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6:
DISEASES OF
THE THYEOID GLAND
AXD
THEIR SURGICAL TREATMENT
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DISEASES OF
THE THYROID GLAND
AND
THEIR SURGICAL TREATMENT
BY
JAMES BERRY
B.^.hosv., F.E.C.S.
SL'KGEOX TO THE ROYAL FREE HOSPIT.Ai AND LECTURER OX SURGERY
AT THE LONDON (ROYAL FREE HOSPITAL) SCHOOL
OF aiEDICIXE FOR TTOMEJi ; SURGEON TO THE
ALEXANDRA HOSPITAL FOR HIP DISEASE
PHILADELPHIA
P. BLAKISTON'S SON & CO.
1012 WALNUT STREET
1901
Printed in Great Britain
TO
IX GRATEFUL AND AFFECTIONATE
RECOGNITION OF MUCH VALUABLE HELP
IN n> PREPARATION
THIS BOOK IS DEDICATED
PREFACE.
This book is based upon the Essay to which the Jacksoiiian
Prize of the Royal College of Surgeons for 1886 was awarded.
The essay in its original form was never published because I felt
that at that time I had had so little personal experience of
thyroid operative surgery, that it was undesirable to commit
my observations to print. During the last fourteen years,
however, I have enjoyed unusual facilities for the study of this
branch of surgery, and much of what was written- in the
original essay has been entirely rewritten, by the light of
farther experience.
The Hunterian Lectures, which I had the honour of deliver-
ing at the Royal College of Surgeons in 1891, have also been
incorporated in the present work.
I am fully aware of the many imperfections in, and omissions
from, the book, and should have liked to wait for further ex-
perience before publishing it. But further waiting seems
undesirable, as there would always be something wanting,
something new to be added.
I trust that those who read the book will deal gently with it,
and remember that it is an honest attempt to set forth as clearly
and concisely as possible what is known by myself and others
about a difficult and somewhat obscure branch of surgery.
I have to thank numerous friends for the help they have
afforded me ; some by sending cases for treatment, or for
examination, others by supplying local information about the
distribution of endemic goitre.
The illustrations are mainly from my own photographs,
supplemented by some others taken by friends. To Mr. Charles
viii PRP^FACE.
Cosens I am especially indebted for all the micro-photographs,
and for much invaluable help in photography. The drawings
are mainly by Miss G. Bulkeley-Johnson, who has bestowed an
amount of care and attention upon them for which I am most
grateful. A few are from the skilful pencil of Dr. Ethel
Vaughan ; for a very few I am myself responsible. The patients
from whom the photographs have been taken (excepting those
shown in Figs. 15 and 83) have all been under my own observa-
tion, ana most of them have been under my own care.
The blocks (wdth the exception of those from which Figs. 85,
111 and 112 have been taken), have been prepared by Messrs.
Godart of Maiden Lane, Strand.
Several of the illustrations have appeared elsewhere, illus-
trating papers contributed by myself to the British Medical
Journal, PolycVmic Journal, Tranmctions of the Pathological
Society, and St. Bartholomew's Hospital Reports, and for per-
mission to use these I have to express my thanks.
To Mr. Ernest Shaw I am indebted for much help in the
preparation of microscopic sections.
My best thanks are due to my friends Mr. Anthony Bowlby
and Mr. Edmund Roughton for much valuable advice, and for
the trouble they have taken in revising the proof sheets.
21 WiMPOLE St., London, W.
Feb. 1901.
CONTENTS.
CHAPTER I.
ANATOMY.
Lateral lobes — Upper and lower horns — Isthmus — Pyramid — Relations —
Arteries — Veins — Lymphatics — Nerves — Internal structure — Accessory
thyroids — Parathyroids ........ Pp. 1-13
CHAPTER II.
CONGENITAL AFFECTIONS.
Congenital malformations — Complete absence — Absence of one lobe — Absence
of isthmus — Accessory thyroids — Congenital goitre in man, in lower
animals — Treatment of congenital goitre . . . . Pp. 14-19
CHAPTER III.
ATROPHY AND HYPERTROPHY.
Atrophy: in old age — Myxoedema — Treatment — Cretinism — Sporadic and
endemic — Fatty tumours of cretinism. Hypertrophy : Compensatory —
Physiological — Relation to menstruation — Pregnancy — Puberty — Thyroid
of stout and thin persons ....... Pp. 20—35
CHAPTER IV.
GOITRE AND ITS VARIETIES.
Meaning of the word goitre — Parenchymatous — Cystic — Fibrous — Adenoma-
tous (foetal and cystic adenomata) — Malignant — Exophthalmic — Hfemor-
rhagic — Colloid — ' ' Vascular '" — Endemic — Sporadic — Epidemic — Acute —
Suffocating — Substernal — Intra-thoracic — Retro-tracheal — Retro-i esopha-
geal ........... Pp. 36-48
x contents.
c'haptj:r v.
ENDEMIC GOITRE-CAL'SATION AND DISTRIBUriON.
Alleged causes — Climate — Physical configuration of soil — '' Want of air and
sunshine "' theory — Erroneous nature of — Relation to geology — Geological
and geographical distribution in England — Relation to calcareous rocks
and waters derived from them — Lime — Magnesia — Iron — Organic impuri-
ties — Epidemic goitre — Goitre wells — Artificial production of goitre —
Goitre in lower animals — Habits of life, exertion, strain, &c. — Heredity —
Conclusions Pp. 49-71
CHAPTER VI.
SYMPTOMS AND DIAGNOSIS OF THYROID ENLARGEMENTS
—PHYSICAL SIGNS.
Mobility — Shape — Size — Position with regard to muscles, great vessels,
sternum — Pulsation — Diagnosis from aneurism — Consistence — Pressure
effects, on veins, recurrent laryngeal nerve, sympathetic, cervical and
brachial plexuses, larynx and trachea, ctsophagus and pharynx
Pp. 7-.^-104
CHAPTER Vn.
THE DYSPNCEA CAUSED BY GOITRE.
Frequency and importance — Pressure upon trachea — Lateral compression^
Scabbard-shaped trachea — Effect on trachea of bilateral goitre, unilateral,
median — Softening of tracheal wall — Pressure upon recurrent nerves —
Direct extension to trachea — Rupture of cyst or abscess — CEdema of
glottis — Swelling of tracheal mucous membrane— Varieties of goitre
most likely to cause dyspntea ; relation to age and sex — Danger of
bilateral goitre of puberty and of deeply seated goitres — Table of cases of
goitre causing death by suffocation ..... Pp. 105-129
CHAPTER Vni.
INFLAMMATION,.
Acute idiopathic inflammation — Typhoid fever — Rheumatism — Pyasmia — Trau-
matic inflammation — Symptoms — Results of suppuration — Diagnosis —
Treatment. Chronic inflammation — Primary chronic inflammation —
Diagnosis from malignant disease — Treatment . . . Pp. 130-14.5
CHAPTER IX.
TUBERCLE AND SYPHILIS.
Tubercle : Miliary — Usually secondary — Caseating — Rarity of— Extirpation of
tuberculous goitre. Syphilis : frequently affects thyroid in form of slight
general enlargement — Gummata rare — Congenital syphilis Pp. 146-1.51
CONTENTS. xi
CHAPTER X.
CYSTIC DISEASE.
Frequency — Age — Modes of origin — Transition of adenomata into cysts —
Single and multiple cysts — Hsemorrhagic cysts — Structure of cyst wall —
Of contents — Vacuolation of colloid — Intra-cystic growths — Malignant
nature of — False intra-cystic growths .... Pp. 152-164
CHAPTER XI.
HYDATIDS.
Karity of — Museum specimen — Age — Sex — Absorption of gland by pressure —
Symptoms — Suppuration — Diagnosis — Urticaria — Eupture into trachea —
Treatment — Table of cases Pp. 165-175
CHAPTER Xn.
EXOPHTHALMIC GOITKE AND ITS TEEATMENT.
(GEAVES'S DISEASE; BASEDOW'S DISEASE.)
Age — Sex — Pathology — Morbid anatomy — Characteristic appearance on sec-
tion — Microscopical appearance — Absence of accumulated colloid —
Secondary changes — Exophthalmos — Cause of — Enlargement of thymus —
Symptoms and Diagnosis — "Formes frustes " — Treatment : Medical, Sur-
gical — Operations upon the thyroid — Extirpation — Eesults — Exothyropexy
— Operation upon vessels — Operation upon sympathetic — Section — Eesec-
tion — Unilateral — Bilateral — Eesults — Mortality — Prognosis without
operation — Conclusions ....... Pp. 176-196
CHAPTER Xin.
MALIGNANT DISEASE AND ITS TREATMENT.
Affects both normal and goitrous thyroid — Age — Sex — Varieties — Sarcoma
and carcinoma — Eelative frequency — Symptoms and diagnosis — Infiltra-
tion of neighbouring parts — Skin rarely involved — Duration of the disease
— Mode of death — Unusual forms of malignant disease — " Malignant
adenoma " — Papuliferous cyst — Treatment — Extirpation — Difficulties and
dangers — Of ten incomplete — Eesults of operations — Recurrence — Statistics
— Slowly growing forms — Palliative treatment — Partial removal — Simple
incision — Tracheotomy — Difficulties — Dangers of sepsis — Treatment of
dysphagia- and pain — Conclusions . . . . . Pp. 197-226
CHAPTER XIV.
TEEATMENT OF INXOCEXT GOITEE— NON-OPERATIVE.
General — Eemoval of cause — Medicinal — Iodine — Thyroid extract — Other
drugs — Cases suitable for — Local — External applications — Indian method
Pp. 227-230
xii COXTKNTS.
CHAPTER XV.
TREATMENT BY TAPPING— INJECTION— INCISION— SETOX—
LIGATURE OF THYROID ARTERIES— EXOTHYROPEXY.
Tapping : For cystic goitre — Occasionally cures — Risks of — Hiemorrhage.
Injection : Of parenchymatous goitre — Directions — Risks — Fatal cases — -
Of cystic goitre — Directions — Risks — Results. Incision : Rarely desirable
— Cases suitable for. Seton : Dangers of. Ligature of thyroid ar«^^eries:
Historical — Recent revival — Methods of operating. Exothyropexy :
Historical — Objects of — Objections — Methods of operating — Results —
Complications— Mortality Pp. 231-249
CHAPTER XVI.
DIYISIOX OR RESECTION OF THE THYROID ISTHMUS.
Early cases — ''Atrophy" of later.il lobes — Explanation of — Dyspntta not due
to backward pressure of isthmus — Results of the operation — Re-appear-
ance of goitre — Conclusions . . . . . . Pp. 250-256
CHAPTER XVn.
TREATMENT BY EXTIRPATION (THYROIDECTOMY).
Difference between extirpation and enucleation — Partial extirpation — Pre-
paration of patient — Question of general anaesthetic — Local anesthetic —
Position of patient — Skin incision : oblique, vertical, transverse — Treat-
ment of infra-hyoid muscles — Recognition of gland — Isolation of lobe —
Ligature of thyroid vessels — Veins often thin and liable to tear — Treat-
ment of inferior thyroid artery — Avoidance of recurrent nerve — Treatment
of isthmus — Arrest of haemorrhage — Cleansing of wound — Asepsis better
than antisepsis — Suture of muscles, of skin — Question of drainage —
Dressings — Use of sponge — Fixation of head and neck — Position of patient
after operation — After-treatment — Convalescence . . Pp. 257-274
CHAPTER XVHI.
MODIFICATIONS OF EXTIRPATION- RESECTION- RESECTIOX-
EXTIRPATION— AMPUTATION.
Mikulicz's resection — Description — Results — Kocher's resection-extn-pation —
Comparison of the two operations — Advantages over other operations —
Amputation Pp. 275-279
CHAPTER XIX.
TREATMENT BY INTRA-GLANDULAR ENUCLEATION AND
ITS MODIFICATIONS.
Intra-glandular enucleation : History — Cases suitable for — Description of
operation — Htemorrhage — Suture of gland. Resection-enucleation ; Cases
COXTEXTS. xiii
suitable for — Description — Advantages and disadvantages. Intra-capsular
enucleation. ■'Bloodless'' enucleation. •' Evidement '' : Cases suitable
for . Pp. 2S0-294
CHAPTER XX.
COilPLICATIOXS OF OPEEATIONS FOR EEMOYAL OF
XOX-ilALIGXANT GOITEE.
I. Accidents occurring during the operation : Sudden death — Causes of —
Cases — Importance of avoiding tracheotomv, if possible — Primary haemor-
rhage in extirpation, in enucleation — Injury to nerves — Recurrent
laryngeal nerve, sympathetic, vagus — Injury to trachea, pleura, pharynx
and oesophagus. II. Complications occurring shortly after the operation :
Secondary haemorrhage — Recurrent liaemorrhage — Sepsis — Treatment of —
Rapid pulse with restlessness — Causes of — Late compression of recurrent
nerve by scar — Tetany ....... Pp. 295—317
CHAPTER XXI.
REMOTE COjIPLICATIOXS— CACHEXIA STEOIIPEIYA.
Historical — Reverdin and Kocher — Horsley's experiments — Early observation
of Paul Sick — Symptoms — Relation to complete removal, to partial
removal — Hypertrophy after partial removal — Treatment of cachexia
strumipriva . . . . . . . - . Pp. -315-327
CHAPTER XXII.
RESULTS OF OPERATIONS.
Gradual improvement — Mortality after removal of innocent goitre — Liebrecht's
and Reverdin's statistics — Mortality after partial extirpation, after
enucleation — Complicated cases — Author's results — Causes of death —
Relief from dyspnosa — Question of recurrence after extirpation, after
enucleation — EfEects upon voice — Effect upon general health — Healing of
the wound — Scar.
