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THYROTOXICOSIS BV SIR CARRICI ROBERTSON, F.R.C.S., F.R.A.C.S., Hon

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THYROTOXICOSIS BV SIR CARRICI ROBERTSON, F.R.C.S., F.R.A.C.S., Hon 57' Postgrad Med J: first published as 10.1136/pgmj.24.277.571 on 1 November 1948. Downloaded from THYROTOXICOSIS BV SIR CARRICI ROBERTSON, F.R.C.S., F.R.A.C.S., Hon. F.A.C.S. Auckland, New Zealand A goitre is an enlargement of the thyroid gland. lating hormone (T.S.H.) goes forth from the It may be either a diffuse smooth enlargement or pituitary which causes increased activity in the a lumpy one. The lumps are due to the presence thyroid and a rise in the production of the thy- of nodules, varying in size from a pea to a cricket roxin. The opposite effect takes place if there is ball; this type used to be called adenomatous not sufficient thyroxin in the blood stream. goitre, but the pathologists say these nodules are A few years ago, it was discovered that the pro- formed by alternating phases of hyperplasia and duction of thyroxin by the thyroid gland could be involution (Reinhoff & Lewis) and are not true suspended by administering thiourea, thiouracil adenomata, so it is better to reserve the name or other thio compounds by the mouth. These 'adenoma' for the single adenoma which may drugs act by their toxic effect on the thyroid gland occur in the thyroid as in any other glandular itself: they render it incapable of synthesizing organ. Both the diffuse and the nodular enlarge- the blood iodine into thyroxin. Continued admin- ments can be present without doing apparent harm istration of the drug eventually leads to a state of to the patient: but as time goes on, something myxoedema. secretion of the thyroid hormone It should be remembered that thiouracil has no happens to the Protected by copyright. and an insidious change takes place in the health of action on the anterior pituitary gland, so that with the patient, which we call thyrotoxicosis. These the decreased production of thyroxin, there is a goitre enlargements are prone to occur in parts of reflex increase in the quantity of T.S.H., the stimu- a country where there is an absence of iodine in the lator of cellular activity in the thyroid. A micro- soil. Without iodine, the synthesis of thyroid scopic section of a gland under treatment with hormone or thyroxin, cannot be completed. thiouracil shows a hyperplasia similar to that seen The function of this little gland is to trap the in Graves' disease, but all to no avail, the thiouracil inorganic iodine in the blood as it passes, through inhibits the formation of thyroid hormone in and use it in the manufacture of thyroxin. In spite of the activity in the acini of the gland. spite of its small size, it contains over 20 per cent. It is useful to have a working classification of of all the iodine in the body. It is supplied by four pathological enlargements of the thyroid. One in comparatively large arteries so that all the blood general use is in the body must pass through it many times a day. (i) Nodular or lumpy enlargements: Thyroid hormone stimulates the metabolism of (a) Simple the body and it becomes of great importance at (b) Toxic http://pmj.bmj.com/ puberty, so that children living on an iodine (2) Diffuse or smooth enlargements: deficient soil are very prone to have diffuse enlarge- (a) Simple, such as colloid goitre in the ments of the thyroid gland. It is almost as if the young. enlargement of the thyroid at puberty may rep- (b) Toxic or Graves' disease. resent an addition in the size of the factory, in (3) Inflammatory-thyroiditis, abscess, gumma, order to augment its efficiency in abstracting and Riedel's woody thyroid. and more of the iodine present in New growth-benign or malignant, cysts, utilizing more (4) on September 28, 2021 by guest. the blood. It is in childhood that nearly all nodular hydatids, dermoids. goitres commence their career: for if the diffuse (5) Hashimoto's disease-a rare condition in enlargement persists till about 20 years of age, which the tissue is infiltrated with lympho- small nodules begin to form in the substance of cytes. For full information see article by the gland. Once this has happened, it is unusual Joll. In this paper we are only concerned for them ever to disappear. On the other hand, with thyrotoxicosis as occurring in the toxic administration of quite small doses of iodine or nodular and toxic diffuse groups. thyroid extract before nodulation occurs, is usually a preventive of further goitre trouble. Nodular Goitres The quantity of thyroid hormone in the blood A patient with a nodular goitre need not neces- stream is controlled by the anterior pituitary sarily have a visible tumour in the neck-the nodules gland: should there be too little, a thyroid