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GOITRE: SIMPLE AND MALIGNANT
Causation and Treatment of ''Derbyshire Neck'' and Other Varieties
Always disfiguring, often distressing and sometimes dangerous, enlargement of the thyroid gland is a morbid condition the nature and treatment of which are still the subject of investigation. All.the known facts relating to itare summarised here, the treatment, both local and general, commonly applied is reviewed and the question of surgical operation is discussed.
A goitre or bronchocele is the name given to an enlargement of the thyroid body, or gland. Goitres are of three main kinds- simple, exophthalmic and malignant.
Smokh   Derbyshire Neck
There is one disease," wrote James Pilkington in 1789, "to which the inhabitants of Derbyshire are so much subject, that it has taken its name from its great prevalence in this situation."

Derbyshire Neck, also called Goitre, is a swelling of the thyroid gland and is now known to be caused by lack of iodine. It is almost unknown today because iodine is added to drinking water. In the eighteenth century no-one knew for sure what caused it. Some thought it was hereditary in particular families, others that it was caused by living "on the bleak sides of hills." They all agreed that women, particularly "child-bearing poor women" were the main victims of "this very unfortunate female disease."
 
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The thyroid, which is one of the ductless glands (q.v), lies in front of the windpipe in the Lower part of the neck. It is a small, fleshy body weighing about an ounce. though this is subject to great variation even in health. It is closely applied to the larynx and trachea and follows them in their movements.
Goitre is far commoner in women than in men, for the thyroid plays a greater part in the female organism than in the male. In fact, slight enlargement of the gland is almost a normal occurrence in young women at the monthly periods. Such a temporary swelling of the thyroid is, of course, not a true goitre.
The condition, however, often arises in girls soon after menstruation is established and frequently persists throughout life. The swelling is quite painless, but is important for other reasons. From its close relation to the windpipe it may give rise to interference with breathing; it is often a gross disfigurement and a simple goitre may cause symptoms skin to those of mild exophthalmic goitre.
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GOITRE: THE VARIOUS KINDS OF ENLARGEMENT OF THE THYROID GLAND The thyroid gland, the normal relative size of which is indicated (left), may undergo a general enlargement, in which the structural formation is more or less retained. This is parenchymatous enlargement. In the fibro-adenomatous form there is a new formation of fibrous tissue and abnormal gland tissue, and in the cystic large, fluid-containing spaces.
As regards the difficulty in breathing, a goitre may reach a large size without giving rise to the least inconvenience in that respect. Occasionally a part of the tumour has grown down behind the breast bone and is thus prevented from enlarging forwards; and it can only enlarge backwards by pressing the windpipe against the spine. In other cases the early onset of difficulty in breathing marks the onset of malignant disease in the aoitre. In yet others the cause remains somewhat of a mystery. For the same reasons difficulty in swallowing may arise, the gullet lying directly behind the windpipe.
The enlargement of the thyroid giving rise to goitre may be a general increase in the bulk of the gland with very little alteration discoverable in its structure; and it is possible such an increase in size is the response of the gland to some call for more thyroid tissue on the part of the body generally. Such cases are undoubtedly the most amenable to treatmeut. In other forms of enlargement, however, small tumours may arise in the gland. and the goitre is then seen and felt to consist of rounded projections varying in size from a pea to an orange. Such tumours are caled adenomata of the thyroid, and may be solid masses of cells closely resembling developing thyroid tissue, or cysts containing fluid. General increase in size; usually affects the whole gland; adenomata are more often localised to one part of it.
Cause Of the Condition
The cause of goitre cannot be regarded as fully determined, iodine deficiency is one form, but there a is possibly a disease ultimately due to infectious microorganisms. The disease is prone to attack the inhabitants of mountainous limestone regions, and thus it is very common in the Swiss and Himalayan valleys; and the valleys of other mountain ranges of less not so hilly districts of England are by no means immune; and "Derbyshire neck" is a well-known name for goitre.
It has been shown that the cause is closely conneoted with the question of water supply, and the incidence of the disease has been proved to diminish when the inhabitants of a given distriet have boiled their water, or have been provided with a new supply.
It has also been suggested that endemic goitre is a deficiency disease due to lack of a vitamin substance. Like rickets it can be produced by deprivation of iodine. There are probably several factors at work.
Treatment of Goitre
Normal thyroid tissue is peculiar in containing a high proportion of iodine; and it is certain that the administration of iodine in some form or other has a very beneficial effect in goitres of some kinds; in some dietricts where the disease is endemic a small amount of iodine in the form of an iodide, is being added to the table salt.
Three lines of treatment are possible, namely. the administration of medicine, local applications to the thyroid, and surgical treatment.
When the tumour is due to uniform enlargement of the gland medicines offer a good prospect of cure, but they will require the supervision of the medical attendant. Iodine in some form is usually given, either alone or in addition to thyroid substance obtained usually from the sheep. The latter is obtainable in the form of tablets or as a liquid extract.
