502 Original Communications. [April, Art. IV. On the Nithsdale Neck, or Goitre, in Scotland. By Arthur Mitchell, A.M. & M.D., Deputy Commissioner in Lunacy. The connexion between goitre and cretinism being generally regarded as very intimate, it appeared to me of interest to ascertain whether bronchocele prevails in any part of Scotland, and if so, whether the form of idiocy in that district presents any of the cretinoid characters? the nature of my duties giving me the opportunities necessary for doing this. I have already officially visited more than three-fourths of the parishes of Scotland, and with much of the rest I am well acquainted. In every locality visited I have endeavoured, by careful personal obser- vation, and by frequent inquiries, to determine the existence or non- existence of goitre as an endemic affection; and of all that I saw and heard I have preserved written notes. The general result is briefly as follows : Goitre exists nowhere in Scotland, as an endemic disease, except in the southern counties. The extent of the district which it occupies may be laid down as including the greater part of Roxburgh, the upper parts of Selkirk and Peebles, the eastern parts of Ayrshire, where it touches Lanark and Dumfries, the upper districts of Lanark, the whole of Kirkcudbright and Dumfries, the west of Berwick, and the east parishes of Wigton. The endemicity reaches a maximum in the upper Yalley of the Nith. As you approach the outer margins of the whole district named, the affection becomes less and less frequent; but even there, as compared with the rest of Scotland, it is common. In the coun- ties of Dumfries and Kirkcudbright I had myself an opportunity of seeing 93 cases, and of these about 60 were well marked, the rest being less so, but still undoubted cases of goitre. A considerable pro- portion of the 93 were seen in Upper Nithsdale, and I have therefore given to the affection the name of the Nithsdale neck. The accuracy of my own impressions, as formed on observation and from verbal reports, I tested in various ways, so as to leave as little doubt as possible about the correctness of the conclusions. Our asylums, for instance, furnish a proof of the comparatively great frequency of this affection in the southern counties. They at the same time show, so far at least as acquired insanity* is concerned, not only that there is no necessary or intimate connexion between the two diseases, but that there is possibly no connexion at all. In other words, it does not appear that the insane from an ungoitrous district will, because of their insanity, be goitrous ] nor that the insane from a goitrous district will be found more liable to goitre than the ordinary population, living under similar health conditions. I communicated with the physicians of our public asylums, as also with those of the licensed poor-houses and private asylums, requesting information as to the number of goitrous persons among the insane * By this I refer to mania, melancholia, dementia, &c , or those forms of insanity which usually appear after puberty. 1862.] Mitchell on Goitre in Scotland. 503 under their care, and as to the parishes from which these had come, and the form of mental malady under which they laboured. I have pleasure in stating that this information was in nearly every instance furnished to me, and the result I now embody in a tabular form. The table is drawn up from statements in writing furnished by the medical gentlemen residing in the various establishments, or pro- fessionally in charge of them. In 110 instance have I used observations made by myself. No. of in- No. of pa- County to Name of Institution. m ites, as on tients affected which these Remarks. 1 Jan. 1859. with goitre. belong. Eoyal Asylums: 1. Morning-") ? ? side; 2. Montrose; 3. Perth; >1321 ... 0 ... ... and 4. Dundee J 1. Private Asylums; Garngad; ^ 2.Baldovan; 3, Longdale; 4. Lillyblank ; 5. Newbig- ging; 6. Hallcross; 7. Cam- f 627 pie Lane; 8. Millhohne; 9. Spring-bank ; 10. Gilmer House; and 11. Eastport..J Lunatic Wards of Poorliouses I. Cunningham Combina- tion; 2. Govan ; 3. Inver- ness; 4. Falkirk; 5. Stir- ling; 6. Rhins of Galloway; }? 546 7. Greenock; 8. Barony ; 9. S. Leith; 10. City of| Glasgow; 11. Abbey; 12. Burgh; 13. St. Nicholas ... ? Sum 2494 ... 0 ... ... small, but distinct; one large, but de- creasing; and one dubious. Gartnavel 504 ... 2 IOne Eoyal Asylum, {Dumbarton.' Sum 32S8 ... 5 ... ... /17\ /Dumfries. Cricliton Institution and South- t 15 marked, 13 ~) " ern Counties Dum- >447 | j ! and 2 Asylum, ...-/ ^ slight, fries Ayr. doubtful.