Appendix : Table of the last 100 operations performed by the author
for removal of goitre ....... Pp. 32S-3.53
Index Pp. 3.54-367
LIST OF ILLUSTRATIONS.
fig:
1,
3.
4.
9,
12.
13.
14.
15,
17.
18.
19,
21.
22,
24,
26.
27.
28.
29.
30.
31.
32.
33.
34,
37.
38.
39,
41.
42.
43,
4.5.
46,
2. Parenchymatous goitre showing relation to larynx, trachea, and
thyroid vessels . . . . . . . . . . 2, 3
Pyramid, not enlarged ......... 4
Pyramid, enlarged, in parenchymatous goitre ..... 5
Variations in form and size of human thyroid (from Marshall) . 6, 7
Diagram to show suspensory ligament ...... 8
Diagram of thyroid veins (from Kocher) ...... 11
Accessory thyroids, situation of ....... 12
10, 11. Congenital goitres . . . . . . . . 17, 18
Thyroid gland of myxia/i^ fuJrNoina, which will be discussed more fully in
chap. xiii. on malignant disease.
40
THE THYROID GLAND.
liGs. 24 and 25. — A JSihuriai (■(>itn\ iii.iinly parenchymatous-
situiitei low dowu aud eventually causiug- very severe dyspua'a.
(From an outpatient seen at St. Bartliolomew's Hospital.)
GOITRE AND ITS VARIETIES. 41
that of the normal foetal thyroid. To the naked eye it presents
a solid homogeneous appearance. Microscopically it is com-
posed chiefly of masses of epithelial cells, representing undevel-
FiG. 26.— Section of a Parenchymatous Goitre removed by opei-a-
tiou on account of dyspnoea. Thj dark parts show colloid material
distending- the thyroid vesicUs. From a boy aged 15 (Case 22*).
(See Koy. Free Hosp. Miis. No. xxii. 11.) (Nat. size.)
oped thyroid vesicles. Fig. 29 shows a normal thyroid gland
from a six months foetus, and is introduced here for comparison
with Fig. 30, which shows an ordinary foetal adenoma removed
by operation from a goitrous patient aged twenty-five. Foetal
* Published in Brit. Med. Juurn., July 7. 1900.
42
THE THYROID GLAND.
adenomata seldom attain a large size. The largest that I have
iiivself ever had to remove was not larger than an orange. They
are of importance chiefly on account of their vascularity. Opei'a-
Fjc. 27. — Section of Goitre removed by operation, from a woman aged 39,
on account of severe dyspnoea. Numerous adenomata of various
sizes are seen. The white portions show coagiilated colloid. (See
Appendix, Case 30, p. 344 and Eoyal Free Hosp. 3Ius. No. xxii. 23.)
( Slightly enlarged, ^.)
tions for their removal are apt to be attended by smart haemor-
rhage.
The cystic adenoma is by far the most common form of
adenoma. It differs from the preceding in containing numerous
GOITRE AND ITS VARIETIES.
43
cavities visible to the naked eye. The microscopic structure
(see Fig. 31) resembles to a certain extent that of the normal
th}Toid, but the vesicles are usually more irregular., and show
a tendencv to run one into another, owing to the breaknig
?>.^\
. ^^
:»-a
■^^:.,^^_
Fig. 28.— KigliT LoljL- of a Thyroid Glaud sliowiuo- at the lower part a
lnvge soUd Adenoma. (Koyal Free Hosp. Mas. Xo. xxiL 31.)
( Enlarg-ed ±.)
down of the intervening tissue. The connective-tissue between
the vesicles is usually more abundant than in the normal thyroid.
Cysts of various sizes are seen in the tumour. They contain
colloid matter and frequently blood.
Fibrous Goitre. — Occasionally a general increase in the
44 THE THYROID GLAND.
amount of connective^tissue in the gland forms the bulk of the
goitre. To such the name of fibrous goitre may be applied.
The purely fibrous goitre is, however, a very much less common
form than is generally believed.
All the above-mentioned varieties may run one into another,
so that we frequently meet with mixed forms. Thus the paren-
chymatous goitre almost always contains small cysts, and
frequently one or more large ones. So do many adenomata.
Both parenchymatous and cystic goitres frequently contain
Fig. 29. — Tbyroid i Gland l)-om ;i FcetuS of Six Mouths. Tlie gland
is arranged iu lobnles and is almost solid. The rudimentary vesicles
contain very little colloid. ( x 90 di:im.)
much fibrous tissue, and adenomatous nodules may be found in
association with any of the preceding varieties. Fig. 32 shows
an old goitre with several adenomata and much fibrosis.
There are two other important varieties of goitre that stand
somewhat apart from all the preceding. These are malignant
goitre, in which the tumour consists wholly or in part of
malignant disease (carcinoma or sarcoma), and exophthalmic
goitre or the goitre of Graves's disease.
Both these forms of goitre differ widely, both structurally and
clinically, from the preceding varieties.
There are several other minor varieties which have received
GOITRE AND ITS VARIETIES.
45
Fig. 30. — A Pcetal Adenoma fi-om a. Udy agei 2.5. it consists cliiufly
of solid masses of cells, with immcrous vascular spaces (white). Thei'e
are hardly auy vesicles and uo colloid, (x 90 diam.) (Case 25.)
Fig. 31. — Portiou of a Cystie Adenoma from a woman aged 21.
Numerous small cysts of various sizes and full of colloid are seen lying'
in a matrix of coniiestive and glaudular tissues. (Appendix, C:ise 99,
p. 350.) ( X 90 di.im.)
46
THE THYROID GLAND.
separate names. H£emorrhagic goitre is a term used to
signify a condition in which haemorrhage takes place into a
V
, .;, » ^«?■^5"
Fig. 32.— Section of part of a Goitre removed by operation from a woman
aged 43, on account of severe dyspnoea. Several Adenomata are
seen imbedded in a Parenchymatous Goitre which has under-
gone much fibroid idegeneration. (See Appendix, Case 34, p. 3i4, and
Koyal Free Hosp. Mus. Xo. xxii. 25.) (Slightly enlarged.)
goitre, generally a cystic one, or in which an innocent goitre
causes ulceration of the skin over it and bleeds externally. {See
Fig. 33.)
Colloid goitre is a term applied by some authors to paren-
GOITRE AND ITS VARIETIES.
47
chymatous goitres in which the colloid material is unusually
abundant and obvious.*
The term vascular goitre is one that is frequently heard,
and is often applied to the goitre of Graves's disease. The term
Fig. 33. — " Haemorrhagie Cyst." The right lobe of the thjroid is
occupied by a large cyst, Tvhich, after removal, was found to be filled
with uearly pure blood. Several severe haemorrhages had taken place
from the ulcerated opening on the surface. (From a woman, aged 60,
seen at the Kensington Infirmary with Mr. H. P. Potter, under whose
care she was. The tumour is noT\' in tlie Museum of the Royal College
of Surgeons, Xo. 2905a.)
is, however, a bad one, and should, in my opinion, not be
employed. If it be intended to signify a goitre composed
mainly of blood-vessels, then it is a name for what probably does
* A good example of such a goitre may be seen in the Eoyal College of
Sm-geons' Museum, No. 2908D,
48 THE THYROID GLAND.
not exist, for there is no evidence of the existence of any such
o-oitre. If it be used for the goitre of Graves's disease, it conveys
a false impression that the enlargement that is present in that
form of goitre is mainly due to unusual vascularity in the
gland. This is an erroneous but widespread belief.
Amyloid, syphilitic, and tuberculous goitre are all
of them extremely rare ; the names explain themselves. It is to
my mind doubtful whether the cases described as amyloid disease
of the thyroid are really of that nature.*
The terms endemic and sporadic goitre refer, not to
pathological varieties of the disease but to its distribution and
causation. The same may be said of epidemic goitre, a
term that is used for goitre when it attacks a number of people
in the same place and at or about the same time.
Acute goitre is a term used to denote a goitre that develops
rapidly, es})ecially in young subjects.
Suffocating goitre is naturally any goitre that produces
much dyspnoea.
Substernal, intra-thoracic, retro -tracheal, and
retro -oesophageal goitre are terms that explain them-
selves.
* See remarks on pp. 34, 35. concerning- the yellow waxy looking thyroid found
in emaciated persons.
CHAPTER V.
ENDEMIC GOITRE— CAUSATION AND DISTRIBUTION.
Alleged causes — Climate — Physical configuration of soil — "Want of
air and sunshine " theory — Erroneous nature of — Eelation to geology —
Geological and geographical distribution in England — Eelation to
calcareous rocks and waters derived from them — Lime — ilagnesia —
Iron — Organic impurities — Epidemic goitre — Goitre wells — Artificial
production of goitre — Goitre in lower animals — Habits of life, exertion,
strain, etc. — Heredity — Conclusions.
Thehe can be but little doubt that, in the great majority of
cases, goitre is to be regarded as an endemic disease. It is well
known that in some parts of the world, the endemicity is present
in a high degree. In other parts where the cause or causes
are less powerful, the disease is less common and the endemi-
city is not so obvious. It is exceedingly difficult to know
where to draw the line between endemic and sporadic goitre.
Probably in this country, most goitres mav fairlv be considered
to belong to the endemic class, but the endemicity is so widely
spread oyer the country while at the same time it is so slight,
that it easily escapes notice, and cases of goitre are often
considered to be sporadic which should more coiTectly be classed
as endemic.
One kind of goitre, however, the exophthalmic variety, stands
quite apart from all others, both structurally and in its geogi'aphi-
cal distribution.
This form will be dealt with subsequently in chap. xii.
With the exception of exophthalmic goitre, there is no
structural difference between sporadic and endemic goitre.
But although goitre, in most cases, is to be regarded as an
endemic disease, caused bv a definite poison, whatever that
poison may be, it is impossible to assert that all cases of goitre
originate from the same cause. To cite an analogous example :
D
50 THE THYROID GLAND.
there are many malarious districts in which a considerable
number of the inhabitants suffer from enlargement of the spleen
caused by the malarial poison. But enlaro-ement of the spleen
may be due to other causes than malaria ; and just as we do not
consider every case of enlargement of the spleen to be malarious
in its origin, so we need not consider every case of goitre, even
when it is found in a markedly goitrous district, to be due to the
same poison that usually produces the disease.
The number of theories that have been advanced to account
for the causation of endemic goitre is very great. St. Lager *
in his classical work upon the subject mentions more than forty
and occupies no less than four pages of his book in simply
enumerating these different theories and the names of the
authors who have supported them.
In endeavouring to ascertain the relative frequency of goitre
in different parts of England, one is met by this great difficulty
that there exists no source from which reliable statistical infor-
mation can be obtained. In France, Germany, Switzerland and
many other foreign countries, there does exist such a source,
namely the official returns of the number of young men who
have been exempted from military service on account of goitre.
From the statistics thus obtained, maps have been constructed
which show fairly accurately the distribution of goitre in these
countries. Excellent maps of this kind have been published,
for example, in Switzerland by Bircher and in France by Baillarger
and Nivet. In this country, however, there exists no such means
of obtaining information.
The alleged causes of endemic goitre may be conveniently
discussed under the following heads :
(1) Climate and other atmospheric conditions.
(2) Physical configuration of the soil.
(3) Geological structure of the soil, and its influence upon
drinking water.
(4) Habits of life, exertion, strain, etc.
(5) Heredity.
(1) Climate. — That climate has little or no influence upon the
production of goitre is shown by many facts. Although the
* "Etudes siir les Causes du Cretinisme et du Goitre Endemique," J. St.
Lager, Paris, 1867. ■
ENDEMIC GOITRE. 51
disease appears to be, on the whole, most prevalent in temperate
zones, yet it is by no means limited to them. It has been found
in extremely cold regions such as the north of Siberia and in
the Hudson's Bay Territory of North America, and also in
the tropics. My friend Dr. Sidney Davies, late of Cairo,
informs me that he has seen it among the Egyptians. Accord-
ing to other observers, it occurs also in the Soudan and in the
Andes near the equator. It is also well known to be common
in some of the hottest parts of India. That heat and cold have
no share in the production of the disease, there can thus be but
little doubt.
Some authors have endeavoured to show that the prevalence
•of goitre is dependent upon the amount of rainfall, but I have
failed to confirm this statement.
The map published in the Sixth Report of the Rivers Pollution
Commission shows that in England the annual rainfall is
greatest in the centre of Devonshire and in the Lake district,
being over fifty inches in each of these localities. Now the
neighbourhood to the south-east of Dartmoor is one from which
I know goitre to be almost entirely absent. Similarly, in the
neighbourhood of Windermere, goitre is, as I am informed by my
friend Dr. John Mason, distinctly rare. On the other hand I have
found goitre to be common in parts of Buckinghamshire and
Bedfordshire, where the annual rainfall is less than twenty-five
inches. Probably the real reason why goitre has been associated
with excessive rainfall is because it is chiefly in mountainous
regions that goitre is most common, and it is also on mountains
that we expect to find the greatest amount of rain.
Rarity of the atmosphere has been assigned as a cause of
goitre, chiefly also on account of the known prevalence of the
disease in certain mountainous districts such as the Alps,
Pyrenees and Himalayas. But here again, closer examination
shows that it is not to the rarity of the atmosphere that goitre
is due. In Switzerland it has been shown that in manv of the
highest inhabited parts of the Alps goitre is absent. In this
country I have not been able to find that the disease bears any
definite relation to the altitude of the district in which it occurs.
It has been stated by some that goitre is unknown upon the sea
coast, but I have myself observed cases among people who lived
52 THE THYROID GLAND.
and had always lived close to the shores of the Burry estuary in
Glamorganshire. Some of these goitrous people lived but a few
feet above the sea-level.
