GOITRE, OR BRONCHOCELE.
The treatment of endemic goitre is often satisfactorily carried out by the simple procedure of removing the patient from the goitrous district in the early stage of the disease, when the thyroid swelling will soon begin to diminish rapidly. The chief source of mischief is certainly contaminated drinking water, but it is not the only source; boiling and filtering the water minimises but does not always remove the condition, hence even a change of the water supply is deemed insufficient as long as the person resides in the infected district. In some places excess of lime salts in the drinking water is a causal factor, whilst in other districts absence of these salts is believed to be the cause. McCarrison states that the goitre so common in Gilgit in Kashmir is readily cured by removing the patient from the district to the sea level, but believing that the disease is due to infection of the alimentary canal by micro-organisms, he has successfully treated it by the administration of Thyme] in cachets; 3o grs. are given at the start in the morning and followed up by a purge the same evening; ro grs. night and morning are given for several days afterwards till the swelling dis appears. Salol, /3-Naphthol, Dilute Hydrofluoric Acid, and other intes tinal antiseptics and Koumiss have been proved valuable.
Iodine is the most reliable agent in all forms of simple parenchymatous goitre. McCarrison gives 5 mins. of the weak tincture with 5 grs. Iodide of Potassium. Arsenic may be advantageously combined with it.
Thyroid Extract has a very decided curative action in many cases, and is now often administered as a routine by many surgeons, but it has no influence over fibrous goitres, though usually the parenchymatous variety of growth yields rapidly to a 2 gr. tablet twice a day. (Should there be signs of Graves's disease present this remedy is very dangerous.) Kocher believes that the best internal remedy is free Phosphorus, and that not more than io per cent. of cases require surgical treatment.
Autogenous Vaccines prepared from types of the colon bacillus have been successfully employed in doses of Soo million. Local treatment may
be tried in many forms, the most innocent of which is the daily application of a mixture of equal parts of the strong and weak Tincture of Iodine. If a decided counter-irritant action is desired, the strong tincture may be painted on, layer after layer, till vesication is produced.
Iodine ointment may be used instead of the liquid preparation. Some surgeons have found better results from the application of a weak solution applied with the view of effecting absorption of the iodine. In this case half tincture and half glycerin or weak spirit may he employed, the object being not to injure or destroy the cuticle.
Biniodide of Mercury is most successful in India, but has been of little use in this country. The Indian practice is to rub in for ten minutes an ointment consisting of 3 drs. of the biniodide to i pound lard. The patient is afterwards to sit with his goitre exposed to the direct rays of the sun till he is unable to bear the smarting. After this some more oint ment is gently applied, the patient is sent home, and the case seldom requires further treatment.
_More11 Mackenzie injected Iodine in solid bronchoceles, but the practice has been abandoned owing to the danger of sudden death from the injec tion entering a vein, and the same remark applies to the injection of lodoform, Osmic Acid, &c. In cystic cases this danger is less, but the injections are valueless. Electrolysis has proved valuable in the hands of Duncan in some cases.
Operative procedures are indicated when the tumour presses upon the trachea, and it is a well-recognised fact that the danger of suffocation bears no proportion to the size of the tumour, the most serious symptoms often being present in small goitres which extend downwards behind the sternal notch. Dysphagia is a clear indication for operation and should arouse suspicion of malignancy, and the same may be said where pain is a prominent symptom. In some cases operation is undertaken for the relief of the deformity occasioned by the size of the tumour, especially when it is steadily increasing in size in spite of medical treatment.