PAPERSPAST

Goitre and Hyper Thyroidism

F. T. BOWERBAKK.)

(By Dr.

(A Lecture given before the Members of the Wellington Provincial Masseurs' Association, at the Pioneer Club Rooms, on June 11th, 1923. R. T. McLean, Esq. (Vice-President), in the chair).

I must first of all apologise if my lecture is somewhat less comprehensive than I should like. There is a great deal of sickness about, and it has been really very difficult to find sufficient time to sit down and write a connected lecture. The subject matter of my lecture to-night is " Goitre/' which, as you all know, is a disease of the thyroid gland. I think it would be as well first to give you some facts concerning the anatomy and physiology of this particular gland, which I suppose has been more written about and discussed than any other organ of the human frame. It seems to be connected withWery other gland in the body, and has a tremendous importance in all the functions of metabolism. The subject of goitre is very important to everyone. It is especially so to you because, although numbers of the patients who come to you may not be suffering from it, you should recognise some of the indications of the disease, in order that, though you may not be treating your patient for goitre, you will remember to be alive to any symptoms that are present. The thyroid gland — a ductless gland — weighs about an ounce. Its position is in the lower part of the thyroid. It has two lobes and a connecting isthmus ; and a very large blood supply considering the size of the organ. As far as the physiology of the gland is concerned, it is very closely related to the sexual organs, and it has been noticed that at adolescence (i.e., puberty) during pregnancy, and at the climacteric the gland temporarily increases in size. You are aware, of course, that, as far as sex is concerned, this gland is physiologically much more active in females than in males. A number of secretions have been discovered in the thyroid gland ; but the one of the greatest importance is that of iodine. lodine, of course, is by way of being an antiseptic ; and the thyroid gland makes it and secretes it, apparently absorbing it more or less from othor parts of the body,

and that is one reason why it is very important that people— especially children from twelve to fourteen— should have plenty of vegetables (lettuce, spinach, cauliflower, and that class of vegetable). The iodine of the thyroid gland is practically the same as that which we are in the habit of employing for medical purposes. This disease of goitre has, of course, been known from prehistoric times ; and it is interesting to note that Hij)pocrates (who has been termed the " Father of Medicine ") about 500 years 8.C., noticed that children and other people suffered from an enlarged thyroid gland. As a remedy he used seaweed, and seaweed contains iodine ; somehow or other he had dropped to its medicinal quality, seaweed being given simply because of the iodine it contained. The thyroid gland has a number of functions. First of all is that of metabolism — which is really the construction and destruction of the nourishment of the body. This construction and destruction is constantly going on, and the important gland we are discussing has a very great deal to do with it. Any alteration in the secretion of the thyroid gland (whether there is more secretion or whether there is less) will affect this constructive and destructive process, and, as will be apparent, tremendous changes may be produced. For instance, we will take Cretinism. The cretins are not so numerous as they used to be, and it may be that this is due to the more modern methods of treatment. Cretinism is due to a practical absence of the thyroid gland. The cretin is a small dwarf child, with body stunted, skin coarse, hair as a rule thin and dry. It is usually perfectly harmless, but remains in a condition of mental infancy, though it may sometimes attain an age of thirty or even forty years. This cessation of growth and mental torpor indicates the importance of the presence of the thyroid gland.

You will notice in this connection that great changes are produced in the body as a result of the thyroid gland being deficient. In some cases the person grows to adult life and then for some reason the thyroid gland ceases to function ; and in that case we get the disease called Myxsedenea, in which the individual tends to become stout and heavy — heavy physically and mentally. The same result may be produced by an operation on the thyroid gland, where too much has been removed or perhaps the whole of it. Obesity is practically the consequence of an insufficiency of thyroid secretion, and the majority of people afflicted with it are usually contented enough and do not worry about anything, but as a rule they do not think very quickly — though I must confess to some exceptions. The second great function of the thyroid gland is what is termed Detoxication,— which means simply resistance to poisons that are thrown into the system ; for instance, unhealthy tonsils, suppurating glands, and any poison produced in the body and tending to get into the lympathic and blood system. As a result of this happening, the thyroid gland becomes more active and throws out its secretion to attack the enemy ; and I suppose this is the explanation of why iodine, when it is administered, has the beneficial effect it had — it has an antiseptic and alternative action. The above process is going on all the time ; people are faced with all sorts of small menaces to health, and the thyroid gland has very frequently to assist in preventing the disease from getting the upper hand. The third great function of the thyroid gland is as regards sexual development,— this gland being more active in women than in men. Havelock Ellis, the great psychologist, states : " The thyroid gland plays a considerable part in the characteristics of the two sexes. The female is sharper witted and less stable. She jumps to a conclusion without any process of reasoning, but simply intuition. Women of the reasoning type have their suprarenals perhaps more developed than their thyroids, and present other masculine characteristics." In thyroid insufficiency the sexual organs remain small and infantile, just as other parts of the body do.