(2) Physical Configuration of the Soil. — Allusion has already
been made to the prevalence of goitre upon most of the great
mountain chains of the world. In F)'ance, especially, is this
connection apparently striking. Nivet, in his excellent mono-
graph upon goiti'e,* gives for each department of France, the
number of recruits rejected from military service on account of
this disease. The four departments for which the figures are
highest, are Hautes Alpes, Hautes Pyrenees, Aisne and Vosges
(9-28, 3-33, 2-84 and 2-77, per thousand, respectively). It is
worthy of notice that three out of four of these departments
are occupied, as the very names imply, by well-known mountain
chains.
In our own country, too, there are many hilly parts in which
goitre is common. The Pennine range in Derbyshire and
other countries in the centre and north of England is well
known to be a great seat of goitre. Less known, but never-
theless well marked, is the prevalence of the disease among
the Cotswold Hills of Gloucestershire and neighbouring
countries.
But on the other hand, there are many mountainous countries
in which goitre is very rare or altogether absent.
One of the best examples that can be adduced of a mountainous
country almost entirely free from goitre, is Norway.
In the highlands of Scotland, too, goitre appears to be almost
unknown.
It is not, then, the mountainous nature of a country alone
that causes goitre. If one of the mountainous districts in which
goitre is prevalent be examined more closely, it will often be
found that it is only in certain parts of the mountains that the
disease occurs. Thus in Switzerland, the higher parts of the
Alps are much less affected than the lower, and, speaking
generally, it may be said that goitre is more often found at the
foot of a hill or mountain than near the summit.
Bircher of Aarau has constructed, from the military statistics
of Switzerland, an excellent map showing the exact distribution
* Nivet "Traite du goitre," Paris, 1880.
ENDEMIC GOITRE. 53
of goitre in everv part of that country. It may be seen from
this map that in some parts of the country, especially in the
cantons of Berne and Fribourg, the percentage of goitre is
eighty or eyen ninety. Now, the highest gi'ound in Switzerland
is that occupied by the main chain of the Alps in the southern
and south-eastern part of the country. But the district in
which goitre is most preyalent is that \vhich lies to the north
of the Alps, stretching from the canton Fribourg in a north-
easterly direction towards Lake Constance.
It has been asserted that goitre is not so preyalent on the
most exposed parts of mountains, but occurs rather in the
valleys upon the slopes of the mountains, and this is to a
certain extent true. Perhaps, nowhere in the world, is the
disease so common as it is in some of the deep yalleys of North
Italy, on the southern side of the Alps, in that of Aosta, for
example. In Sayoy, at the western end of the Alps, a similar
distribution may be noticed. The Rhone yalley, especially
between Brieg and Martigny, is a well-known example. In
our own country a similar prevalence of goitre in valleys may
be noticed. Among the Cotswolds, the villages situated in
valleys appear to be chiefly affected.
This marked prevalence of goitre in valleys, and especially
in the valleys of mountainous regions, has led to a widely
accepted, but an entirely erroneous theory of the cause of goitre,
namely, that it is due to zcant of air and sunshine.
At first sight, the theory seems plausible enough. No one
Avho has visited the valleys in Switzerland, in which goitre is so
prevalent, can have failed to notice that many of them are deep,
narrow, and gloomy.
But if the depth, the naiTowness, and the gloominess, of
valleys and the consequent lack of air and sunshine in them,
were the real cause of the goitre, then Ave ought to find the
disease prevalent in all similar vallevs in other parts of the
world. Norway may be cited as a country in which such valleys
abound. Yet evidence is quite wanting to show that goitre is
at all common there. In the course of four visits to the western
parts of Norway, I failed to see a single case of goitre.
Again, if want of air and sunshine w^re the cause of goitre,
the disease ought to be connnon among printers and others
oi THE THYROID GLAND.
whose occupations often compel them to work at night in
crowded and ill-ventilated work-rooms.
^Miners, too, can hardly be supposed to get their full share of
sunshine and of good air. But inquiry among them has not
shown that they are particularly liable to the disease.*
The horses, too, that work for years in mines, and never see a
rav of sunshine, are not especially liable to the disease. Yet
horses, as well as other animals, are, like man, subject to goitre,
in districts where it is prevalent.
Some of our text-books state that goitre is especially common
in the overcrowded and poorer parts of our great cities, but the
statement does not rest upon any solid foundation of fact.
Indeed, it may confidently be asserted that in the east end of
London, as well as in the poorer parts of most of the largest
English towns, goitre is not nearly so common as it is in many
country villages situated far more favourably as regards pure
air and sunshine.
In the village of Chacombe, in Northamptonshire, I found
numerous cases of o-oitre. This villao-e is situated in a more or
less sheltered hollow among the hills, and it might be supposed
that its position alone was the cause of the goitre. But a mile
away is a farmhouse situated upon the very top of the hill, in
an exposed and open situation ; in this house several members
of one family have suffered from goitre ; one of them actually
died from suffocation caused by the disease.
A similar example is afforded by the village of Oberbalm in
the canton of Berne. Here the percentage of goitre among
the recruits is twenty-three. The village is situated near the
top of a hill ; on the very summit is a farmhouse ; among the
inhabitants who had always lived in it during the whole of their
lives, I found well-marked goitre. So exposed is the situation
of this farm, that from it I could see, on the one side, the
glaciers of the Bernese Oberland, forty miles away, while in the
opposite direction was visible the equally distant range of the
Jura in France.
A^^ere it necessary to do so, many more similar examples
* It should be remembered that some mines naturalh- exist in goitrous
districts, as in the carboniferous limestone regions of Derbyshire and Yorkshire
and that in these regions ■\ve find goitre just as common among miners as
among other inhabitants of the same districts, but not more so.
ENDEMIC GOITRE. 55
might be cited, pointing towards the fact that endemic goitre
may be found in elevated and exposed situations, where good
air and sunshine are abundant.
It seems clear that, although certain valleys contain a great
deal of goitre, yet the disease is quite absent from others which
are equally deep, narrow, and gloomy, equally devoid of pure
air and sunshine.
(3) Geological Structure of the Soil in relation to goitre. —
The true explanation of the association of goitre with hills and
valleys is to be found, I believe, not in the mere external con-
figuration of the ground but in its geological structure and the
influence which this has upon the drinking water of the district.
Water which has percolated through thick masses of pervious
and more or less soluble rock contains, cateris paribus, more
mineral constituents than water which has not done so. Hence
water issuing at the foot of a hill composed of such rock is
likely to contain a considerable quantity of mineral matter.
The nature and quantity of the minerals will naturally depend
upon the nature and solubility of the constituents of the
rock.
The close connection between goitre and limestone was pointed
out long ago. MacClelland especially has brought forw^ard striking
facts to illustrate this point.*
Now it is in limestone and sandstone districts especially that
we meet with deep and narrow valleys. At the foot of a great
mountain chain we generally find extensive deposits of these
rocks, the upper parts of the mountains being often composed
of granite, gneiss, and other crystalline rocks. Such is the
structure of the Alps. The mountain streams descending
rapidly from the higher levels will generally cut deep and
narrow valleys in the limestones and sandstones which they
meet, and thus are formed the typical valleys in which goitre is
most abundant. When the valleys occur among rocks which do
not readily allow of percolation and solution such as those in the
West of Norway there we find that goitre is not common in
them.
A vast amount of work has been done by those who have
laboured to trace a causal connection between goitre and
* " Observations on Goitre," 2>«w.s". M. and Pliyy. Sor. Calcutta, 1834, vii.
56 THE THYROID GLAND.
geology. That there is a more or less direct connection cannot,
I think, be denied. If a comparison be made of two maps of
Switzerland, one geological, the other showing the distribution
of goitre, it cannot fail to be observed that the area over which
goitre is most common corresponds roughly with the region of
that great deposit of sandstones, marls and limestones known as
the molasse. Further, it is especially upon the marine molasse
that the disease is seen to be most plentiful, although there
are also other deposits upon which it occurs. It is scarcely
possible to resist the conclusion that in Switzei'land at least,
there must be an intimate causal connection between goitre and
the geological nature of the soil upon which it is found, and
that the marine molasse is one at least of the geological formations
that give rise to goitre.
The conclusions arrived at by Bircher who has studied the
subject very carefully in Switzerland are as follows :
(1 ) Goitre occm's only upon marine deposits and especially
upon the marine sediments of the palaeozoic, triassic and tertiary
periods.
(2) Free from goitre are eruptive rocks, the crystalline rocks
of the Archaean group, the sediments of the Jurassic, cretaceous
and post-tertiary seas as well as all fresh water deposits.
With these conclusions I am on the whole disposed to agree,
although as far as England is concerned, it is not correct to
assert that Jurassic and cretaceous rocks are wholly free from
goitre. Endemic goitre does undoubtedly occur upon both
these formations, although somewhat sparselv, especiallv as far
as the chalk is concerned.
It may be well to point out that in investigating the relation
of geology to goitre, care should be taken to bear the following
facts in mind.
Geological formations are classified according to the period at
which they were formed and not necessarily accordingly to their
chemical composition or mineralogical structure. Hence two
rocks totally different in composition may bear the same
geological name. It would obviously be wrong to draw conclu-
sions from them respecting goitre, as if they were the same.
On the other hand sometimes even large formations such as
the chalk are tolerably uniform in composition and structure
ENDEMIC GOITRE. 57
over wide areas, and these are particularly well suited for
purposes of investigation.
Again, the occurrence or not of goitre upon a particular
formation depends not merely upon the formation but upon the
water supplying the people who live upon it. Thus a village
mav be seated upon soil not usually the seat of goitre and may
yet be affected with the disease. The converse is equally true ;
a village or town situated in a goitrous district upon rocks
usuallv associated with the disease mav remain exempt if it
derives its water supply from some distant source, from rocks
not associated with the disease.
Again, the drinking water supplying any particular village or
district may be derived from some verv deep seated source quite
unconnected with the rocks at the surface. In this case, if the
water be such as will produce goitre, it matters not in the least
whether the surface rocks are or are not those on which the
disease is usually found. Great care must therefore be taken
lest erroneous conclusions be drawn.*
The relation between geology and water supply is an exceed-
ingly complex subject and is especiallv complicated in our own
country in which so many different geological formations occur,
few of them occupving anv very extensive region. +
Geological and geographical distribution of goitre in England
and Wcdes.X
The extent to which goitre is associated wdth each of the
geological formations of England will now be briefly discussed.
The various geological formations will be taken in descending
order.
The tertiary rocks of England occur in two areas forming the
* I cannot lielp thinkinjj that some harm has been done by those, who,
without any practical knowledge of geology, have drawn hasty conclusions from
the simple comparison of surface geological maps, and maps showing distribu-
tion of goitre, wiithout taking sufficient care to consider whence the water
supply is derived.
7 The subject has been investigated by the Eivers Pollution Commission
fi'om whose sixth Eeport I have derived much valuable information. I am
also considerably indebted to De Eance's " Water-supply of England and Wales,"
Woodward's " Geology of England and Wales," and several other books on
similar subjects.
% The following account of the distribution, of goitre in these counti'ies does
not pretend to be complete : concerning many large areas I have at present no
information at all.
58 THE THYROID GLAND.
London and Hampshire basins. Taking the former first, the
disease occurs very sparingly over the Bagshot sands in some of
the villages between Aldershot and Chertsey, for example at
Windlesham, Bagshot and Pirbright. In Essex it does not
occur at Loughton or Chigwell, nor in the neighbourhoods of
Harwich, Colchester or Chelmsford.
In the Hampshire basin, it is said to occur at Romsey, but it
is certainly absent from the neighbourhoods of Lymington, Poole
and Bournemouth.
Over the extensive region of the chalk, goitre appears to
prevail to a very slight extent but tolerably uniformly. I have
found a few cases near Hatfield, Hitchin and Hadham in Hert-
fordshire, and at Luton in Bedfordshire, and I have been informed
that the disease occurs to a slight extent at villages in the north
of Essex (Sible Hedingham, AVethersfieid) and on the boi-ders of
Suffolk, especially in parts of the valley of the Stour (Cavendish
Melford, Sudbury and Xayland). It has been asserted that part
of Norfolk is affected. Some of the villages a few miles to the
west of Swaft'ham are however certainly not affected. I am
informed that goitre occurs also upon the chalk in the neighbour-
hood of Driffield in Yorkshire. In the villages situated upon
the chalk of the North Downs there is very little goitre and the
same may be said of those upon the South Downs. The chalk
is the source of such an abundant water supply that it is worth
while to draw attention to the rarity of goitre in connection
with it, especiaUy as some text-books even now assert that it is
especially prevalent in the " chalky parts of England.''
Coming next to the upper greensand and gault which under-
lie the chalk and come to the surface as a comparatively narrow
band, extending from Devonshire to Yorkshire and also skirting
the Weald district of Kent, Surrey and Sussex, we find that goitre
is rarely present upon either of these rocks. The lower green-
sand area, on the contrary, is one upon which I have found a
considerable amount of goitre. In the south of Bedfordshire it
forms the low sandy hills in the neighbourhood of Ampthill,
itself a known seat of the disease. I have seen cases at Aspley
Guise, Ridgmount and Woburn — all villages in this neighbour-
hood. Examination of the books of the Bedford Infirmary *
* Kindlv undertaken for me bv mv friend Dr. Skeldino; uf Bedford.
ENDEMIC GOITRE. 59
showed that a considerable proportion of the cases of goitre
treated there came from these villages and from others such as
Moulsoe, Eversholt, and Maulden, all similarly situated. I have
been unable to find any goitre in many of the villages situated
upon lower greensand in the south of Surrey, but it is said to
occur at Haslemere.
With regard to the Wealden area, goitre appears to be
tolerably common over the central and more hilly parts.