* Lanark. England. Total 3735 From this it appears that in twenty-seven of the institutions for the insane in Scotland, with a population of two thousand four hun- dred and ninety-four, there is not a single case of goitre. In two others, with 794 patients, there are 5 cases; while in Dumfries alone, which is the district asylum for the southern counties, there are 30 patients affected with goitre out of a population of 447. It appears still more striking, when I state that 26 of the 30 are found in that division of the Dumfries Asylum which specially serves the district, * Of the whole 35 cases, 26 are females and 9 males. The majority labour under dementia, but cases of melancholia, mania, monomania, and idiocy arc included. 504 Original Communications. [April, wliich may be regarded as filled from it, and which has only 277 inmates; and further, that, with two exceptions, all of the 26 are entered as belonging to the counties which I have called goitrous. In other words, among 3288 lunatics found in twenty-nine asylums scattered over Scotland, only 5 goitres occur, while in one-seventh of that number found in the Asylum at Dumfries, there are six times as many. Had the proportions been equal, instead of 5 there ought to have been 221. It was not without satisfaction that I found these facts so fully supporting my own impressions. Sporadic cases of enlargement of the thyroid I have encountered here and there all over Scotland, in the sane and insane, and I look upon the five cases out of the Dumfries Asylum as of this nature. I would here again remark, that the foregoing table, supported by all that I have observed myself, goes to show that a lunatic?be he imbecile, idiotic, demented, melancholic, or maniacal?appears to have no predisposition to this affection, in virtue directly of his lunacy, in so far at least as Scotland is concerned. Assuming that on the whole the boundaries which I have assigned to the goitrous district are correct, I shall now endeavour to show that the maximum of intensity occurs, as I have asserted, in the upper valley of the Nith. In addition to what I had opportunities of observing myself, I have on this point the advantage of possessing the opinions of many of the resident medical men, partly through per- sonal intercourse, and partly by correspondence. Dr. Chalmers, of Thornhill, in Nithsdale, informs me that in the poor-house there, of fourteen females above the age of twelve, eight furnish " unmistalceable evidence of goitre," or more than one-half. As is usually the case, males are less liable to the affection than females, and accordingly in six men above the age of twelve it occurs only once, and that not very distinctly. He further states it as his opinion, " that about one woman in ten is affected with the disease in that part of the country." Dr. Grierson is substantially of the same opinion. Dr. Kay, of Sanquhar, communicates his own view and that of Mr. Laurie, in these words?" We are still of opinion that every fifth or sixth female here has more or less of it." What I saw myself led me to conclusions as to its extent very nearly the same as the foregoing. In one of the annual reports of the Crichton Royal Institution, Dr. Browne states that during the preceding year not less than eight cases in the valley of the Nith had been under observation, in which goitre was complicated with some form of mental disease. " Dr. Carlyle considers the disease to be of frequent occurrence" in the neighbourhood of Langholm; and Dr. MacLeod writes me, that it "prevails to a great extent" in the district about Hawick. It is also very general about Wanlockhead ; and in the Castle Douglas and New Galloway districts it is far from uncommon. As you enter Wigton from Kirkcudbright, and proceed westward, it seems gradually 1862.] Mitchell on Goitre in Scotland. 505 to decline in frequency. Over the whole district it prevails, but no- where does its force appear to be so great as in Upper Nithsdale. Taking the accuracy of this for granted, I am now led to the inter- esting question?Do the forms of idiocy in these districts differ in any respect from the forms which are found throughout the rest of Scot- land ? or, more precisely, Does cretinous idiocy appear to occur in association with the goitrous manifestations? It becomes necessary, however, before answering this question, to define what I regard as a cretin. The most distinctive characteristics are to be found in the physiog- nomy and in the condition of the skin. As regards the first, the nose of a cretin, which is short and flat, is always depressed and broad at its root; the eyelids are loose and flabby; the lips thick and swollen; the general face prognathous; the mouth open; the tongue large and often protruding; the teeth irre- gular and decayed ; the palate high and narrow; the cheeks and face generally full, loose, and wrinkled; the hair thin, and in the adult often wholly absent on the chin, in the axillae, and on the pubis; the complexion blanched, and the expression dull, heavy, stupid, and child-like.