There is still another great function, and that is what is called Emotional Mentor. The French call the gland under discussion ' The Gland of the Emotions," because they consider this gland's great function is connected with the emotions — fear, terror, anger, happiness, misery, and so on. You will notice that the person with the over large thyroid gland has the appearance of suffering from chronic fright. Take the average sufferers from Exophthalmic Goitre. Their eyes stare, their pulse is rapid, they suffer from tremors. Also in connection with this emotional state we have what is known as the instinct of self-preservation. Our first desire in the presence of what appears to us to be danger being either a state of fight or else flight from what threatens our safety. A normal person experiences a severe fright, and as a result of that fright toxins are produced. The thyroid gland then throws out its secretion to an abnormal extent in order to combat this poison ; hence it is that in the case of even an ordinarily healthy person having a fright the gland becomes much more active than before the fright or after. It may possibly become normal after a time ; but of course the condition may become permanent, and that is where we are faced with the disease. Goitre may be divided into : — (1.) Simple or Endemic Goitre, and (2.) Exophthalmic Goitre. At adolescence the thyroid gland becomes enlarged often without other effect on the constitution. In some cases this enlargement may go beyond what might be termed the physiological size, and then it becomes pathological. As a rule, however, it is very easily treated, and if the child can have proper nourishment, plenty of air, and absence from worry and school, usually the goitre will gradually become normal again. It is extremely common amongst the children of New Zealand, where unfortunately a large proportion go to pathological simple goitre or the more dangerous exophthalmic condition. This matter has been considered so important in New Zealand, in America to a great extent, and in Great Britain, that all sorts of schemes are being tried to obviate the menace. As we know that goitre is

produced by an insufficiency of iodine — or rather, that for some cause the thyroid gland is forced to over-produce it — it has been suggested that iodine should be given to the children so that the thyroid gland would not then be so active as to cause the diseased conditions. People in America (I do not know that it has been tried in New Zealand) believe it is quite sufficient to place iodine in an open bottle in the different class-rooms and the exhalation, though slight, will be adequate to restore the thyroid balance. Of course if too much were given you would overdo it, and with children one has to be very careful. As I have already indicated, simple or endemic goitre is merely an enlargement of the thyroid gland without any other effect on the constitution. This enlargement, which is usually quite small (though of course in some cases it may extend half way down the chest), so long as it remains a simple goitre does not appear to affect the health at all ; and the only objection to it (especially in these days of low-necked dresses) is its unattractive appearance. The geographical distribution of this particular type of goitre is endemic (as its name implies) : i.e., prevalent in certain localities . It is much more common in the temperate zone, in Derbyshire in England, in Nith sdale in Scotl and , and in certain provinces in France practically the whole of the population suffer from this disfiguring condition, and people who come from other parts to live in the district develop the trouble. In New Zealand, Christchurch is considered to be the place where the malady is most common — particularly in the Canterbury Plains ; but there is no very marked demarcation as in the Old World. The reason for this probably may be that we move about more than people do in the older countries. Simple goitre is also found among animals. For example, I have just been attending a patient who knows a great deal about animals, and he showed me a number of goitres he had removed from dogs, the thyroid gland being enlarged as in human beings. Simple goitre is supposed to have its origin in an infection. I do not think heredity affects it much. It can be acquired at any age whereas exophthalmic goitre does