Several cases came under my notice at Cuckfield, and I have
heard of many others from other parts of the same area. I have
reasons for believing that the disease is distributed tolerably
uniformly, although not very thickly, over the whole of the
central (Hastings sand) area of the Weald. I have been told
that it is common at Horsham, but I have not personally
examined this district. Villages situated upon the Weald clay
appear to be slightly affected. I found several cases at Hadlow,
and in neighbouring villages. From a similar district further to
the east, a small number of cases have been reported to me. I
have made personal inquiries at most of the villages on the tract
of country extending from near Eastbourne to Steyning, immedi-
ately north of the South Downs. These villages are situated
upon greensands, gault and Weald clay. I saw no cases of
goitre and heard of only an occasional one here and there.
Those of the inhabitants who knew what ffoitre was ao-reed in
saying it was much commoner further north in the Hastings
sands area.
Underlying the cretaceous strata, and appearing on the
surface in this country to the west and to the north-west of these
rocks, comes the great series of the oolites. It has been stated
by most of those who have written upon the subject of the
distribution of goitre in England that goitre does not occur
upo7i the oolites, except at Helmsley in Yorkshire. ]\ly own
experience does not lead me to endorse this statement. I have
on the contrary found that goitre is tolei'ably common upon
certain members of the oolite series, and is especially frequent
in the villages situated just at the junction of the oolites with
the lias.
In Somersetshire it is prevalent at Chinnocks, Stoke-under-
Ham, and Chiselborough ; the latter village has long been noted
60 THE THYROID GLAND.
as a seat of cretinism. Further north I have found it at Corton
Denhani and neighbouring vdlages. It is said to be common at
^Vootou-under-Edge in Gloucestershire. I have seen many
cases at and near Stroud,* and in many of the villages situated on
the oolites to the east of Cheltenham. Still further east I found
that in many of the villages round Xorthleach,* as well as in
Northleach itself, the disease was common. In Yorkshire it is
known to occur at Helmsley and I have been informed that it is
found also in several villages to the east of Easingwold. I have
seen a few cases near Malton.
The next formation that we have to consider is the lias. The
upper members of this series he immediately mider the oolites,
and goitre occurs in numerous villages alreadv mentioned, just
at the junction of the two formations, being most common
apparently upon the sands that are now considered to be the
lowest members of the oolites.-*- Upon the middle lias, the
disease, so far as mv observations extend, is less common.
I have found a few scattered cases to the west of Chiselborough
and Stoke-under-Ham.
In the south of Northamptonshire and the neighbouring parts
of Warwickshire, m districts where the oolites are absent, I have
nevertheless found a considerable amount of goitre. The village
of Chacombe, where goitre is decidedly prevalent, rests upon
marlstone (middle lias). The Warwickshire villages of Warm-
ingtou and Avon Dassett, where the disease prevails to a slight
extent, are situated at the foot of hills of similar rock. !My
friend Dr. Bernard Rice has kindly examined the outpatient
books of the Wharncliffe Hospital in that town, in order to
ascertain the distribution of the disease in that neighbourhood.
He found that out of twentv-two cases that had come from
surrounding villages, no i'ewer than eighteen came from the
liassic district to the east and south-east of Leamington. On
the other side of the town is the new red sandstone, and only
four cases came from this district. A village in which the dis-
ease appears to be especially prevalent is Napton, situated at the
* Two of the patients upon whom I have operated for goitre had always lived
within a few miles of Stroud and a third came from the neighbourhood of
Xorthleach.
t H. B. "Woodward, " Geology of England and Wales," 1887, p. 287.
ENDEMIC GOITRE. 6l
foot of a hill of marlstone, underlaid and surrounded by lower
lias clay and limestone.
So far as I can j udge, this district appears to be fairly typical
of the distribution of goitre upon the lower lias. The disease is
either absent altogether or is thinly diffused over it. It must
not be forgotten, however, that in many parts of England, as
for example in the neighbourhood of Cheltenham, the lias is
thickly overlaid with drift oolite, not marked upon an ordinary
geological map. The water supply in such regions is frequently
derived from shallow wells in this drift and not from the lias
at all.
Upon the triassic division of the new red sandstone, goitre
appeal's to occur very sparingly if at all. At West bury -upon -
Severn, situated upon this rock near the lias, I could not hear of
any. From the region of the triassic rocks of South Derbyshire,
it appears to be almost absent — at least such is the case at
Findern, Newton Solney, Foremark and Repton, according to
information supplied to me by Dr. Cronk and from personal
inquiries made in this district.
Its scarcity upon the trias to the west of Leamington has
already been mentioned. Over the large area in which this rock
comes to the surface in Nottinghamshire, the disease appears to
occur but rarely.
The lower division of the new red sandstone is the Permian,
often known as the magnesian limestone because a large pro-
portion of its rocks is composed of that material. It occurs in
this country chiefly as a narrow band extending from North-
umberland to Nottingham shire.
It has long been a favourite belief that magnesian limestone
is especially associated with goitre, but I doubt whether there
is much truth in this. In part of the magnesian limestone
area of Nottinghamshire I found goitre to be distinctly rare.
In other parts it appears to be less common than upon the
carboniferous limestone. It is said to be common in the
neighbourhood of Knaresborough, in Yorkshire. I ought to
mention that the term " magnesian limestone" is used ffeolooi-
cally, to denote a large series of marls, sandstones, and lime-
stones, and that it consists by no means wholly of magnesian
limestone in the chemical or mineralogical sense of the word.
62 THE THYROID GLAND.
Magnesian limestone — using the terin in the latter sense — is
found in other rocks besides those of the Permian series.
The next series of rocks that engages our attention is the
carboniferous. At the top of this series come the coal measures,
and upon them goitre appears to occur to a moderate extent. The
counties best known to me in which this foruiation occurs are
Derbyshire and Yorkshire, and in both of them I found that
goitre was fairly common upon the coal measures. I have also
foLuid it near Llanelly in Glamorganshire. The millstone grit,
on the contrary, appears to be much more free from the disease.
I have been informed that at Ilk ley goitre does not occur in
places upon, or supplied by water from this formation, whereas
on the carboniferous limestone not far away, the disease is not
uncommon.
At the Saltaire Hospital in one year, out of 780 patients
applying for treatment only four did so on account of goitre.
At Chapel-en-le-Frith, in Derbyshire, I was informed that
cases of goitre were more often seen in the districts to the south-
east of the town, where the carboniferous limestone prevails,
than in other districts where millstone grit and Yoredale rocks
are found. I was also told that since the introduction of a new
water supply from the millstone grit goitre has become less
common.
It has been stated that goitre is common in the Peak district
of Derbyshire, where the rocks consist chiefly of millstone grit
and Yoredale rocks (grits, sandstones and shales with thin earthy
limestones). Upon inquiry at Castleton, upon the southern
edge of this district, I was assured that goitre was much less
prevalent in the Peak district than on the carboniferous lime-
stones further south. The millstone grit formation is the source
of water supply to so many of the towns in the north of England
that the absence of goitre from it becomes a matter of consider-
able importance.
The carboniferous limestone regions of England have been
described as a very hotbed of goitre, and I am inclined to believe
that this is a tolerably accurate statement. Over the whole of
this area in Derbyshire, but especially along the eastern border
of it, I found numerous cases, for example, in the neighbourhoods
of Cromford, Matlock, Youlgreave, Bakewell, Baslow, and Stony
ENDEMIC GOITRE. 63
Middleton. The same may be said of the region on the north
side of Ashbourne, and I am told that the disease is also common
over the similar districts in the east of Staffordshire.
In Somersetshire it occurs, I am informed, upon this forma-
tion at Clevedon, and I have heard of a number of cases upon
various parts of the carboniferous limestone of the Mendip Hills.
In Northumberland, on the other hand, it appears to be less
common, but it is worth noticing that, in the north of England,
this formation loses its markedly calcareous character and is
represented largely by sandstones and shales. In the Forest of
Dean goitre is said to be common, but I do not know whether
upon the carboniferous limestone or upon the other rocks of this
region.
With regard to the occurrence of goitre upon Devonian and.
old red sandstone rocks, my information is chiefly of a negative
character, but such information as I have tends to show that the
disease occurs but rarely upon either of them. At Ilfracombe
and probably over the north of Devonshire generally, goitre does
not occur. The same may be said of the western extremity of
Somersetshire. I am informed also that in the neighbourhood
of Talgarth, in Brecknockshire, the disease is not prevalent.
Of the Silurian and Cambrian and pre-Cambrian rocks which
form so large a portion of Wales, I have scarcely any practical
knowledge, and consequently cannot say much about the occur-
rence or otherwise of goitre upon them. The little information
I have obtained, how^ever, tends to show that here also goitre is
rare. In Anglesea, for example, I am informed that goitre does
not occur at all in the north-west portion in the neighbourhood
of Amlwch, and is probably absent from the whole island. With
regard to granite and other igneous rocks, I believe that they
are free from goitre ; at least, I have never heard of any goitre
upon them, and those districts of them that I have been able to
examine, such as Widdicombe on Dartmoor, are quite devoid
of the disease.
From the foregoing it will be seen that goitre is distributed
over a very large surface of this country. Its coincidence every-
where with calcareous rocks, which are also very widely dis-
tributed in England, is one of the most marked features of its
distribution. It is not only upon limestone but also upon
64 THE THYROID GLAND.
calcareous sandstones that goitre is found. ^Vhether it ever
occurs as an endemic disease upon non-calcareous rocks is at least
doubtful. The igneous, metamorphic, Cambrian, Silurian,
Devonian, Yoredale, and millstone grit rocks, and some of the
non-calcareous parts of the coal measures and tertiaries, appear
to be mainly free from the disease.
Now, speaking generally, the water derived from these rocks,
whether it be upland surface water or spring water, or deep well
water, differs considerably from water derived from most of the
other rocks in containing a smaller quantity of mineral matter
and in being less hard. Of eighty-one samples of upland surface
water derived from metamorphic, Cambrian, Silurian and
Devonian rocks, the Rivers Pollution Commission found that
the average total solid impurity was only 5.12 parts per 100,000
(or 3^ grains per gallon). The average hardness was only 2 5.
Water from the Yoredale, millstone grit and non-calcareous
portions of the coal measures and tertiary rocks, although con-
taining rather more total solid impurity than water from the
preceding, is nevertheless on the whole fairly soft, and contains
rather less total solid impurity than that from the more
calcareous rocks.
That there is a general connection between goitre and the
amount of mineral matter in the drinking-water, and its hard-
ness, there seems good reason to believe. But that many
waters contain a large amount of such mineral matter, and are
very hard, and yet do not produce goitre, seems also to be true.
Conversely, I believe that in a few instances I have found
that a goitre-producing water was not particularly hard. Thus
in one of the Derbyshire villages I found that a water which
apparently produced goitre had not more than H" of
hardness.
But it is probable that goitre-producing waters always contain
a large amount of total solid impurity, although the impurity
may not necessarily be such as to render the water very hard.
This statement appears to be, on the whole, confirmed by
published analyses of goitriferous waters in Switzerland and
France.
As the chief hardening ingi'edients of water are bicarbonates
and sulphates of lime and magnesia, it is not unnatural that
ENDEMIC GOITRE. 65
these salts should have been considered to be the cause of goitre.
But examination of numerous water analyses have failed to con-
firm these theories.
Another ingredient which is by many belie^■ed to be the
essential cause of goitre is iron.
This view has received the strong support of St. Lager, whose
elaborate researches compel one to receive with much respect
any opinion that he has expressed. At first sight the occurrence
of goitre upon many ferruginous sands, such as those of the
lower greensand, the Weald, and part of the oolite districts,
lends support to this view. But, on the other hand, I examined
in Derbyshire numerous samples of water which undoubtedly
produced goitre ; in the majority of these no iron \\hatever wrs
found, in others onlv the faintest possible trace. Other
observers, too, have tested for iron, with similar negative
results.
It should be remembered that in drawing conclusions as to
the cause or otherwise of goitre bv iron, care should be taken
not to pay too much attention to the mere presence or absence
of this metal in the rocks upon which goitre is found. A rock
may abound in a particular metal, but it does not follow that
the water percolating that rock will contain any of the metal,
unless the latter happen to exist in a soluble form, which is
often not the case.
As regards metallic impurities other than iron, but more or
less allied to it chemically, it is not impossible that one or more
of them may be found to be the essential cause of goitre, but
proof of this is quite wanting ; on the contrary the evidence we
possess tends to point in the opposite direction.
The suggestion that the cause of goitre may be some organic
impurity of water has, within the last few years especially,
attracted a good deal of attention, and received a certain
amount of support.
Professor Klebs* has examined microscopically the water
taken from springs in goitrous districts of Salzburg and
Bohemia, and has apparently found in it numerous micro-organ-
isms, chiefly Infusoria. He believes that certain forms called
* E. Klebs, •• Ueber die Ursache des Kropfes," Ffa/j. ined. Woclienscltr., 1877,
ii. 45.
66 THE THYROID GLAND.
navicuUt are the essential cause of goitre. Bircher, following
Klebs, has made microscopical examinations of the water derived
from different geolog-ical formations in the neighbourhood of
Aarau. He examined waters from springs in the molasse, Jurassic,
triassic, and crystalline rocks, and found various forms of
diatoms in them. But they were not found equally in all the
waters. Some of them occurred only in waters from a particular
formation. Thus in waters from granitic areas, and from the
Jurassic and upper fresh water molasse, he found meridion to be
extremely plentiful. But in water derived from the trias and
from marine molasse, it was absent, or nearly so. On the other
hand, eucyonema w^as found abundantly in waters from the
formations on which goitre prevails, while it was absent from
those from the Jurassic and granitic areas, which are free from
the disease. Bircher expressly states that he does not maintain
that any of these organisms are necessarily the cause of goitre.
He simply relates the fact that different kinds of diatoms w^ere
found in waters derived from different geological formations.
Besides the above-mentioned forms of diatom, Bircher
describes a form of rod shaped micro-organism that he found in
waters from goitrous districts, but not in waters taken from
regions in which the disease is not prevalent. He found them
in the waters of Asp, Oeschgen, Eiken, Mumpf and Habsburg
on the trias ; also in those of Buchs, Aarau, Gri'michen, Suhr,
and Brugg on marine molasse : thev were most numerous in two
springs at Buchs(close to Aarau); here goitre is extremely common.
