from this supposed causation among other things.*

The tumour, as we have stated, is of a chronic or indolent nature, increasing gradually, and often continuing for many years, or even a whole life-time, without affecting the general health. It usually appears in early life, and is much more common among women, especially those of a lax fibre, than among men; insomuch, that in this country it is very rarely met with in the male sex. In all the cases admitted at the Hampshire County Hospital during the last ten years, amounting to fortynine, the patients have, with only one exception, been women. We are informed by Dr. Forbes, that out of seventy patients treated at the Chichester Dispensary and Infirmary during the last nine years, only two have been males. It is also worthy of notice, that both the latter cases occurred in boys of a very feeble and feminine habit of body, and very backward for their years. The disease has, in some instances, been observed to make its first appearance during parturition, and, in other cases, to have made rapid progress during gestation or suppression of the menses. The swelling generally embraces the whole gland, but is sometimes confined to the lateral lobes, or the middle lobe, separately. It is usually soft and rather flabby to the touch, though somewhat unequal in that respect, and is for the most part free from pain and of a natural colour. It varies in shape, at first presenting but little outline, and, while of moderate dimensions, possessing a more rounded and compact appearance than it afterwards preserves. When of considerable size it has a pendulous form, not unlike the dewlap of a turkey-cock, the bottom being the largest part. In point of magnitude it varies still more remarkably; often remaining through life of no very conspicuous size; in other cases increasing to a degree of hideous deformity: sometimes it rises as high as the ears. Alibert mentions one instance in which it descended to the middle of the sternum; and another in which it was of a tapering cylindrical shape, and reached to the middle of the thigh. cases of great enlargement it impedes respiration, deglutition, and the return of the blood from the head, by its pressure; thus occasioning hoarseness, wheezing, flushings of the face, headach, giddiness, and, in some instances, even death. In these extreme cases there are occasional pains in the tumour, and the skin becomes of a livid appearance, with the veins on its surface much swollen. The late Dr. Parry, of Bath, often observed bronchocele to follow diseases of the heart, epilepsy, and other maladies in which the blood is propelled with excessive momentum to the head.§ Flajani has seen it accompanied with palpita

In

tions and irregular and intermitting pulse; and he believes that fatal disease of the lungs has been induced by the consequent disorder in the pulmonary circulation.*

On dissecting the tumour, Hunter and Baillie found it to contain cells with a fluid more or less viscid; and Mr. Benjamin Bell states this to be frequently the nature of the disease. "These cells," says Baillie, " vary in their size in different parts of the same gland, and in different swellings of the same kind in different individuals. Some of them are so large as to be able to contain a small pea, but most of them are of a smaller size. The viscid fluid, when the gland has been preserved some time in spirits, is changed into a transparent jelly. From this account of the morbid change of structure which takes place in bronchocele, it seems not unreasonable to suppose that the swelling depends upon a vitiated and increased secretion in the gland. The secretion, being in large quantity, gradually distends the cells, increasing thereby their capacity, and this enlargement of the cells forms the general swelling of the gland." The tumour is sometimes steatomatous. It is rarely found to contain purulent matter. Occasionally it has been in part converted into cartilage or bone. Dr. Hedenus, of Dresden, states that he has almost uniformly found this to be the case. Sometimes the enlargement of the gland is a true sarcoma. Dr. Mason Good names it sarcoma cellulosum, or cystose tumour, and states that it generally consists of “oval cells, currant-sized or grape-sized, containing a serous fluid, sometimes caseous."§ Celsus has briefly and accurately described the appearances on dissection in these words: "Modo caro hebes, modo humor aliquis, melli aquæve similis, includitur; interdum etiam minutis ossibus pili immisti."|| There have been instances in which the tumour has exhibited a complication of almost every diversity of structure. De Haen relates a striking example of this, in a person who died of dropsy from visceral tumours. "In cadavere horrendam mole thyroidæam glandulam nactus, publice dissecui. Mecum auditores mirabantur nullum ferè genus tumorum dari, quin in hac sola thyroidæa inveniretur. Hic enim steatoma, ibi atheroma, alio in loco purulentus tumor, in alio hydatrius, in alio erat coagulatus sanguis, fluidus fere in alio, imo hinc glutine loculus plenus erat, alibi calce cum sebo mista," &c. These circumstances countenance the opinion that the same causes may produce most of the different kinds of tumour, the modifications depending upon the difference of site, habit of body, idiosyncrasy, &c.