not usually start until after - puberty, at which period the thyroid gland begins to be stimulated by the sexual organs. As far as sex is concerned, simple goitre appears to be fairly equal in male and female ; though in adolescent life it is supposed to be a little more common among females. As far as the Causes are concerned, there have been reams and reams written on the question. It is agreed by all that the disease is created by an infection ; but what the infection is we do not know. Colonel McGarrison (who is one of the leading authorities of the world on different forms of goitre), when in India, studied the matter very deeply and made a number of interesting experiments. For instance, he took certain goats and fed them on foceal goitrous filtrate, and it was found that the goats developed the disease. Only a few years ago chalky water was thought to be the cause of the trouble, and this view is still held by a certain number of authorities. McGarrison, however, argues that it is not chalky water, but impure chalky water that is the cause of the malady. Regarding the course of the disease. As a rule it gives no trouble, and attention is only drawn to it because of the disfigurement. Prophylaxis : A good supply of fresh air, better sanitation, and personal hygiene, are essentials in combating this disease. In this connection I may say that I think the examination of the teeth of the New Zealand children, and the toothbrush drill that is advocated, cannot fail to have a beneficial effect. I have heard of one authority who fed his children on certain boiled water he thought had been infected, he himself drinking the water unboiled ; the result being that he developed goitre and the children escaped ; which again goes to show the presence of some organism or toxin. The treatment of simple goitre is of no importance to you to-night, because, so far as 1 understand, electricity or massage has no effect upon it. Exophthalmic Goitre : This form of goitre has been variously named ; sometimes, for instance, being known as " Graves' Disease " (from the doctor of that name). It is an enlarged condition of the thyroid

gland, plus excitation of the whole of the sympathetic nervous system. It embraces : — Hyperthyroidism ; Exophthalmos ; Cardiac symptoms ; Tremors. In exophthalmic goitre the enlargement of the gland is not usually so marked as in simple goitre ; in some cases it hardly increases in size at all, and yet there may be marked exc itation of th e sy mpatheti c nervous system. There are usually tremors of the hands and body, often the eyes protrude, which gives an appearance of what I have already designated " chronic fright/ 1 and the pulse-rate may be anything from 150 to 170. In regard to a very great number of patients, however, the eyes are as normal as those of the average person , and the indications of hyperthyroidism may be almost imperceptible except to the trained eye. Exophthalmic goitre is due to the overproduction of the thyroid secretion which passing into the blood stream, upsets the balance of power. It has been said that the world is suffering from neurasthenia ; but is it not rather hyperthyroidism ? We have seen how the secretion of this gland normally keeps up the tone of the body ; it makes the mind alert and quick. Now imagine the condition if there is over-production. It may be that electricity, if given in moderate medicinal quantities, tones up the skin and the muscles ; but, if administered in large doses, it will produce spasm and overexcitation, and (as in the case of the " Chair ' : in America) it may even cause death. Age : As I have already stated, the thyroid gland is closely connected with the organs of sex, so that at any outstanding sexual period (puberty, pregnancy , etc . ) it is more commonly to be detected. As far as Sex is concerned, this disease (as already mentioned) is more usual in females than in males. Climate appears to have nothing to do with exophthalmic goitre ; it seems to exist everywhere, but I think it is more common in towns than in the country districts. In other respects it is quite unlike endemic goitre, and may occur anywhere and at any time from puberty up to old age. The Causes of exophthalmic goitre air practically three : —

Firstly : Infectious disease or foci occurring after an infectious disease, such as influenza, scarlet fever, etc. Poison is thrown into the system ; the thyroid gland produces its secretion to overcome the disease, and when this is achieved, it apparently goes on producing excessive quantities of secretion, e.g., hyperthyroidism. The second great cause is what is termed Psychic ; which embraces the emotions of fear, excitement, etc., some of which have a very grave effect in producing this disease. I had one patient, a girl of about eighteen, who had a very marked goitre and all the signs of hyperthyroidism. Her mother, who brought her to me, told me that some weeks before the girl had gone out in a lonely part of a suburb in order to post a letter at a box about 100 yards down the road. Just after she posted it, some man jumped out and spoke to her. He was a stranger, and apparently up to no good, and she ran all the way home and was extremely frightened. A few days later her mother noticed her neck was very big, after which she brought her to me for treatment. I am quite sure that the cause of this girl's goitre was due to the fright she experienced. The third factor in this disease is Nutrition. Lack of fresh air and various other unhygienic conditions are all instrumental in producing it. Exophthalmic goitre is usually progressive. It may possibly improve, but as a rule it gradually gets worse and worse. If the cause has been removed, the chances are that the disease may of itself clear up ; but if there is any permanent poison circulating in the system, or if for some other reason that we cannot understand the disease goes on and the patient goes from bad to worse, death will supervene, usually from heart failure. The heart, of course, becomes very diseased, as you can imagine it will, running as it does at a rate of 140 to 150 day and night. As far as Treatment is concerned : The only treatment that concerns us to-night is that of electricity and therapeutics. I do not think massage of the gland is much use ; but I am not speaking with any degree of authority, and I hope you will bear with me for that reason, because probably some of you know more about this