Bircher has searched, without success, for these rod-shaped bodies
in the contents of two goitrous cysts in young people.
That goitre can be produced by water has, I think, been
shown by experiments that have accidentally been carried out on
a large scale upon man himself. I refer to the outbreaks of
so-called epidemic goitre that have been so often recorded. For
example, a regiment of young soldiers has been quartered in a
village, and after a few months, or even weeks, a very large
proportion of the men have become goitrous. A town or
village has received a new water supply, and shortly afterwards
goitre has broken out in a large number of the inhabitants.
Conversely, a village affected with goitre has changed its water
supply, and goitre has ceased to occur. On the continent there
ENDEMIC GOITRE. 67
are noted goitre wells to which young men resort who wish to
obtain exemption from military service. After drinking the
water from these wells for a few weeks, they acquire goitres
sufficiently large to enable them to obtain their wish.* Bircher f
mentions several springs near Aarau which have a local reputa-
tion for producing goitre in those who drink of their waters.
One of these is at the village of Asp ; another is at Buren. At
the latter place five children in one family who drank from this
spring all became affected with goitre.
In districbs where goitre is common, not only man himself
but also many of the lower animals become affected with the
disease. It has been observed in dogs, cats, horses, cows, pigs,
sheep, goats, antelopes, camels and many other animals.
Cretinism, too, Avhich always exists Avhere goitre is prevalent,
has been noticed among some of the lower animals.
Various attempts have been made to produce goitre artificially
in the lower animals.
More than thirty years ago, St. Lager carried out a series of
experiments in this direction. He began by feeding two dogs
with sulphate of lime and carbonate of magnesia ; this experi-
ment was carried on for six months with a negative result. His
next series of experiments was upon guinea-pigs, which he fed
for several months with salts of various metals mixed with the
animals'' ordinary food. He does not state exactly what salts
were used, but the results were negative. He then tried feeding
mice with metallic sulphides and sulphates ; after three months,
slight swelling of the thyroid was noticed in three of them ;
these three had been fed upon sulphide and sulphate of iron.
Encouraged by this apparent success, he tried sulphate of iron
again upon a dog, giving several centigrammes a day. At the
end of four months, he thought that the thyroid had increased
in size, but says that it was not prominent enough to deserve
the name of goitre. St. Lager alludes to other experiments
which had been performed by Bouchardat, with lime and mag-
nesia, and by Maumene with fluoride of sodium, but in neither
case with any marked success.
* Further details upon this subject may be found in the elaborate treatises of
St. Lager, Baillarger, Nivet, Hirsch, Bircher and others.
J 0]). clt. p. 128.
68 THE THYROID GLAND.
Bircher experimented upon five puppies three months old,
feeding them upon condensed milk diluted with water taken
from the spring in which Bircher found his characteristic micro-
organisms. At the end of five months, the animals were killed
and it was found that their thyroids had not undergone any
enlargement.
Another series of experiments was carried on in 1890, for
nine months, by my brother, Mr. Edward E. Berry, F.C.S., and
myself. We took four sets of guinea-pigs. To the first set we
gave a mixture of various salts of lime, magnesia, potash, and
soda ; the salts chosen were those obtained by the analysis of
waters from two districts in Auvergne where nineteen and ten
per cent, respectively of the male popidation are afi'ected with
goitre. To the second set we gave sulphate of lime only ; to the
third carbonate of iron in the form of saccharated carbonate.
The fourth set formed simply a control series of experiments
and received nothing but their ordinary food and drink. The
animals were all weighed accurately every few weeks, and the
doses of salts regulated in proportion to the weights of the
animals. After death each thyroid gland was weighed accurately
and subsequently examined microscopically. The results were
entirely negative as far as the production of goitre is concerned,
but they tend at least to show that neither sulphate nor carbonate
of lime, nor carbonate of magnesia, nor carbonate of iron is
capable of producing goitre in guinea-pigs.*
Lustig and Carle have published some interesting and careful
experiments upon the artificial production of goitre in the lower
animals.f They made use of water from certain infected parts of
the valley of Aosta in North Italy. The subjects of the experiments
were a young horse and several dogs. The horse after drinking
for several weeks water suspected of being capable of producing
goitre, developed a slowly progressive and perfectly evident
swelling of one thyroid. This was removed by operation and
the experiment with water was continued. After some weeks
the remaining thyroid became still larger. After the adminis-
* Fui'tlier details of these experiments will be found in the Brlt'isli Medical
Jovrnal for June 13, 1891.
t " Sull .■Mi()log;ia del gozzo endemico." Lustig e Carle, 6-'/('r«. d. R. Accad.d.
med. dl Tormo, 1890, p. 689-717.
ENDEMIC GOITRE. 69
tration of this water bad ceased, the size of the thyroid gradually
diminished until eventually the swelling could no longer be felt.
Thirteen dogs, mostly young, were given water from the
Buthier stream, a suspected source of goitre. In one of these
and perhaps in another, some swelling of the thyroid was
produced. From the first of these animals the enlarged left
thyroid was then removed and the experiment continued. A
month later the right thyroid was visibly enlarged. The ad-
ministration of natural Buthier water was then discontinued
and the same water freed from bacteria was given instead. The
result was that the swelling gradually diminished and finally
became imperceptible. In some of the thirteen animals, swelling
of the lymphatic glands was noticed and in some of them diarrhoea
occurred.
Ten young and healthy dogs treated solely with Buthier
water, boiled and filtered, did not show any alteration in their
thp'oids, A young puppy born in an infected region, and the
subject of a considerable goitre, was removed to a region free
from the disease. Water supposed to be capable of producing
goitre was given to it and the goitre became larger ; the ad-
ministration was discontinued in favour of filtered water and the
goitre disappeared completely.
These experiments, if confirmed, tend to prove that goitre
can be produced artificially by the administration of certain
waters. Further, boiling and filtration seem to deprive the
water of its goitre-producing elements.
Further experiments in the same direction and upon a larger
number of animals are however necessary before they can be
considered conclusive. The authors themselves seem fully aware
of this and speak with praiseworthy hesitation.
Dr. Grasset ''•' has recently stated that the cause of goitre is to
be found in certain hsematozoa which he has found in the blood
of patients recently affected with the disease. This micro-
organism is said to resemble Lavaran's ha?matozoon found in
ague, but differs from it in certain minor details. Grasset's
observations are interesting but require confirmation.
(4) Habits of Life, Exertion, Strain, etc. — A popular theory
attributes goitre to violent muscular exertion such as carrying
* La France Medicale, .July IS, 1898, and Glasgow Medical JuurnaJ. Jau. 1899.
70 THE THYROID GLAND.
weights on the head, straining, couohing, and blowing wind
instruments. It is at least doul)tful whether any of these
habits ever cause enlargement of a previously healthy gland.
The habit of carrying weights on the head is common in
many countries where goitre exists and also in many Avhere it
does not. The disease frequently shows itself in quite young
children who have never can'ied upon their heads anything
heavier than a hat. I have several times examined large numbers
of school children in affected districts* and found a considerable
proportion of them affected with the disease. The occurrence
of the disease in the lower animals is another proof that carrying
weights on the head is not the cause of goitre.
It is possible that although muscular exertion does not itself
produce goitre it may aggravate the disease. A thyroid gland
already somewhat enlarged may be injuriously pressed upon by
^■iolent action of the muscles of the neck. In this manner
extravasations of blood within the gland may be produced and
cysts may be formed. Nearly all very large goitres contain
cysts, and it is possible that some of them may have originated
in the manner described.
Intermarriage as a cause of goitre is hardly worthy of serious
discussion. Intermarriage is doubtless common in many isolated
villages where goitre abounds but is equally noticeable in many
similar villages where the disease is quite unknown.
(5) Heredity is supposed by many to play an important part
in the causation of goitre. Undoubtedly goitre is often found
to occur in many members of one family. Numerous instances
in which every member of a family was affected with goitre
have been found by myself both in Switzerland and in this
country ; also many instances of goitre existing for generations
in the same family.
But such facts, however numerous they may be, do not afford
proof that mere heredity is in anv way responsible for the
disease. There is good reason to believe that the cause that
produced the disease in one member of a family caused it in
all the others. It is well knoMU that the apparent heredity
of goitre is most marked in places where the endemicity is
highest.
* e.fj., at Triora in X. Italy, and at Clii.selboroii2:li in Somersetshire.
ENDEMIC GOITRE. 71
In order to place beyond dispute the hereditary nature of
goitre, it must be shown that the goitre in the child is not due
to the influence of the same exciting causes that produced it in
the parent. It is obvious that so long as we are in doubt as to
the exact nature of the goitre-producing poison, so long will it
be difficult to prove definitely that the disease is cr is not
hereditary. Nevertheless the evidence that we at present possess
tends to show that heredity ought not to be considered as one
of the probable causes of goitre. Although mere heredity
cannot be considered to be a cause of goitre, it is conceivable
that some hereditary tendency may render a person more suscep-
tible to the influence of the goitre-producing poison, but there
is little or no evidence of this.
Summing up, there can be no doubt that climatic and atmo-
spheric conditions have little or no share in the causation of
goitre. That want of air and sunshine has absolutely nothing
whatever to do with it is equally certain. Habits, such as
carrying weights on the head, violent exertion and the like, play
but a secondary part in the production of the disease. That
heredity is a cause of goitre is extremely doubtful. Interniarriaice
has certainly no share in its causation.
That there exists some definite relation between endemic
goitre and some poison in the soil upon which it is found is
tolerably clear, and there can be no doubt that in the vast
majority of cases drinking water is the vehicle by means of
which that poison obtains access to the body. Such water is
usually, if not always, derived from calcareous soils, but it is
probable that the goitre-producing poison is not a salt of lime
or magnesia. It has not yet been proved satisfactorily that any
sail of iron is the essential constituent. The same mav be s;iid
of micro-oru;anisms.
CHAPTER VI.
SYxMPTOMS AND DIAGNOSIS OF THYROID ENLARGE-
MENTS—PHYSICAL SIGNS.
Mobility — Shape — Size — Position with regard to muscles, great vessels,
sternum — Pulsation — Diagnosis from aneurism — Consistence —
Pressure effects, on veins, recurrent laryngeal nerve, sympathetic,
cervical and brachial plexuses, larynx and trachea, oesophagus and
pharynx.
The thyroid gland may be the seat of various diseases, each of
which has some chai'acters peculiar to itself. There are many
characters, however, which are more or less common to all forms
of enlargement of this organ.
These will be discussed in this and in the following;
chapter.
In most cases it is not a difficult matter to determine whether
a given swelling in the neck does or does not belong to the
thyroid. Occasionally, however, the most marked characteristics
of a thyroid swelling are absent, or are closely simulated by other
conditions, and thus mistakes may occur.
The diagnosis of an enlargement of the thyroid is made partly
by examination of the physical signs of the swelling itself and
partly by the pressure effects which it exerts upon surrounding
structures. To a very small extent the effect of the disease
upon the function of the gland may produce signs and symptoms
which are of some help in diagnosis.
Physical Signs. — Among these we have to consider, (1)
Mobility; (2) Shape ; (3) Size; (4) Position ; (5) Pulsation ; (6)
Consistence.
(1) Mobility. — Owing to the close connection already described
which exists between the larynx and the thyroid gland, the
latter follows the former in all its movements. Hence one of the
SYMPTOMS AND DIAGNOSIS. 73
most important signs of a thyroid tumour is that if rises and
falls loitli the larynx and trachea during deglutition.
In the great majority of cases the presence of this sign alone
is sufficient to enable us to form a correct diagnosis of the thyroid
nature of the swelling under examination. Care must be taken,
however, not to rely too implicitly in all cases upon this sign
only. For there are two sources of fallacy with regard to it,
that may lead to mistakes.
In the first place a swelling which is not of thyroid origin
may present the above sign ; and in the second place one which
is really thyroid may not present it.
The cases which come into the former category are fortunately
rare ; and most of them are generally easily distinguished,
because the tumour will be found not to occupy exactly the same
situation as a tumour of the thyroid.
Such are cysts of the subhvoidean region which lie in the
middle line on a level with the upper border of the thyroid
cartilage. It is possible that a very large cyst of this kind might
be mistaken for a tumour of the upper horn, or of the pyramid
of the thyroid, but its high situation in the middle line would
almost invariably be quite enough to distinguish it.*
In 1893 I saw with Mr. Bowlby at St. Bartholomew's Hospital
a man who had a rounded prominent swelling covering the whole
of the front of the thyroid cartilage and firmly fixed to it. It
was almost exactly in the middle line, and at first sight closely
resembled a subhyoidean bursa. A careful examination, how-
ever, showed that it was connected with the left lobe of the
thyroid gland.
Tumours, both innocent and malignant, spi'inging from the
larynx or trachea and growing outwards, may occasionally
simulate swellings of the thyroid gland. They are, however,
rare.
Mr. Percy Furnivall has kindly given me notes of the follow-
ing case that came under his notice in 1893 :
'' A gentleman aged 55 had had for thirteen years a swelling on
the right side of the neck. In 1887 he had seen Sir Morell
Mackenzie, who wished to aspirate and inject it. Later he was
* See a paper by Larrey, Gaz. d. Hoj)., 1853, pp. 212. 22.5.
74 THE THYROID GLAND.
seen by another surgeon who also considered that it was • probably
a thyroid cyst.' On the right side of the neck, close to the middle
line, was a sausage-shaped swelling, situated partly under the
sterno-mastoid at its lower end. The upper part lay between that
muscle and the middle line and extended nearly up to the lower
jaw. It was well defined, very soft and elastic, and apparently
fluctuated. // mored distinctly with the larynx on deglutition. It was
removed by operation and was found to be a lipoma attached to the
side of the thyroid cartilage."