There are some other diseases with which bronchocele might be confounded, and which have, indeed, at times been included under

*Collezzione d'Osservazioni e Riflessioni di Chirurgia, t. iii. p. 283, 8vo. Roma.

+ Morbid Anatomy, 8vo. pp. 87, 88. Graefe's Journ. der Chir. b. ii. Berlin. Study of Medicine, vol. v.

Lond.

Lib. vii. cap. 13.

Rat. Medendi, pars

vii. p. 285.

the same name. Thus, the thyroid gland is occasionally attacked with acute inflammation, though, perhaps, less liable to it than most other glands of the body. In such cases, however, the swelling is more rapid in its progress than in bronchocele, but does not attain so large a size: it is firmer to the touch, painful on pressure, and the disease is much more liable to terminate in suppuration. Again, scirrhus of the gland may be distinguished from goitre by its great hardness, by occasional darting pains in the part, and by its generally occurring in advanced age, and seldom attaining to any great size. Alibert, however, states that he has seen an instance of true goitre terminating in cancer.* Aneurisms, though they do not frequently occur in that situation, might possibly be mistaken for bronchocele; but they may be distinguished by their sudden appearance after violent exertion, particularly in coughing or laughing, by their being soft and compressible, by their situation directly in the course of the carotid arteries, and by their strong pulsation. The lymphatic glands are sometimes so enlarged, in scrofulous cases, as to form tumours of considerable size in the course of the trachea; they may, however, be distinguished from this disease by their greater tenderness on pressure, sometimes by an evident sense of fluctuation, by their being accompanied with swellings in other parts, and by the state of the general health. In some instances, indeed, the thyroid gland has, on dissection, been found in a natural state, the whole of the tumour consisting of a diseased state of the lymphatic glands and cellular membrane surrounding it. Instances have occurred of tumours arising in consequence of the lining membrane of the trachea being forced out between the cartilages in violent fits of coughing, sneezing, laughing, or other exertions of the lungs. Cases of this kind are styled the real bronchocele by M. Larrey. They might, perhaps, with more propriety, be called hernia gutturis or hernia bronchialis, names which have been sometimes given to the common bronchocele. Certainly, however, this is not the disease which has been usually known by the name of bronchocele, and to which the term is now almost universally confined; and as we are not at present considering the nosological propriety of the designation, we would include such cases among the spurious goitres. Their most characteristic symptom is the complete disappearance of the tumour when compressed. The voice, too, is almost entirely lost, and the respiration performed with the mouth wide open. Larrey observed it most frequently among the blind people who are employed by the priests to chaunt at the tops of the minarets in Egypt; and he met with two cases of it in subaltern officers, who had for a considerable time been employed as military instructors. Dr. Barton, in his Memoir on Goître as it prevails in America, states, on the authority of Foderé, that air has sometimes been forced, in like

Nosologic Naturelle.

† Medical Gazette, vol. vii. p. 88.

manner, into the substance of the thyroid gland and the surrounding cellular membrane.* Whether this be so or not, it appears certain, from the statements of various authors, that the tumour is often increased on exertion of the lungs. Goitre may also be confounded with encysted tumours situated in the course of the trachea. The latter, however, are generally rounder, more moveable, more elastic, and more equal to the touch: they are sometimes diaphanous, and fluctuation may often be perceived on pressure. The period of life, too, may at times assist in the diagnosis. In addition to these spurious or complicated cases of bronchocele, there are other instances in which the gland itself is healthy, and the tumour consists of condensed cellular membrane, sometimes interspersed with cysts. Sometimes a cyst, filled with matter of a pultaceous or purulent nature, has been formed around the gland; and there have been cases in which the enlarged gland was surrounded by a yellow fatty mass.