than I do. Of course in some cases of marked hyperthyroidism and continual excitement, gentle general massage is very soothing, and a certain amount of massage of the head and spine would have a beneficial effect in sending the patient to sleep normally, as insomnia is often a troublesome symptom. As far as treatment by electricity is concerned, there is a great deal of controversy about it. Some authorities think it excellent ; while others are of opinion that it is absolutely useless — one man's meat, of course, being another man's poison. There is so much diversity of thought that I am afraid I can give you no definite rules, except that you must watch the patient's general condition. Remember that the size of the goitre is not the important point : watch the pulse, the tremors, and the weight. If your patient says she feels better after (say) an application of the Galvanic current, it is safe to persist , — but go carefully, erring always on the side of caution. Explain what you are doing and are going to do, keeping in mind that the patient is in what I have already indicated as a state of " chronic fright/' and therefore that your treatment essentially should aim at soothing the over-excited nervous system. If you are using High Frequency, remember that to one unaccustomed to it the apparatus is all rather aweinspiring. Gain the confidence of your patient, treat her as you would a frightened child — especially on her first few visits to you. The lay public have an idea that electricity means shock, and few patients will come into your room and look without wonder and a certain amount of fear at what they consider the alarming instruments of your profession. Think of how you j^ourself felt that first time you went into the operating theatre : how dreadful appeared the instruments, the glass trays, the operating table. Your patients have the same feeling of shrinking when they look around and notice a static machine and other terrifying instruments of your craft. In my opinion there is no doubt that in some cases electricity in itself does good ; bu t there is also the psychic effect of ophthalmic goitre to be considered, and my experience is that no one form of treatment alone is of much use — it must be combined with other methods.

Galvanism, I believe, is held to be best. You should start off with small doses and increase. Bram recommends 25 milliamperes, increasing to 50, with broad electrodes over the neck and back — neck positive, back negative. Static Electricity : In the later stages I should not care to recommend it. In the early stages it is beneficial, with energetic successive contraction and relaxation, with a not too rapid discharge at the spark gap. Place the metal electrode over the thyroid gland, and secure by bandage. Spark gap must be long enough to cause the tissues to vibrate energetically, but not sufficiently long to produce tonic contraction in the neighbouring muscles : this treatment for twenty minutes daily. The High Frequency current applied with the Vacuum Electrode : Apply over the thyroid gland for ten minutes two or three times a week. It may also be applied between the eyes for exophthalmic. Faradism, I do not think is of any use at all. You cannot draw any hard and fast rules as to this disease, but must study each patient individually. American and English authorities differ as to the beneficial results of electricity, and in regard to the X-ray treatment, many authorities consider that it is pra ctical ly valueless for goitre . On the other hand, Dr. Morison has published an account of a series of cases of goitre in which he used X-rays, and according to his statistics the results have been extremely good, the number of cures effected by this method of treatment (if I remember rightly) reaching a total of 50 per cent. In the face of these conflicting opinions, the only thing one can do is to endeavour to take a middle course. There are certain points I should like to emphasise. Watch the patient's general condition. She possibly is suffering from endemic goitre, which is of itself not serious. On the other hand, in exophthalmic goitre there may be a very small goitre and otherwise extremely bad symptoms. Study the patient's pulse ; take note of the tremors of the body, and if a patient with exophthalmic goitre is increasing in weight (other things being equal) you may be sure she is improving in health even though the goitre is as large as ever.

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