Several cases have come under my own notice in which malig-
nant growths springing from the lower end of the pharynx and
upper end of the oesophagus were verv difficult to distinguish
from growths in the thyroid gland itself.
Tracheal hernia is said by Norris Wolfenden and others to
simulate bronchocele very closely.
Dr. Wolfenden * has given an account of three cases supposed
to be of this nature, and remarks that " the practitioner is not
likelv to recoo-nise the true state of affairs unless he has caused
the patient to voluntarily distend the tumour."
On the other hand it should be remembered that some goitres
are visible onlv when the patient makes an expiratory effort.
Both Wolfler and myself have had to operate upon such cases. I
am disposed to agree with Wolfler, who is sceptical about the
existence of tracheal hernia resembling goitre. He states t that
one of Wolfenden's cases was subsequentlv pro^■ed by operation
to be a true goitre and not a tracheal hernia.
Necrosis of a portion of one of the laryngeal cartilages may
cause an abscess which sometimes can scarcely he distinguished
from a cyst, suppurating or not, of the thyroid gland.
Kohn I has recorded a remarkable instance of such a case :
" A woman had, in the region of the right lobe of the thyroid
gland, a swelling which was taken to be a chronic abscess of that
organ. But after evacuation of the pus it was found that the
* Jvurnal'Of Laryngology, 1888, p. 99. See also a long and very complete
paper on the same subject by Dr. J. H. Petit in Reviie lie CItlnirgie, Paris,
February, March, May and June 1889.
f " Die chirm'gische Behandlung des Kropfes," Berlin, 1890, ii. p. 2.
X " Ceber Strumitis und ThjToiditis," Allgem. Wien. 3Ied, Ze'itung. 1885,
p. 215.
■ SYMPTOMS AND DIAGNOSIS. 75
abscess was due to necrosis of one of the laryngeal cartilages and
was wholly unconnected with the thyroid gland." *
Various swellings having their origin in tissues external to the
larynx and trachea may become adherent to them secondarily
and so participate in their movements. Such are affections of
the cervical lymphatic glands. Some years ago while dissecting
out a thyroid gland from a dead body in the post-mortem
room of St. Bartholomew's Hospital, I came upon an oval swell-
ing, close to the lower part of the right lobe ; at first sight this
appeared to be an abscess in the thyroid gland. It was firmly
connected with the trachea and the recurrent laryngeal nerve
was spread out over it. There can be no doubt that, had it
been detected during life, it would have been found to follow
the trachea in all its movements, and it would almost certainly
have been taken for a thyroid swelling. It was, however, simply
a chronic abscess that had originated in one of the cervical lym-
phatic glands.
In 1895 I saw a patient of ]\Ir. Bowlby's, a young man with a
mass of enlarged tuberculous glands adherent to the side of the
larynx ; the resemblance to a tumour of the thyroid was con-
siderable.
In St. George's Hospital ^Museum is a specimen of a sebaceous
cyst situated immediately in front of the larynx.-*" During life
it had been mistaken for a cyst of the thyroid, and had been
injected with perchloride of iron with a fatal result.
I have seen one case in which a dermoid cyst lay immediately
in front of the larynx and followed its movements during deglu-
tition.
We come now to the second class of cases, those that fail to
move with the lar^^nx during deglutition although they are of
thyroidal origin.
This may occur, first, when the bulk of the tumour is so great
as either to conceal or to mechanically prevent the movements of
the larynx and trachea ; and, secondly, when the tumour is pre-
vented from moving by reason of its adhesions to neighbouring
* A somewhat similar case came under my own notice some years ago ; this
was one in which a swelling caused by perichondritis of the thyi'oid cartilage
had been mistaken by the surgeon for tumour of the thjToid gland.
f New Catalogue Xo. 2lA.
76* THE THYROID GLAND.
parts. Malignant disease and inflammation are the most common
causes of such adhesion.
In the case of the patient depicted in Fig-. 82 deglutition
failed to make the huge tumour rise as a whole. It did cause,
however, what is an almost equally valuable sign, namely a
peculiar shake felt in the tumour. The tumoiu" was tilted
forwards each time that the larynx, to which it was attached
posteriorly, attempted to rise.
In cases then of large tumours that do not rise with the
larynx during deglutition attention should be directed to the
shaking or tilting caused by this action.
Malignant tumours in their later stages frequently become
quite fixed. I have seen several cases both in my own practice
and in that of others, in which such tumours were firmly fixed to
the vertebral colunm.
In September 1885, by the kindness of Dr. Reece, then acting
as one of the medical officers at the Kensington Infirmary, I had
the opportunity of examining a case of what we, at first, sup-
posed to be a tumour of the thyroid gland. The patient was
an elderly woman who had a hard oval mass, of the size and
shape of a goose's egg, apparently exactly in the position of
the right lobe of this gland. It extended from near the middle
line of the neck to beyond the outer border of the sterno-
niastoid. It touched the larynx and trachea when these were
in their natural position, but it was found possible to push
them considerably to the left of the middle line without dis-
placing the tumour. Indeed a finger could be laid in the groove
thus produced between them. The tumour did not appear to
move during deglutition. For these two reasons, then, it was
concluded that the tumour was not of the thyroid gland. No
operation was deemed advisable. A few days later the patient
died, and on making a post-mortem examination, it was found
that the tumour was a mass of malignant growth (probably
starting in a lymphatic gland), secondary to disease of the
mediastinum. The thyroid gland itself was small and had
been flattened between the larynx and the growth. The latter
had displaced the carotid artery and internal jugular vein to
the outer side.
It should be remembered, therefore, that a movable tumour
SYMPTOMS AND DIAGNOSIS. 77
of the thyroid gland ought to follow, not only the vertical but
also the lateral movements of the larynx and trachea.
Large masses of malignant growth may be found in the neck
Avhich are adherent to the larynx and trachea and surrounding
parts. Occasionallv in such cases, it may be difficult to say
whether the growth is primarily of the thyroid gland.
Figs. 34, 35 and 36. — A large Bilateral Parenchymatous Goitre.
The rig-ht and central lobes were removed by extirpation from a
woman aged 52. {See Fig. 37.) The tumour removed weighed 3 lbs.
1 oz., and is now in the Eoy. Free Hosp. Museum, Xo. xxii. 19. (See
also Appendix, Case 119, p. 352.) (From pbotogTaplis by Dr. Image.)
A few years ago I had a case in the Roval Free Hospital
illustrating this point. A small child had a large mass of
lympho-sarcoma in the left side of the neck. The larynx and
trachea were displaced to the right and so much buried in the
tumour that it was difficult to ascertain Avhether they moved on
deglutition or not. The tumour might easily have been mis-
taken for a sarcoma of the thyroid gland.
78
THE THYROID GLAND.
W. Osier has recorded a case of lympho-sarconia of the deep
cervical o^lands, involving- the thyroid and simulating goitre.*
Wolflerf records a case in which a tumour of the right lobe
of the thyroid was mistaken by Professor Billroth for a lym-
phoma. It was not until the operation for its removal was being
performed, that the thyroidal nature of the tumour was dis-
covered. In the notes of this case it is stated that there were
Fio. 3o. — For ik'scription si'u pp. 7 7 ami 352.
two tumours, each nearlv as large as a goose's egg, and they
were onlv slightlv movable. It was probably the absence of the
usual mobility of a thyroid tumour that led to the error in
diagnosis.
We will now consider some of the other less important signs
and endeavour to ascertain their value from a diagnostic point
of view.
* JTuntrcal Gen. Hn.y). Bep. 1880, i. 340.
J '• Uebei-der Entwickelung und den Ban des Kropfe.s." Anton Wolfler, Arrh.
f. Jdln. C/iir., Berlin, 1883, vol. xxix. p. 788.
SYMPTOMS AND DIAGNOSIS. 79
The shape of an enlarged thyroid may be very characteristic
or, on the other hand, it may have no diagnostic value what-
ever. When the gland is enlarged uniformly as, for example,
in the early stage of the simple parenchymatous form of goitre
it presents an appearance similar in shape to that of the normal
thyroid gland. Allusion has already been made to the resem-
blance which the latter bears to a horseshoe, with concavity
Fig. 36. — For ilescviptiou see pp. 77 and 352.
upwards. But every deviation from this normal typical shape
may be met with when the gland is enlarged asymmetrically,
by the formation of a tumour or tumours within it. A portion
only of the gland may be enlarged and the resulting tumour
will then probably present a more or less round or oval
shape.
The size of a thvroid tumour may be very great ; it may even
attain that of a man's head.
It is probably among the cases of cystic disease that the
80 THE THYROID GLAND.
largest goitres are to be found. Alibert\s cases* are among the
largest with which I am ac(|uainted. Keser f describes a goitre
removed by Professor Socin at Basle ; it was as large as a man's
head, and came down in front of the sternum to below the level
of the xiphoid process.
The largest goitres which have come under my own notice
during life, are represented in Figs. 34, 39, 46 and 82.
Fig. 37. — The pi-ccetliiig, two moiitlis aftci- Extirpation of tlio wliole of
tlie right and middle lobes. (See Appendix, Casell9, p. 352.) (From a
photograph by Dr. Image. )
The degree of prominence also varies considerably. Some
tumours present scarcely any external swelling, others form huge
projecting masses which may be more or less pedunculated, and
may even hang down over the front of the chest for a consider-
able distance. Instances of huge goitres, extending as far
* " Nosologic Xaturelle," Paris, 1817, i.
f Samuel Keser, " L'enucleation ou extirpation inti-a-glandulaire du goitre
parenchymateux,"' Paris, 1887, p. 20.
SYMPTOMS AND DIAGNOSIS.
SI
downwards as the waist have been figured bv Alibert.* In oiie
of these, the tumour is curiously elongated and narrow, and
unlike any other that has yet come before my notice. ••■
Position. — The position of a thyroid swelling naturally differs
according to the part of the gland involved.
The swellino; may be in the middle line of the neck. This is
Fig. 38. — A "Woman, aged 38, yritli a Bilateral Goitre. Tlie right lobe,
wliicli contained a solid adenoma weighing- 7j ounces, estended deeply
behind the sternum and right clavicle, and was extirpated on account
of severe dvspnoe:!. (See Appendix, Case .50, p. 346.)
the case when the enlargement affects either the isthmus alone
(which is exceedingly rare), or the whole gland, including the
isthmus.
* Alibert, " Xosologie Xaturelle," i. p. 466, Plates C aud D.
t The same author also alludes to, but does not figure, a case in which the
tumour was cylindrical and tapering and reached as far down as the middle of
the thigh. " Formee comme un long cylindre qui seprolougeoit jusiiu'a la paitie
nioyenne de la cuisse." — " Xosologie Xaturelle,"' p. 468.
F
82
THE THYROID GLAND.
^ 3. 3
" "3 ~
5 2 d Ji-i
■^ ~ s '^
r r- >>
SYMPTOMS AND DIAGNOSIS. 83
It should be borne in mind also, that a swelling situated in
the lower part only of one lateral lobe will often push the
trachea over to the opposite side to such an extent that the
tumour itself occupies a position in the middle line of the neck.
Such a tumour may closely simulate an enlargement of the
isthmus itself and is frequently mistaken for this. It is a
very common condition. The correct diagnosis is easily made
by a careful exaiiiination of the exact position of the larynx or
trachea. {See Figs. 43, 55 and Qo.)
Very frequently, however, a thyroid swelling lies more to one
or other side of the middle line, one lateral lobe alone of the
gland being enlarged, or the enlargement affecting one lobe more
than the other. {See Figs, 87, 103.)
Often, only a portion of one lobe is enlarged bv the
presence within it of a cystic or solid tumour. Such a
tumour may be situated in almost any part of the front of
the neck.
It may even lie mainly or entirely ^^■ithin the thorax
behind the upper part of the sternum. In this case, the
tumour has grown downwards from the lowest part of the
gland.
On the other hand a thyroid tumour may involve only the
apex of the superior horn of the gland and lie entirely at the
upper part of the neck near the angle of the jaw. Of this I
have seen several cases, from one of which the photograph
shown in Fig. 41 was taken.
It is important to remember that a swelling of thyroidal
origin may occasionally occupy such a situation. This
high position is frequently a source of erroneous diagnosis.
Tumours in such a position are often mistaken for lym-
phatic glandular swellings or even, as in one case that came
under my notice, for a tumour of the submaxillary salivary
gland.
In July 1894, 1 operated with Dr. Eminson at Scotter, Lincoln-
shire upon a man of 30 who had had for many years a globular
swelling nearly two inches in diameter which lay directly in
front of the thyroid cartilage and hyoid bone and slightly to the
right of the middle line. Its lowest border was on a level with
84
THE THYROID GLAND.
the crico-thyroid membrane, that is, wholly above the thyroid
isthmus. The lateral lobes of the thyroid gland were not
enlarged. A process of thyroid gland found at the operation
to run up from the
tumour behind the
hyoid bone, together
with the subsequent
microscopic examina-
tion of the cyst wall,_
proved the tumour to
have originated in the
thyroid pyramid. The
patient made an excel-
lent recovery.
In February 1895, a
young woman was sent
to me by Miss Aldrich
Blake, M.D., on account
of an oval tumour as
large as a pigeon's ef^g
situated directly over
the thyroid cartilage and
slightly to the right of
the middle line. On
account of a slight band
of tissue which could
be felt passing down-
wards from the tumour
to the inner side of the right thyroid lobe, the tumour was
recognised as one of the thyroid pyramid.
It may be noticed that in both these cases the tumour lay
exactly in the line of the right thyroid pyramid.
