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

by Unknown

Vascular goitre may also be a transformation from the follicular variety, in which, with an increased hyperplasia of the follicular elements of the gland, there is a new formation of blood-vessels taking the place of the connective tissue present in the fibrous form of goitre. When the arterial element predominates, the vessels will be found to be very much dilated and anastamosing freely. These goitres are compressible, have a soft, spongy feel, sometimes pulsate, and on auscultation disclose a distinct bruit, hence the term aneurismal goitre often applied to such. In other instances the venous element predominates, when the swelling will, as in the arterial variety, be compressible and communicate to the ear a well-marked blowing sound or murmur. As the superficial veins, in common with the deep ones, are enlarged and tortuous, the surface of the tumor will often exhibit at different points a bluish appearance. In two instances, and in females of a highly-wrought nervous temperament, I have known the vascular goitre to enlarge in a few minutes to wellnigh twice its usual size, threatening the patient with suffocation for the time, and almost as quickly subside after a free emesis.

In gelatinoid goitre the follicles of the gland are distended so as to form large cavities filled with a gelatinoid- or colloid-looking substance, the product of the enclosed cells. As the distension of the follicles progresses the vascularity of the gland becomes notably less, the vessels being obliterated by the pressure. This tumor may attain a very great size, is much firmer than the vascular goitre, and to the touch has a doughy feel.

Cystic goitre is rarely such in the beginning of its history, being often an advanced stage of the follicular variety. In the transition the compartments of the latter undergo enlargement, their normal cell-contents being replaced by an albuminoid transudation from the vessels of the follicles. This process continuing, the interfollicular connective tissue disappears—a mechanical result caused by pressure. Still later, and from this cause, the walls of the adjoining follicles suffer a similar fate, and as these melt away larger cavities are formed, until at length the whole interior of the gland is converted into a number of loculi, and in some rare instances into one great sac. The gelatinoid or colloid goitre may undergo a similar transformation, and much in the same way. The fluid contents of cystic goitre vary in their physical properties as also in their chemical constitution. Generally the substance contained in the cysts is rich in albumen, has a ropy appearance resembling somewhat the white of an egg, and to the feel is viscous or unctuous, similar to that of the synovial secretion. Sometimes it is dark, resembling coffee-grounds—a condition due to the decomposition of extravasated blood derived from ruptured blood-vessels belonging to the gland. Crystals of cholesterin are also present, formed by fatty degeneration of the cells of the follicles, and mingled with a variable amount of sodium chloride. The cystic goitre is soft and fluctuating, and often grows to a large size.

The blood-vessels of goitre are not exempt from pathological changes, but frequently become the subjects of atheromatous and amyloid changes.

Carcinoma and Sarcoma of the Thyroid Gland.

Malignant growths of the thyroid body are comparatively rare, and when present are accompanied by symptoms sufficiently significant to differentiate them from those which are benign. In both carcinoma and sarcoma the increase of the tumor is rapid; the surface veins become very distinct, and the enlargement is general, affecting the entire gland. In addition to the above phenomena, the evil effect resulting from pressure is sooner realized and more pronounced than in goitre, and in a short time the generalization of the disease becomes apparent in the loss of flesh and strength. Should the tumor be a carcinoma, there will likely follow the infection of those lymph-glands in nearest relation to the neoplasm.

EVIL EFFECTS OF GOITRE.—In this country, though goitre may grow to a large size, it is not common for patients to suffer any inconvenience other than that which results from the unsightly appearance of the tumor; hence life is not seriously imperilled by the disease. Occasionally, however, there are exceptional instances in which unpleasant and even troublesome symptoms are developed. Among these may be mentioned alteration of voice or a slight aphonia in consequence of pressure by the tumor on the recurrent laryngeal nerve. An irritating cough may also exist, and when no evidence of pulmonary trouble is present it must be referred to pressure upon the pneumogastric nerve. Dyspnoea when present results usually from pressure upon the trachea. It has been observed that when this pressure is long continued, particularly in cases of vascular goitre, some of the rings of the trachea gradually disappear, leaving only a membranous tube, which may collapse and cause the sudden death of the patient.

Hiccough and diaphragmatic spasms have also occurred when the enlargement of the gland extended laterally, in consequence of pressure on the phrenic nerve. In addition to the above phenomena there is often experienced in goitre severe neuralgic pains on the side of the neck, in the ear, and over the back of the head, and indeed in the course of any of the branches of the cervical plexus of nerves.

Occasionally I have seen a red blush of the integument on the side of the neck, answering to the largest portion of tumor, accompanied by increased heat, doubtless from the growth encroaching on the sympathetic nerve.

TREATMENT.—The treatment of goitre may be divided into constitutional and local. Too often the management of the disease is conducted in an empirical manner, every variety being subjected to the same routine of remedies. No greater mistake can be made. To attain any satisfactory success it is absolutely necessary that a correct diagnosis of the composition of the tumor shall be known. In follicular and in fibrous goitre much may be anticipated from constitutional and local measures. Those remedies which possess the property of inducing retrograde changes of structure and their subsequent absorption are the ones to be selected for administration, and among these iodine and its combinations rank highest. The compound solution of iodine, the iodide of potash, and the iodide of iron, all have their therapeutical adaptiveness. The earlier treatment is commenced the more hopeful will be the prognosis. If the patient is in all other respects in good health, and especially is somewhat fleshy or given to obesity, the compound solution of iodine should of preference be selected. At first the dose should be small, in order to test the tolerance of the stomach, not exceeding five or six drops three times a day, taken in some sweetened water, orange syrup, or curaçoa, and always about one hour after meals. Every two or three days the dose may be increased one or two drops until eighteen or twenty are taken, beyond which it is not desirable to go. It is in these forms of goitre that the burned sponge (spongia usta) was at one time very generally used as an internal remedy, half a drachm to a drachm being taken twice or thrice daily. As the virtue of the article was due to the iodine it contained, it must necessarily be inferior to the solution of the same substance.