, scarcely causing any change in the appearance of the neck which could be deemed a deformity; in other instances the growth will be progressive, attaining to the size of a goose egg, when it may again remain stationary. It is not common in the United States to meet with those excessive hypertrophies of the thyroid so common in Switzerland, where the gland extends up behind the ears, outward to the margins of the trapezii muscles, and hangs down in front of the sternum a large pendulous mass and imparting a most hideous appearance to the patient.

Pressure Symptoms and the Attendant Phenomena.—It is very remarkable to what a degree hypertrophy of the thyroid may reach without giving rise to any marked functional disturbances. This is due, no doubt, to the character of the enlargement, the cystic and vascular causing less inconvenience than the fibrous or more solid varieties. The pressure symptoms which may ensue are—first, difficulty of respiration. This is likely to follow when the central portion of the gland enlarges in common with the lateral masses, thereby causing pressure directly upon the trachea. This pressure may result in softening, and even complete absorption, of one or more of the rings of the trachea. An irritative cough may appear in the course of the hypertrophy, which is to be referred to the encroachment by the gland on the pneumogastric nerve. Hoarseness and a peculiar croaking voice are also sometimes witnessed, indicating the contact of the tumor with one or both recurrent laryngeal nerves.

Redness of the skin and elevation of temperature on one side of the neck are occasionally present, and sometimes accompanied by dilatation of the pupil of the eye corresponding to the affected side. These symptoms result from pressure upon the sympathetic nerve, and may exist in either unilateral or bilateral goitre. When associated with the latter form of the disease, the sides of the tumor will be found asymmetrical.

GEOGRAPHICAL DISTRIBUTION.—Goitre is met with in all parts of the 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. 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.