Sometimes enlarged portions of a thyroid gland occupy still
more curious situations. In a case of multilocular cystic goitre
shown to me at St. Bartholomew's Hospital by Mr. Butlin,
besides a swelling of the whole left lobe of the gland there
existed a portion which appeared to extend transversely across
the neck at the level of the hyoid bone from the apex of the
.11. \ - -- — _- ^
l<'n;. 41. — A Cxstic Tumour of the Tliyi-i>iil. iic-i-iiii,\ iiii;
an nuusually high, position in the neck. (Seen
at St. B:'ortliolomew's Hospital.)
SYMPTOMS AND DIAGNOSIS.
85
enlarged left lobe to a point beyond the middle line of the
neck.
In 1892 there came under my notice another patient of
Mr. Butlin's, a young woman who had a movable tumour as
large as a hazel nut situated just below the tip of the right great
corner of the hyoid
bone ; after removal
it was found to consist
entirely of thyroid
tissue.
In the very rare
cases in which tumours
of thyroidal origin
exist actually within
the larynx it may be
impossible to make a
correct diagnosis.
The position of a
thyroid swelling with
regard to the larynx
and trachea has al-
ready been discussed.
It remains for us to
consider its position
with regard to (a) The
muscles of the neck ;
(b) The great vessels
of the neck ; (c) The
sternum.
(a) Position with Regard to Muscles. — The position of the
sterno-mastoid first demands our notice. This muscle, if the
tumour be sufficiently large, is almost always displaced outwards
and forwards. The tumour usually lies to its inner side and comes
forwards more or less between the muscles of the two sides. If
bilateral it displaces both sterno-mastoids.
Now a large number of tumours of the neck, especially those
of lymphatic glands which at first sight may closely resemble
tumours of the thyroid gland, differ from the latter in that they
Fig. 42. — All ryj I Swiss ^Vum,•.ll with :i iiromiucnt Cyst' '
Goitre of sm vll size The tumour hail existed for many
yc:irs but hml c.inseJ no dyspnoea. (Seen at Fiilo ivj,
Swltzerl.'.ud, in 1886.)
86
THE THYROID GLAND.
o 2
B. <
g a
^ 8
.if >>
O o
considered the disease to be malignant, and
ad^■ised that no operation should be performed. The diagnosis
was subsequently verified,* the patient dying in the course of
the following year.
* The subsetiuent history of thi.s patient has been published by Mr. Sydney
Jones and Mr. Battle in St. Tlunnati's IIo- lateral
flattening should be carefully borne in mind since it has an
important bearing upon operative proceedings canned out for
the relief of dyspnoea.
In some rare cases of uniform enlargement the whole gland
may be rotated to a certain extent upon its vertical axis, so that
one lobe projects a little more than the other. In such cases the
trachea is also slightly rotated axially with the goitre.
If the gland be enlarged on both sides, but more on one side
than on the other, the flattening of the trachea partakes more
or less of the character described in the next paragraph,
according to the disproportion between the two lobes.
Unilateral Goitre. — ^Vhen the enlargement affects one
lateral lobe only, the trachea is flattened upon the side next to
the enlarged lobe. (Figs. 53, 58b.) In these cases the trachea is
also more or less curved longitudinally and pushed over towards
* " De Texcision clu goitre parenchymateux," P. Liebrecht, Brus5e''s, 1883,
p. 1.').3.
7 Langenbeck's ArcJiirf. hint. Chir., 1883, vol. xxix. plate xi.
110
THE THYROID GLAND.
the opposite side. There is generally also a certain amount of
rotation upon a vertical axis, so that the trachea presents an
oblique lateral surface against which the enlarged lobe rests.
Fig. 53* was taken from a specimen Mhich I removed post
Fig. 52. — Shows the ordiuary Bilateral Flattening of the Trachea
prodiieed by pareueliTmatoiis yoitre and other forms of s\-imiietrical
eulargemeut of the thyroid. From a girl ay ed 13. who died of suffocation
c:in., i. IIIS.
THE DYSPNGEA CAUSED BY GOITRE. 125
The degree of prominence of the tumour is of importance in
relation to dyspnoea. The more firmly a goitre is held down by
resisting structures such as fascia or bone (sternum), the more
likely is it to cause serious respiratory trouble. Thus, some of
the most danoerous tumours are those which lie behind the
sternum and which send down prolongations into this region
(substernal and aortic goitres, "goitres plongeants" of French
authors).
In countries where goitre is prevalent one often sees huge
prominent and even pendulous tumours causing comparatively
little dyspnoea. Fig. 46 shows such a case. As examples of
the opposite condition in which the goitre causes hardly any
external swelling may be cited the case recorded on p. 105, and
that of the boy whose goitre is now in St. George''s Hospital
Museum.*
In the latter case although gradually increasing dyspnoea had
been present for sixteen months yet no external tumour was
noticed until three days before death, which occurred from
suffocation.
Strictly median tumours, not involving the lateral lobes, are,
as has already been explained, extremely rarely the cause of
dyspnoea.
There are some reasons for believing that the bilateral fibrous
goitres of adults are especially liable to cause severe dyspnoea.
Several cases have come under my observation which seem to
support this view.
One was that of an elderly woman seen with Dr. Favre at
Fribourg (Switzerland) in 1886. This patient had a very small
hard goitre which appeared to be shrinking in size and causing
increasing and severe dyspnoea as it did so.
Other cases are described in the following chapter.
* Xo. liJB. Also case 2 in the lable.
126
THE THYROID GLAND.
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p
CHAPTER VIII.
INFLAMMATION.
Acute idiopathic inflammation — TAi^hoid fever — Rheumatism — Pj')
shows a solid adenoma with much surrounding fibrous tissue and an
abscess cavity in the centre.
Still more serious is the condition of affairs when a thyroid
fistula opens on to a mucous surface, the trachea or oesophagus.
In the Museum of Charing Cross Hospital is a specimen * of
a large solid thyroid adenoma which was removed by Mr. John
H. Morgan on account of a fistula which opened both externally
and also internally into the oesophagus.
The patient was a woman aged 46", whose goitre had been
injected four years previously at another hospital. After other
methods had failed to cure the fistula, the whole tumour was
removed by operation. The opening into the oesophagus which w«s
just below the cricoid cartilage was closed with fine silk sutures,
and the wound drained. The patient made an excellent, although
somewhat tedious recovery.!
Primary Chronic Inflammation.
Under this name may be described a remarkable and somewhat
rare affection which seems to have attracted but little attention
in this country. It is characterised by the development in the
thyroid gland of a tumour of exceeding density and hardness,
which shows a remarkable tendency to become adherent to, and
* No. 877a.
t A full account of this case has been published by Mr. Morgan in the
Illustrated Med. News for June 2i). 1889.
138 THE THYROID GLAND.
even to surround and infiltrate, neighbouring structures. Various
names have been given to the affection, the pathology of which
is still somewhat obscure.
Tailhefer,* in an excellent paper upon the subject, uses the
name " primary canceriform chronic inflammation.*'' Bowlbyf has
published a typical case under the name of " infiltrating
fibroma," and seems to think that the disease is allied to
sarcoma. There can, however, be but little doubt that chronic
inflammation is the term that is most correct. The remarkable
similarity which exists, both clinically and pathologically,
between this disease and some of the harder forms of malignant
disease is very striking. Indeed almost every case hitherto
described has been diagnosed at first as malignant disease. To
Riedel i of Jena we are indebted for drawing attention to the
true nature of the disease and in the publication of two cases
that came under his care.
I have myself seen three cases. One of these was the case
published by ]Mr. Bowlby, which was under the care of Sir
Thomas Smith. The other two were under my own care at the
Royal Free Hospital.
The disease occurs both in men and in women. It appears to
be most common in middle age but cases in childhood have been
recorded. A swelling is noticed in one or other, or both, lobes,
of the gland. It grows steadily and painlessly, and when it
reaches the exterior of the gland it becomes firmly fixed to the
trachea, carotid vessels, I'ecurrent nerves, and other structures.
It exerts pressure upon all the structures and causes dyspnoea,
dysphagia, dysphonia, and obliteration of the carotid pulse. If
untreated it gradually compresses the trachea more and more
and causes death bv suffocation. The swelling does not usually
attain any great size, the lateral lobe of the thyroid being seldom
larger than a goose's egg.
The extreme hardness of the tumour has been likened by
* " luliainmation cJiroiiique ijrimitive ' canceriforme ' de la glande thyro'idi:",''
by E. Tailhefer in Brr. de Chir., Paris, March 10, 1898, vol. xviii. p. -li-^.
f " Infiltrating fibroma (.' sarcoma) of the th^Toid gland,'' Tranx. Path. Soc
1885, vol. XXX vi. p. 120.
X " Die chronische znr Bildung eisenharter Tumoren fiihrende Entziindung
der Schilddriise," YerhnndJ. d. JJeutxch. GexeUtwh. f. Chir., Berlin, 18'J(), i.
p. 101.
INFLAMMATION. 139
various observers to that of wood, iron or stone. It is quite
distinct from the ordinary fibroid degeneration so commonly
seen in parenchymatous and adenomatous goitres. The latter
progresses extremely slowly and does not cause infiltration of, or
adhesion to, surrounding parts.
The following are the three cases which have come under my
own notice :
Mrs. Eliza D , cEt. 42^ was admitted into St. Bartholomew's
Hospital on Nov. 28^ 1883, under the care of Sir Thomas Smith.
Three years previously she had first noticed a swelling of the lower
part of the neck. During the next year this swelling gradually
inci'eased and her breathing then became affected. At this period
she consulted a doctor who found that the thyroid gland was " very
slightly enlarged, firm, and not at all painful."* A year later it was
found that the thyroid was apparently incorporated with the
trachea, the place of the gland being taken by a very hard, painless
growth. She was treated with iodide of potash and biniodide of
mercury ointment, but did not improve. On the contrary her
breathing gradually became worse and worse, and she was liable to
fits of coughing brought on by active movement. " The stony
hardness of the growth was by this time very remarkable and was
of such a nature as to suggest the presence of cartilage or bone.
In April 1883, the patient was seen by Sir Felix Semon, who
expressed the opinion that the disease was of a malignant nature.
He found the trachea much narrowed, the left abductor paralysed,
and the left vocal cord completely fixed in the middle line. " The
dyspnoea continued to increase, and at times suffocation seemed
imminent. Dysphagia and weakness of voice were now noticed.
" On admission to the hospital dyspnoea was very urgent. The front
of the neck was occupied by an excessively hard mass, which enve-
loped the whole of the tissues from the level of the hyoid bone
downwards to the episternal notch, and in which it was not possible
to recognise any of the normal structures of this region. Free
division of the isthmus of the thyroid failing to give any relief,
tracheotomy was performed. Some temporary relief was afforded,
but the dyspnoea returned and the patient died on Dec. 4." The
post-mortem examination was made by Mr. Bowlby who has given
the following description : " The viscera generally were healthy.
There were no signs whatever of secondary growth and none of
glandular affection throughout the body. The thyroid gland and
* The description of this case is largeh' from the account given hy Mr.
Bowlbv in the Path. Sue. Trunx., vol. xxxvi.
140 THE THYROID GLAND.
adjacent parts are occupied by a large new growth. The tumour
is extremely hard, and of a similar shape to the gland in which it
grows, being composed of two latei*al lobes of equal size, joined by
an isthmus. Its cut surface is fibrous. Each lobe reaches the level
of the hyoid bone above and of the bifurcation of the trachea below ;
they are joined by a bi-oad isthmus reaching from the cricoid carti-
lage over the upper half of the trachea. Above, the lobes present a
rounded outline, are quite separate from each other and their limits
are clearly marked. Behind, beloAv and laterally, the limits of the
growth are quite undefined, the surrounding parts being infiltrated
by the tumour and not simply pushed aside. Thus the common
carotid artery, the external and internal carotids, the internal
jugular vein, the pneumogastric, recurrent laryngeal and sympathetic
nerves are on each side entirely included in the tumour. The
depressor muscles of the hyoid bone are infilti'ated and fixed ; the
oesophagus is infiltrated and so compressed an inch and a half below
the cricoid cartilage, that the tip of the little finger can barely be
passed. The trachea has been compressed both laterally and in
front ; in the latter situation by the isthmus of the tumour (which
has been divided), while its lower portion,, which in life occupied the
thorax and root of the neck, is infiltrated with new growth on each
side, and so narrowed by lateral compression that the little finger
cannot be passed. The aorta and all its branches, the innominate
veins, with the superior vena cava and the pulmonary artery, are all
incorporated in the tumour to a greater or less extent, but although
the calibre of these vessels is more or less diminished by pressure,
in none of them is there any ulceration or clotting of blood. The
apex of the left lung is closely adherent to, and not separable from,
the lowest portion of the growth. The bifurcation of the trachea,
Avith both bronchi, is adherent to the tumour, as ai*e also the
bronchial Ijaiiphatic glands. Neither in the neck nor in the thorax
w^ere these latter at all enlarged or otherwise altered. I made a
very careful examination of different parts of the tumour, sections
being taken both from the centre and the periphery. The structure
was entirely fibrous without the least appearance of either alveola-
tion or of epithelial cells."
The following case was under my own care at the Royal Free
Hospital and differs from the others in that spontaneous ulcera-
tion of the skin occurred, as may be seen in the accompanying
photograph (Fig. 59).
Mary S , a?/. 63, widow, was admitted into the Royal Free
Hospital on Jan. 20, 1899, on account of dyspnoea and an enlarged
INFLAMMATION.
141
thyroid gland. She had had for many years a swelling in the neck
■which had given her no trouble until about fifteen months before
admission. At this time the swelling on tlie right side became
lai-ger and eventually broke through the skin. An indolent sinus
had been present ever since. In the last two months she had had
much severe dyspnoea, especially at night. She had also lost flesh
in the last few weeks.