We are so completely unacquainted with the uses of the thyroid gland, and consequently with the peculiar causes of disease in it, that it is not wonderful, perhaps, that there should have been so much conjecture and discordance of opinion with respect to the origin of bronchocele. Whatever may be the primary source of the disease, there is much reason for supposing that, once established, it is often continued in families by inheritance; or, at least, that a strong predisposition to it is in this manner acquired. Thus we have known a woman with goître, whose grandmother, father, paternal aunt, and cousins, also had it; although they did not all live in the same place, and no other person in their neighbourhood was affected with the disease. Similar instances have presented themselves to others; and it is well known that where cretinism prevails, infants are often born with goître. In such places, therefore, the effect of intermarriage among the inhabitants is not to be overlooked, as tending to spread and perpetuate it. The disease has sometimes been attributed to a scrofulous taint in the constitution; but as it is only met with in particular districts, as it is not always accompanied with swelled lymphatic glands or disordered general health, and as the tumour in bronchocele is scarcely known to suppurate spontaneously, while, on dissection, it has mostly been found of a totally different nature from strumous swellings, the conjecture must be abandoned. It has been held by some that bronchocele arises from a deficiency of nutritive food; and Dr. Mason Good countenances this opinion. He states, that on a visit to Derbyshire "he found a much larger number of the poor affected with this disease than he had ever seen before, while the rich escaped; and he found, also, that by far the greater part of those who were labouring

Medico-Chirurg. Trans. vol. xi. p. 242.

Dr. James Clark. Notes on Climate, Diseases, &c. in France, Italy, and Switzerland, p. 109, London, 1820.

Thomas's Practice of Physic, p. 573. 2d Ed.

may be found as an endemic disease in all mountainous and marshy districts of the United States; that it generally prevails in valleys at the bottom of the highest mountains, in the neighbourhood of rivers, falls, lakes, or of the sea, and where the soil is rich and sheltered. Dr. James Johnson, in his Excursion through France, Switzerland, and Italy, recently published, has some excellent remarks on the phy

sical causes of bronchocele and cretinism in the valley of the Rhone, drawn from his own personal observation. "Were this valley beneath a tropical sun," says he, "it would be the seat of pestilence and death. As it is, the air must necessarily be bad; for the high ridges of mountains, which rise like walls on the north and south sides, prevent a free ventilation; while in summer a powerful sun beats down into the valley, rendering it a complete focus of heat, and extricating from vegetation and humidity a prodigious quantity of malaria. In winter, the high southern ridge shuts out the rays of a feeble sun, except for a few hours in the middle of the day; so that the atmosphere is not sufficiently agitated at any season of the year. To this must be added the badness of the waters, which, along the banks of the Upper Rhone, are superlatively disgusting." In farther allusion to the same subject, he states that "it is remarked that cretinism is bounded to certain altitudes above the level of the sea. The Vallais itself, and the ravines or gorges of the mountains by which it is enclosed, are the chief seats of this deformity. All, or almost all, those who inhabit the higher ranges of the mountains overlooking the valleys, are exempt from the malady. This single fact proves that cretinism is owing to a physical rather than a moral cause, or series of causes. There can be no material difference in the moral habits of peasants residing at the base and on the brow of the same mountain. If the former be more subject to goître and cretinism than the latter, it must be owing to something in the air they breathe, the water they drink, or the emanations from the soil on which they reside. Saussure, Ferrus, Georget, and all those who have personal knowledge on the subject, acknowledge that at a certain height (five or six hundred toises) among the Alps, goître and cretinism disappear."- "In short, we find in the Vallais, and in the lower gorges or ravines that open on its sides, both cretinism and bronchocele in the most intense degrees; as we ascend the neighbouring mountains, cretinism disappears, and goître only is observed; and when we get to a certain altitude, both maladies vanish." (pp. 56 to 58.) We believe that careful observation of the circumstances under which bronchocele is found to prevail in certain districts of our own country would lead to similar views respecting its origin; and in this manner may be explained the fact, that with us it almost exclusively affects the lower orders, who are of necessity the most exposed to such causes, and to those concurrent circumstances which poverty and ignorance entail upon them. Dr. Reeve, who visited the Vallais in 1805, for the purpose of