stimu- may be small and deeply situated, The size of a Postgrad Med J: first published as 10.1136/pgmj.24.277.571 on 1 November 1948. Downloaded from 57:2 POST GRADUATE MEDICAL JOURNAT, Novenmber T948 puberty goitre often decreases, even without treat- (3) All kinds of psychotic symptoms- ment: possibly the extra fat and development of emotional, depressive, irritability and the neck muscles, as the patient grows older, phobias of various kinds. covers any swelling that may remain, so that even It is obvious that there are many causes of such if there was a recognizable swelling as a child, it is symptoms, for example, the anaemias, early forgotten. Later in life, pregnancy, general infec- phthisis, anxiety neurosis. The first can be ruled tion or some serious emotional disturbance, such out by obtaining a blood count, the second by an as domestic unhappiness occurs, and the simple X-ray of the chest. A former H.S. of mine who is gland becomes a toxic one. The nodules increase now an authority on chest diseases, told me that in size and the goitre again becomes obvious. when he first went into the wards of the Brompton During acute systemic infections, or even during Hospital for Diseases of the Chest, he thought all chronic infection elsewhere in the body, the thy- the patients looked like early Graves' disease. roid gland, especially the already diseased one, There are some further points in the signs and (whether diffuse or nodular) may become inflamed. symptoms of thyrotoxicosis which should be men- As a result, a severe thyrotoxicosis can develop. tioned before discussing differential diagnosis, There may still be people who advocate removal of especially the difficult problem of distinguishing septic tonsils for thyrotoxicosis-it used to be a between mild thyrotoxicosis and anxiety states. very general treatment-but it fell into disrepute A palpable thyroid gland : It is quite unusual to because the thyrotoxic symptoms once started, are find a normal sized thyroid in a thyrotoxic patient, not appeased by taking out the septic focus. How- even in primary Graves' disease, which attacks an ever, as a prophylactic measure, it is sound pro- apparently normal gland; the sequent hyper- cedure. plasia makes the gland larger. A normal thyroid, except for the isthmus, cannot be felt except in a Diffuse Goitres very thin neck, so if the gland is palpable, it is The other common form of toxic goitre is probably enlarged. A useful test is to ask the Protected by copyright. primary Graves' disease. This may appear at patient to stretch his or her neck and swallow: almost any age and, in what up till then, has been this will sometimes induce a hidden swelling in a perfectly healthy gland. The same causes that the lower poles to come out from behind the ster- turn the simple nodular into a toxic nodular goitre num, because all thyroid swellings move up and are probably present. The symptoms are so down during deglutition. This sign is also useful simnilar that no useful purpose is served by dif- in distinguishing a large nodule in the upper pole ferentiating them. from a swollen lymphatic gland or other tumour A microscopic section of a toxic diffuse goitre of the neck. shows great increase in the size and activity of the In doubtful cases, it is helpful if the patient cells lining the vesicles throughout the gland. admits to a goitre during adolescence, because this Exactly the same hyperplasia is seen in toxic greatly increases the chances of there still being nodular goitre except that it does not occur some enlargement remaining. throughout, but only in patches. Tachycardia which does not settle after a short rest. The heart sounds will be found to be loud http://pmj.bmj.com/ Diagnosis of Thyrotoxicosis and slapping. When asked if they have any dis- When the signs are well developed, there can be comfort it' bed at night, they will frequently com- no difficulty. The combination of staring eyes, plain of a ' bumping of the heart.' nervous restless movements, tachycardia or short- A fine tremor on holding out the hands, difficult ness ofbreath with a visible almost pulsating goitre, to describe and of unknown cause, but very can hardly be mistaken. In such a case, a B.M.R. characteristic. Eye signs: This will vary from a staring appear- is not necessary for the diagnosis, but may be on September 28, 2021 by guest. useful if taken from time to-time\in checking the ance to marked exophthalmos, usually in both progress of whatever treatment is adopted. eyes, but may be more marked on one side than However, in the early stages, or milder cases, the other. diagnosis may be anything but easy; for in such Lid Lag (von Graefe): This is a very distinctive a case, the following symptoms will be found:- and helpful sign.
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