On admission she was found to be pale and thin. She breathed
Fig. 59. — Primary Ch.ronic Infl.amm.ation ol tlie Thyroid,
leading to spouMiifons ulceration of the skin. (.Tlie darkness of
the skin is dtie to a photoiiTapliie error.")
with much difficulty and stridor, and had to lie in a semi-recumbent
position, as she could not breath while lying down. Temp. 9^' •
Pulse 120, Resp. 36. There was also a good deal of bronchitis.
There was little or no dysphagia.
The right lobe of the thyroid formed a hard irregular mass about
as large as a goose's egg. The skin over it was adherent ; in the
middle of the adherent area was a shallow, narrow, ulcerated surface
two inches long bv half an inch wide and extending nearly half an
[42 THE THYROID GLAND.
inch into the substance of the gland. On the left side of the neck
was a similar but somewhat smaller swelHng not nearly so hai'd ;
the skin over this was not ulcerated. The whole swelling moved
Avith the larynx, but not very freely. With the laryngoscope great
lateral flattening of the trachea was seen, the walls were about ^
inch wide at the narrowest part. The vocal cords moved naturally.
The diagnosis of the case was not clear ; the swelling was
believed to be chronic inflammation of a peculiar nature, possibly
tuberculous, but the idea of malignancy could not be altogether
excluded. It was clear that, owing to the fixity of the growth, no
removal was possible. It was thought that tracheotomy would soon
be required. The case was seen by my colleague, Mr. Battle,
who agreed both with the diagnosis of probable chronic inflamma-
tion and also with the impossibility of removing the tumour by
operation.
On June 23, the patient having had several attacks of severe
dyspnoea, tracheotomy was performed without any general
anaesthetic. The operation which lasted ten minutes was diflicult
owing to the hardness and nodularity of the gland, Avhich made it
difiicult to distinguish the trachea from neighbouring parts. A long
Koenig's canula was inserted. The patient's breathing was easier
after the operation. On the following day the tube was removed
for cleansing and then replaced. The patient's temperature which
had been 100" before the operation Avas never afterAvards quite
normal : her pulse Avas generally between 120 and l60. The
patient died six days after the operation Avith symptoms of septic
bronchitis.
The post mortem showed a bilateral parenchymatous goitre of
moderate size and Avith a fcAv cysts evidently of long duration. The
lower half approximately of the right lobe Avas occupied by a
densely hard, yellowish-white, ill-defined mass, Avhich Avas firmlj-
adherent to the trachea for about an inch and a half, and also to the
left carotid vessels. In the corresponding part of the left lobe is a
similar, but much smaller mass of the same nature. The resem-
blance to a scirrhous carcinoma Avas Aery great, but careful micro-
scopical examination shoAved nothing but dense fibrous tissue Avith
remains of thyroid tissue here and there. There Avas no trace of
malignancy anyAvhere.^
The third case illustrates a much earlier .stage of what I
belieA'e to be the same disease, but as the dense fibrous growth
had in this case not reached the capsule of the gland, there Avere
* The specimen is now in the Koyal Free Hospital Miiseuni, Xo. xxii. .">.
INFLAMMATIOX. 143
no adhesions to surrounding parts and complete removal of the
affected lobe was possible.
Mrs. Charlotte G ,* cet. 40^ was admitted under my care into
the Royal Free Hospital, on account of a swelling of the right lobe
of the thyroid.
Five weeks before admission she had first noticed a lump in this
region ; it had steadily increased in size. She complained of
occasional shooting pains in the lump, and also of a slight
"■'choking" feeling. Otherwise she appeared to be in good health.
The extreme hardness of the lump, its slight irregularity together
with the history of a rapid growth and sharp pains led to a strong
suspicion of malignant disease in an earlv stage.
Accordingly on May 13, 1898, extirpation of the right lobe was
performed. The operation presented no unusual difficulty of
any kind ; the subsequent course of the case was quite ordinary :
the Avound was drained for twenty-four hours and then healed
throughout by primary' union. The tempei-ature never reached
100° at any time. The patient left the hospital eleven days after
the operation quite well in every respect. She came to show her-
self from time to time and remained perfectly well. She was last
seen about two vears after the operation.
The tumour that had been removed Avas as large as a hens ^gg.
The peripheral portion to a depth of about a quarter of an inch
consisted of normal dark coloured thyroid tissue. All the central
part however consisted of a somewhat ill-defined mass of connective
tissue, which on section was found to be extremely hard, white,
shiny and glistening.
Microscopically it consisted of dense inflammatory tissue with
remains of thyroid tissue between the bundles of fibrous tissue.
Riedel t has recorded the following cases :
A man aged 42 had noticed for about six months a swelling of the
thjToid gland which caused considerable dyspnoea. The tumour
was bilateral, not very large, but extremely hard and fixed. It
was believed to be malignant and on November 30, 1883, an
attempt was made to remove it by operation. After the gland had
been exposed however, it was found to be intimately united on
both sides with the carotid artery and jugular vein. The operation
for its removal was therefore abandoned, and Riedel contented
himself with cutting away a piece of growth as large as a walnut.
* See Appendix, Case .56. p. 346. j Op. cit.
144 THK THYROID (JLANl).
The wound healed without any trouble and the jiatient's breathing
improved so much that at the end of six months his dyspnoea had
entirely disappeared, he seemed quite well and was able to do
his ordinary work. Fifteen months after the operation this patient
died of nephritis and apoplexy. There was no post mortem. The
])ortion of tumour that had been removed was examined micro-
scopicallv. There Avas no sign of sarcoma or carcinoma. The
tumour was composed of chronic inflammatory tissue. There was
no evidence of tubercle or syphilis.
Twelve years later Riedel met with the following case :
A healthy looking woman aged 23 had noticed that for a period
of one year her neck had been swollen. In the last two months
the swelling had increased tolerably rapidly. The patient had
much dyspnoea on exertion. The thyroid gland was enlarged on
the right side to the size of a hen's egg, on the left to that
of a small apple. The tumour was remarkably hard and fixed. As
in the preceding case the operation for removal of the tumour had
to be abandoned on account of the extensive adhesions of the
tumour with the blood vessels and recurrent nerves. Micro-
scopical examination of a portion of the tumour showed chronic
inflammatorj' tissue. The patient's breathing improved after the
operation, she was able to get about and was apparently nearly
well. About two months after the operation she was suddenly
seized with symptoms of embolism and died in a few minutes.
There was no post-mortem examination.
The case that formed the subject of Tailhefer's first paper *
was under the care of ]\1. Jeannel of Toulouse. Tailhefer him-
self assisted at the operation.
The patient Avas a man of thirty who for three months had
noticed aphonia and a swelling of the neck. The left lobe of the
thyroid was found to be occupied by a '• very hard, ill-defined, fixed
and painless tumour, not involving the skin." The tumour was
thought to be malignant and its removal was attempted. The
tumour was found, however, to involve the carotid sheath and
neighbouring parts so extensively that the operation had to be
abandoned, a small piece only of the growth being removed. The
operation was followed by secondary haemorrhage from the carotid,
necessitating ligature of that vessel. Suppuration and hemiplegia
followed but the patient eventually recovered. Histological
* " Vuriete tres rare de tliyro'ia<;nil:!ted colloid ui:iti'ii:il
(St. Bart. Hosp. Mns. Xo. 2310G.) iXat. size.)
156
THE THYROID GLAND.
blood may be extra vasated as the result, either of slight injury,
or, perhaps, of spontaneous rupture of a small thyroid vessel, I
do not consider this, however, to be a common mode of origin.
Fig. 65. — A wuului. a-ed 5u, witli a l;irg-e Cyst '>i the l!iuhr Lobe. It
had been growing' slowly for more than twenty years and caused much
discomfort and some dy.spna?a. It was easily removed by resectioii-
eniicleation. (See Appendix, ('.ise 61. p. 346.)
Haemorrhage into an adenomatous tumour is, however, very
common.
A convenient and simple classification of thyroid cysts is into
single and multiple.
An objection to this classification is that in cases of single
cyst, there exist almost alwavs numerous smaller cysts in other
parts of the gland. As these ho^vever may be quite small and
CYSTIC DISEASE.
157
insignificant in comparison with the larger cyst, the practical
value of the classification is not materially affected.
In cases of multiple cysts, the whole gland is frequently found
to be converted into a mass of cysts, no one of which is much
laro-er than its fellows.
Fig. 66. — TIk- precodiiii;. iMif week alter the operation.
Single cysts form unilateral tumour.s ;* multiple cysts generally
produce bilateral enlargement of the gland. It is mainlv on
this account that this artificial and to some extent incoiTect
classification is worthy of adoption, since unilateral and bilateral
tumours frequently present much difference with regard to
symptoms, prognosis, and treatment.
A term frequently employed is that of Hcemorrhagic cjj.st.
* Except ■when situated exactly in tlie middle line, which is not common.
158
THE THYROID GLAND.
This may be of the nature above nieutioned, but is much more
commonly simply an ordinary retention or adenomatous cyst
into which h;emorrhage has occurred.
A remarkable peculiarity of thyroid cysts is the unusual ten-
dency to intra-cystic haemorrhage which they possess.
In no less than six out of twelve cases mentioned on p, 152
Fig. 67. — A man, aged 5U, with a large Siuglc ThyroM Cyst siniiii;iiin'
li-om the left iipper horn. It luul been gi'owiug- slowly lor more tliiiii
thirtj' years. It was easily and successfully removed by Dr. Comte,
and found to contain over two pounds of semi-solid, partially calcified,
colloid contents. A portion of the c.yst wall and its contents are now
in the Museum of St. Bartholomew's Hospital, No. 2314f. (Seen at
Geneva in 1886.)
distinct intra-cystic haemorrhage had occurred, and museum
specimens likewise show how common it is to find blood in the
interior of a thyroid cyst. In no other class of cysts is found
such a marked tendency to haemorrhage. If a thyroid cyst have
been tapped and clear fluid withdrawn, a second tapping is
extremely likely to evacuate, not a clear but a blood-stained
CYSTIC DISf^ASE. 159
fluid ; frequently indeed on the second tapping the fluid
consists of nearly pure blood.
It is probable that the explanation of this tendency to blood
extravasation is to be found in the fact, already mentioned, that
many thyroid cysts are formed from pre-existing adenomata.
The soft and vascular thyroid tissue within the cyst is naturally
very apt to bleed.
Occasionally this unfortunate liability to haemorrhage leads
to serious or even fatal results. Professor Kocher relates * the
case of a lady who had a cyst of the thyroid. It was tapped ;
clear fluid being withdrawn. A second tapping caused the
evacuation of pure blood. The intra-cystic haemorrhage then
caused such severe dyspnoea that extirpation of the cyst had to
be performed.
Mr. Butlin has kindly communicated to me a case in which,
many years ago, a thyroid cyst was punctured in his out-patient
room ; such severe symptoms were caused by the intra-cystic
haemorrhage which ensued, that the patient subsequently had
to be admitted to the hospital as an in-patient, and the haemor-
rhage was controlled with the greatest difficulty.
In the College of Surgeons Museum is a preparation f of a
large thyroid cyst. The catalogue states that the cyst was full
of coagulated blood, and looked like the sac of an aneurism.
During life it was punctured in consequence of the dyspnoea
produced by its pressure upon the trachea. A considerable
quantity of fluid blood flowed from the wound, and the bleeding-
continued until the patient died.
The following is a case of haemorrhagic cyst that I saw in
1885, at the Kensington Infirmary with Mr. Potter and Dr.
Reece. (Fig. 33, p. 47.)
Mary McD , a4. 60, unmarried^ had had for many years a
swelling in the situation of the right lobe of the thyroid. In the
last two months it had become much lai'ger and more prominent.
In the above-mentioned situation was an irregular rounded swelling
measuring four and a quarter inches transversely, and three and
three-quarters vertically. It projected considerably and over-
lapped the sternum and right clavicle. It was of a dusky red
coloui*, tense and elastic, but with softer spots here and there. At
* Arehivf. Mid. C'/iir.. lSR;-5. p. 308. f ^""o- 2905.
IGO THE THYROID GLAND.
the most prominent part was an ulcer with a slough as large as a
sixpenny-piece. Puncture gave exit to an ounce and a half of
grumous fluid containing much blood. The cyst was dissected out
by Mr. Potter and was found to contain a lai'ge amount of both
fluid and clotted blood.*
The patient made a good recovery.
Haemorrhagic cysts of other parts of the body sometimes
afford a presumption of malignancy, but this is by no means
the case with those of the thyroid. Malignant cysts of this
organ like those of other parts, may, of course, be accompanied
by intra-cystic haemorrhage. But it is important to bear in
mind that the finding of blood in the interior of a thyroid cyst
ought not in itself to be taken as pointing towards the existence
of malignant disease.
On the other hand malignant disease of the thyroid may
produce cysts containing clear fluid. Two examples of this
have come under my own notice.
The situation in which cysts are most often found is the
lower part of one or other lateral lobe, but the only apparent
reason for their more frequent occurrence in this part is that
the main bulk of the organ is situated here. The isthmus and
the comparatively slender upward prolongation of the lateral
lobes form but a small part of the whole organ, t
The structui'e of thyroid cysts may conveniently be considered
under two heads :
(a) Structure of the cyst-wall.
(b) Structure of its contents.
(a) Cyst-wall. — In small recently formed cysts, the wall has
the same structure as that of the normal vesicle ; it consists of
an exceedingly thin and delicate layer of connective-tissue lined
by a single layer of epithelial cells.
In larger cysts it is more fibrous and tough, being composed
mainly of dense layers of fibrous tissue closely packed together.
Sometimes when the cvst is large the wall may measure
several lines in thickness. In these cases there may often be
* This specimen is now in the Museum of tlie Koyal College of Surgeons.
No. 290oA.
j For specimens of cyst in upper part of lateral lohe. see St. George's Hosp.
Mus. No. 20A : in isthmus. St. Mary's Hosp. Mus. 1031. ,'