Thyroid is a dangerous drug, and suferers are earnestly advised never to take it unless under the advice of a qualified doctor.
When the goitre consists mainly of adenomata or cysts, treatment other than surgical is not often of much service. It is certain that the goitre as a whole will often diminish in size as a result of non-surgical treatment,
but often the individual tumours of which it is composed remain, to become prominent again when treatment is discontinued.
Sunlight treatment (q.v.), in which the rays of the sun or sunlight lamp are directed upon the swelling, has given excellent results, especially when the goitre has first been submitted to a good rubbing with an ointment contaming iodine.
Malignant disease of the thyroid gland may take the form either of saraoma or carcinoma, and for a long time may not extend beyond the capsule of the organ, but soonor or later it invades the neighbouring parts; in the blood or lymph stream portions of the tumour may be carried to distant organs. Removal by operation is here the only hopeful treatment.
EXOPHTHALMIC GOITRE
Abnormal Functioning of the Thyroid Gland
Also known as Graves' disease or Basedow's disease, exophthalmic goitre is a morbid condition due to abnormal functioning of the thyroid gland. The gland has not ceased to perform its work but is producing either an excess of thyroid secretion or, more probably, secretion of inferior or deleterious quality.
An advanced case of exophthalmic goitre presents a very characteristic appearance. The patient's eyes seem to be bulging out of his head. The eyeball is thrust forward; the white of the eye, uncovered by the lids, gleams in a most alarming fashion. The patient's whole face is dominated by this condition of "exophthalmos" or protrusion of the eyeballs.
Nor is this expression of fear confined only to the face. The whole attitude of the body is one of anxiety. Thus there is always a fine tremor of the muscles. The rate of the heart is enormously quickened and the patient's skin is usually covered with perspiration. Intense nervousness is the rule, so that life becomes a heavy burden. Moreover, the flushed skin gives its owner a constant sensation of warmth even in cold weather.
In addition to these svmptoms swelling of the neck is always found, in front, just above the top of the breast bone. This swelling may not be very large; indeed, it never approaches the size of an ordinary goitre. But it is invariably present and is usually quite obvious. This swelling is the enlarged thyroid gland. Other prominent symptoms are palpitation and undue rapidity of the pulse rate, loss of flesh due to the alteration in the thyroiDl secretion, and alternating nervous excitement and depression.
The actual nature of the disorder is not as yet fully understood. There is almost certainly some abnormal substance produced by the thyroid gland, but whether this is the primary cause is doubtful. It is known that overstimu'ation of the sympathetic nerous system will produce all the symptoms of Graves' disease in an animal, and it is probable that the disease in man is primarily due to some cause acting as an irritant to this part of the nervous system. It is known that adrenalin, the secretion of the supra-renal glands, will act as a stimulant to the sympathetic nervous system, as will also toxic substances derived from the bowels. This latter is a probable explanation of the disease, i.e. that it is primarily due to poisons elaborated in the body acting on the sympathetic nervous system and through this medium disturbing the activities of the thyroid gland . The abnormal secretion of the gland thus produced is responsible for some of the symptoms.
Exophthalmic goitre may arise suddenly. There are many cases on record in which, immediately after a severe fright or shock, the symptoms showed themselves fully developed. In other cases the onset is more gradual. Influenza, too, seems to play a part in causing the disease, because a considerable number of cases begin after the patients have been laid up with this complaint.
Sometimes, again, the disease goes away as mysteriously and suddenly as it arose. And there may be relapses of as severe a nature as the original attack. Some of the patients never recover. Some of them become very seriously ill and die; some live to old age-even extreme old age-with their trouble fully active. About half the cases with proper treatment recover to a very considerable extent.
Mild forms of the disease show all the symptoms except the bulging of the eyes or the trembling. Indeed, a quick pulse and a slight swelling of the throat may be the only signs present. It must be remembered however, that the thyroid gland swells slightly at certain times in the normal course of living. Thus it always tends to become a little larger during the monthly period. During pregnancy it is usually swollen, and also during convalescence from some illnesses. These enlargements are normal and need cause no anxiety.
Methods of Treatment
Operation seems still to be the most successful method of treatment, although some cases may derive little or no benefit from it. Since cases of the disease vary so greatly in the course they run, it is difficult to assess the value of various treatments adopted. Surgical treatment of the thyroid gland, either by tying off some of its blood vessels or removing part of the gland, has shown a very considerable success in the hands of some surgeons who have specialised in this operation.
GOITRE In Animals. Simple goitre is most frequently seen in young animals, especially dogs, sheep and horses. In the adult, enlargement of the thyroid seems to cause no svmptoms. In the young, however, the enlarged gland may cause asphyxia and death by pressure on the windpipe. It causes no constitutional symptoms. The treatment is usually surgical, i.e. by incision and removal, puncturing cysts and so on. The use of potassium iodide and thyroid extract in the food has given good results. It must be accompanied by good feeding.
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