GOITRE (from guttur, the throat; synonyms, Bron-chocele, Derbyshire Neck), a term in medicine applied to a swelling in the front of the neck caused by an enlargement of the thyroid gland. This structure, which lies between the skin and anterior surface of the windpipe, and in health is not large enough to give rise to any external prominence, is liable to occasional 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 the disease now under consideration, how-ever, the swelling is well marked, and is not only unsightly, but may by its growth occasion much discomfort, and even give rise to serious symptoms from its encroachment on the windpipe and other important parts in the neck. The size to which goitrous growths may attain is extraordinary, Alibert recording cases of goitre where the tumour not only enormously enlarged the neck but hung down over the breast, or even reached as low as the middle of the thigh.

In districts where the disease prevails the 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 somewhat sudden increase is a not unfrequent occurrence. In the earlier stages of the disease 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 super-vene, and it may become the seat of cystic formations, or acquire hardness from increase of connective tissue or cal-careous deposits. Occasionally the enlargement of the gland is uniform, but more commonly one of the lobes, generally the right, is the larger. In some rare instances the disease has been noticed to be limited almost entirely to the isthmus which connects the two lobes of the gland. The growth is unattended with pain, and is not inconsistent with a fair measure of health.

Goitre is a marked example of an endemic disease. There are few parts of the world where it is not found pre-vailing in certain localities, these being for the most part valleys and elevated plains in mountainous districts. The wide distribution of this disease has naturally led to exten-sive inquiry and to abundant speculation as to its origin. It is unnecessary to mention the numerous theories which have been advanced on the subject. Many of these have already been referred to under CRETINISM (q.v.). The most generally accepted view among physicians is that which ascribes the malady to the use of drinking water impreg-nated with the salts of lime and magnesia, in which ingredients the water of goitrous districts would appear always to abound. This theory alone, however, is inade-quate, as is evident from the often-observed fact that in localities not far removed from those in which goitre pre-vails, and where the water is of the same chemical composi-tion, the disease may be entirely unknown. Hence among the best authorities the tendency now is to regard goitre as the result of a combination of causes, among which local telluric or malarial influences concur in an important manner with those of the drinking water in developing the disease. It is noteworthy that goitre can often be cured by removal from the district where it prevails, as also that 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 any hereditary tendencies.





In the treatment of goitre the first step is the removal, if possible, of the patient from the affected locality, and attention to general hygienic rules. The employment of burnt sponge as a cure for goitre was in general use until Dr Coindetof Geneva showed that its acknowledged virtues were in all probability clue to the iodine which it contained, and proposed as a substitute this latter agent in a pure state. Dr Coindet's views were amply borne out, and iodine and its preparations have been universally adopted as the most potent remedy in this disease, and have super-seded all other medicines. Small and gradually increased doses of the drug, either in the form of iodide of potassium or what is known as Lugol's solution appear to be the best methods of administration. The external appli-cation of iodine to the goitre, in the form of liniment or ointment, is of scarcely less value than its internal employment, and would seem to be sometimes capable of effecting a cure alone, as is evident from the method of treatment adopted with singular success in India and originally proposed by the late Major Holmes. This con-sists in applying to the goitre, by means of a spatula, an ointment of biniodide of mercury for about ten minutes soon after sunrise, and placing the patient with his goitre exposed to rays of the sun for six or seven hours. Blistering of the surface generally follows, a second application of the ointment is made, and the patient sent home. This is often found sufficient to effect the cure, but the treatment can, if necessary, be repeated.

The name " Exophthalmic Goitre " is applied to another form of enlargement of the thyroid gland, differing entirely in its pathological connexions from that above described. In this affection the bronchocele is but one of three pheno-mena, which together constitute the typical characteristics of the disease, viz., palpitation of the heart and great vessels, enlargement of the thyroid gland, and protrusion of the eyeballs. This group of symptoms is generally known by the names of Graves's disease or Von Basedow's disease, in reference to the physicians by whom the malady was originally recognized and described. Although occa-sionally observed in men, this affection occurs much more commonly in females and in comparatively early life. It is generally preceded by ill health in some form, more particularly impoverishment of blood, and nervous or hysterical disorders, and is occasionally seen in cases of organic heart-disease. It has sometimes been suddenly developed as the effect of fright or violent mental emotion. The first of tho symptoms to appear is usually the palpitation of the heart, which is aggravated by the slightest exertion, and may be so severe as not only to shake the whole frame but even to be audible at some distance from the patient. An uncom-fortable sensation of throbbing is felt throughout the body, and many of the larger blood-vessels are seen to pulsate strongly like the heart. The enlargement of the thyroid gland generally comes on gradually, and rarely increases to any great size, thus differing from true goitre, as originally noticed by Dr>Graves. The enlarged gland is of soft consistence, and communicates a thrill to touch from its dilated and pulsating blood-vessels.

Accompanying the goitre a remarkable change is observed in the appearance of the eyes, which attact attention by their prominence and 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 in this disease. Much difference of opinion prevails as to the immediate cause of the protrusion of the eyes, but it is generally ascribed to the increase of the fatty tissue and distension of the blood-vessels of the orbits. 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 common accompaniments.





The pathology of exophthalmic goitre is still somevhat uncertain, but there are strong reasons to believe that it is essentially a nervous ailment, and that the symptoms depend on a morbid state of the sympathetic nerve in the neck, which is well known to play an important part in the vaso-motor functions—that is, in controlling the action of the heart and regulating the calibre of the blood-vessels. In numerous instances of exophthalmic goitre a diseased state of this nerve has been found post mortem, although it must be admitted that in some cases no morbid change could be detected. The experiments of Bernard, Brown-Sequard, Schiff, and others upon the functions of the sympathetic nerve lend strong support to this view of the pathology of the disease. Exophthalmic goitre is not directly a fatal malady, but, on the other hand, complete recovery is a less frequent result than partial improvement, the patient continuing to suffer from chronic ill-health. The disturbed condition of the heart's action leads in some instances to permanent disease of that organ in the form of dilatation of its cavities. In the treatment of exophthalmic goitre the most successful results have been attained by the use of digitalis, which has the effect of giving tone to the heart and contracting the dilated blood-vessels. The tincture of digitalis, in doses of 5 to 10 drops twice or thrice daily, is perhaps the best form of administration. Where anaemia is present iron is indicated, and may be combined with the digitalis, although in some cases it is found to be unsuitable. In allaying the palpitation benefit is said to have frequently followed the application of ice to the cardiac region as well as to the thyroid gland. Iodine, which is so valuable in cases of true goitre, is generally admitted to be of no service in this disease, and is rather held to be injurious. (J. O. A.)