making personal observations on the causes of goître and cretinism, remarks that "all the cretins he saw were in adjoining houses in the little village called La Batia, situated in a narrow corner of the valley; the houses being built up under ledges of the rocks, and all of them very filthy, very close, very hot, and miserable habitations. In villages situated higher up the mountains, no cretins are to be seen. It would be wrong, however, to pass over the observations of the celebrated Humboldt, which certainly tend to throw some doubt upon these views. He observes that, in South America, bronchocele is met with both in the upper and the lower course of the Magdalen river, and on the flat high country of Bogota, 6000 feet above the bed of the river. The first of these regions is a thick forest, while the second and third present a soil destitute of vegetation. The first and third are exceedingly damp, the second peculiarly dry. In the first the air is stagnant, in the second and third the winds are impetuous. In the two first the thermometer keeps up all the year between 22o and 23° of the centigrade scale; in the third it ranges between 4o and 17o. The waters drunk by the inhabitants of Mariguita, where goitres are the most hideous, are not those of snow, but of springs which flow over granite. He states, also, that the disease is progressively extending itself from the lower provinces to the flat elevated regions of the Cordilleras.†

Ramond, likewise, in his observations on the Pyrenées, informs us that cretinism and goître exist among these mountains even in greater extent and degree than in the Vallais, and under circumstances of locality very different; namely, in open, well-watered, and wellventilated valleys. Upon the whole, therefore, we are scarcely warranted by facts in considering that bronchocele has its origin in any one exclusive source; though, as we have already stated, we think it probable that most frequently it is the offspring of a close, stagnant atmosphere, impregnated with moisture and the effluvia of the subjacent soil.

As bronchocele arises without our being able to trace with certainty its cause, so does it often unexpectedly disappear without any assignable reason, even after resisting all the approved remedies. This has frequently occurred under a change of residence, a circumstance which favours the view that we have considered the most probable respecting the origin of the disease. Alibert states that he has known many ladies in whom the tumour has subsided after a residence of some time in Paris.

Treatment.-A variety of means have been employed for its cure, both of a local and general nature. The former used to consist of dry rubbing the part; bathing it with cold water; friction with stimulating lotions, liniments, or ointments; mercurial applications, leeches, and * Edin. Med. and Surg. Journ. vol. v. p. 33. Journ. de Physiologie, par F. Majendie, t. iii. Nosologie Naturelle, t. i. p. 473.

p. 116.

blisters, kept open or repeated. Electricity also has been employed, and latterly galvanism, it is said, with some success.

Of the internal remedies, till within these few years, the most celebrated was burnt sponge. This was generally exhibited in doses of ten grains to half a drachm, three times a day, in the form of an electuary, infused in wine, or made into a lozenge, which was kept under the tongue till dissolved, from an idea that, in this manner, its influence was more direct and speedy. It was usual, however, to accompany this remedy with alterative medicines and purgatives, chiefly mercurial; and although we believe the efficacy of burnt sponge, when unadulterated, to be undeniable, it might not perhaps be easy to assign its exact share as a remedy when combined with others. That mercurial preparations, internally administered, have in some cases cured the disease, even when burnt sponge has failed, there can be little doubt. There is an instance related by Mr. Davies, of Alresford, in the 13th vol. of the Medical and Physical Journal, in which two pounds of sponge had been taken without any effect, and yet the tumour entirely disappeared in the course of ten days, while the patient was taking mercury internally for some other ailment. Preparations of soda, potass, and iron; the muriates of barytes and lime; egg-shells, burnt hartshorn, and even burnt toads, have likewise been recommended. Courses of sea-water, or mineral springs, and the use of distilled water, which has appeared to Professor Odier, of Geneva, (who ascribes the disease to the qualities of the water,) to prevent the increase of the swelling, and even to lessen its bulk, have also been advised.

Of all the medicines, however, which have been administered for bronchocele, the substance called iodine is unquestionably the most efficacious, though it may not deserve the name of a specific, which some of its advocates have been inclined to claim for it. Of one hundred and twenty cases, treated by Dr. Manson, of Nottingham, where the disease appears to be endemic, seventy-nine were cured, eleven greatly relieved, and only two derived no relief. It is now considered certain, that on the presence of iodine in burnt sponge depend the virtues of the latter in the cure of goître. The discovery of this fact is disputed between Dr. Coindet of Geneva, and his countryman Dr. Straub of Hofwyl. There is no reason, however, to suspect that either was aware of the other's researches while prosecuting his own. Dr. Straub appears to have been led principally by the similarity of smell between iodine, burnt sponge,

It is stated by Dr. W. Gairdner, that chemists are in the habit of substituting charcoal for burnt sponge, of which an undeniable proof is the fact, that it is sold at a less price than unburnt sponge can be bought for. In this manner Dr. Gairdner explains the inefficacy of this medicine in the hands of British practitioners, whilst its virtues are so palpable and evident at Geneva that not only physicians, but also the inhabitants, in general, are convinced of their reality.-Essay on the Effects of Iodine, p. 2, 8vo. London, 1824.

+ Medical Researches on the Effects of Iodine.

and other marine productions, to suspect the existence of the former in these substances. Dr. Coindet, whilst making researches for other purposes, found that the fucus vesiculosus, or bladder-wrack, had been recommended by Russell for the cure of goitre; and as it is from this plant, and other species of the same family, that the soda, with which iodine is generally found combined, is extracted, he was led to suspect that the virtues of sponge, likewise a marine production, might depend upon the same active principle; a conjecture which was soon after confirmed by the discovery made by Dr. Fyfe, of Edinburgh, that iodine existed in the ashes of burnt sponge. M. Roulin has found, likewise, that the aceyte de sal, a South American remedy for the disease, contains iodine. In whatever manner the question of originality may be decided, it must be admitted that to Dr. Coindet's exertions we are principally indebted for the speedy and extensive adoption of this new medicine. In goitre its effects may be obtained either by local application to the tumour, or by administering it internally. Where the former is sufficient, it is preferable to the latter. The formula recommended by Coindet, and by Professor Brera of Padua, is that of an ointment, composed of half a drachm of hydriodate of potass mixed with an ounce and a half of lard, of which a drachm should be rubbed in over the surface of the swelling, morning and night. Brera, also, uses an ointment consisting of a drachm of pure iodine and an ounce of lard. Of this, the quantity to be rubbed in is a scruple at a time. Dr. Manson uses a liniment, composed of a drachm of the tincture of iodine mixed witth an ounce of the liniment. sapon. comp., which may be kept in a phial, and the evaporation of the iodine, that takes place in the ointment, be thus, he says, prevented. For internal administration, the preparation in most common use in this country is the tincture. Coindet directs this to be made, by dissolving forty-eight Genevese grains of iodine (forty grains troy weight) in one ounce of alcohol. As, however, the strength of the spirit varies, and it is liable to evaporate, a weaker tincture is preferable, from which the iodine is less likely to be deposited, and thus the deleterious action on the bowels, which has appeared to Dr. Gairdner to be more marked in proportion to the free iodine in the preparation, avoided. Dr. Manson directs the tincture to be made in the proportion of twenty-four grains of iodine to an ounce of rectified spirit; and the dose of this may be from fifteen to thirty drops, three times a-day, taken in some dis

tilled water. The dose of Coindet's tincture is from ten to twenty drops; but Dr. Gairdner, who has had considerable experience in the use of iodine, and has given us an excellent description of its occasional mischievous effects, conceives this to be the most objectionable form in which it is used; and in this Dr. Kolley of Breslau seems to agree with him.t Iodine

* Majendie's Journ. de Physiologie, T. v. p. 273. + Reflexions, &c. sur l'emploie de l'iode. Journ. Comp. Fevrier, 1824.