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Thoaa too iarga to ba antiraiy includad in ona axpoaura ara fiimad baginning in tha uppar laft hand comar, laft to right and top to bottom, aa many framaa aa raquirad. Tha following diagrama illuatrata tha mathod: Laa cartaa, planchaa. tablaaux, ate, pauvant itra filmte k daa taux da riduction diff4rants. Lorsqua la documant aat trop grand pour Atra raproduit an un saul cilchA, il aat film* A partir da I'angia supMaur gaucha, da gaucha A droita, at da haut an baa, an pranant la nombra d'imagaa nteaasaira. Laa dlagrammaa suivanta illuatrant la m4thoda. 1 2 3 1 2 3 4 5 6 ^^B^ ^-^35^^^ ■- 1 . :, S*':' It*''*.- ■•". :■' " '■/ 'i^' ' ■; ^^^^WmaGIG CVSTS OF w W. I BRADJ^EY . ^>^^U^ ,ij- K.;-^ /-' ^.■iir.h - ^''i Ea'"'^ ?. J )» ^ '•-^ ■':' \ & ' v. '■'' ^4: -'■::'.-^":' a 1 ^>^*5t # 1 ;rr'';- .": - ^ «^'*'- ^"^^^?K^-"^ ■V. rri>»{ '-■ "■-''^ "t^ l^'L ■ *-r«:rT^!', - '#* \ - r 4 , f I: ■ ..-' ■ -^^^■^'' £#l i3w <>■ -^SJBJli ^J^t^uKSS ■bh^H^^I ^AfeMfeJ ■1 ^^^^1 Vf "Si ON HiEMORKHAGIC CYSTS OF THE THYROID GLAND. By W. I. BRADLEY. B. A., M. D., M. R. C. S. (From the Pathological Laboratory of the Royal Victoria Hospital, and the Molaon Pathological Laboratory, McOill University, Montreal.) Plate XV. It is generally taught that the most frequent form of enlargement of the thyroid gland is the parenchymatous goitre, or bronchocele, a form in which, by the overproduction or retention of colloid mate- rial within the vesicles in general, there is brought about a very considerable increase in the size of one lobe or in that of the whole organ. There is, however, another form of cystic enlargement, not generalized, but localized, in which the enlargement is due not to multiple retention cysts, but to the development of large isolated, cystic swellings, either solitary or not exceeding three or four in num- ber. The size of these cysts greatly exceeds that of the individual distended follicles in the most extreme cases of parenchymatous goitre, and the walls as well as the contents are of a wholly different nature. Judging from the material which I have had the opportunity of studying, this in Canada constitutes quite the most frequent form of unilateral and considerable enlargement of the thyroid presenting itself for operation. Out of eighteen cases of bronchocele operated upon by Dr. Shepherd at the General Hospital in Montreal, the mate- rial from eight of which came into my hands, no less than nine, if not ten, were of this nature,* a proportion much larger than I had been prepared to encounter. A study of the literature bearing upon the morbid histology of the gland has convinced me that, relatively, very little attention has been paid to the nature and characters of these * Of these eighteen, one was a case of generalised parenchymatous goitre, four were definitely " colloid cysts " (adenomatous nodules with retention), nine were definitely of the type here described, the remaining four being of doubtful nature. COPTRIOHT, 1896, BY D. APPLETON AND COJfPANT. On lioBmorrhctgio CyiiU of the Thyroid Gland large cysts; and, though it may be true that elsewhere they do not form 80 large a percentage of the cases of goitre operated upon as they do here in Dr. Shepherd's practice, nevertheless since surgical litera- ture shows that they are very common, and now that operative inter- ference with the thyroid is becoming increasingly frequent and in- creasingly successful, it may be opportune to draw more attention to their structure and characters than has hitherto been accorded to them. Dr. Shepherd has described the surgical features of his cases in detail in the Annals of Surgery * It will, therefore, be only neces- sary to append here a table of the cases, giving a brief epitome of the main points in connection with each. Case. Mrs. S. II. III. IV. V. VI. VII. Name. Mrs. 0. Miss L. Miss C. Age. 66 Mrs. Miss Miss J. McL.f McP.f 26 23 21 30 19 19 Size, poBition, and contents of tumour. Duration. Two cysts in the right lobe— one the size of n Tangierine orange, the other that of a walnut. Contents : a thick, reddish-brown material. Two cysts in right lobe, the larger more superficial. Contents: a thick, greenish-brown fluid. Solitary cyst the size of a lemon in the right lobe. Contents: grumous, containing cholesterine crystals ; extensive papillomatous projections into cyst. Solitary cyst the size of a hen's egg in the left lobe. Contents: dark, yellowish- brown fluid with clots of blood. Solitary cyst the size of a small orange in the left lobe. Contents : straw-coloured fluid. Single enormous cyst the size of a turnip in the left lobe. Contents : dark brown, thickish fluid. Large solitary cysit the size of a grape-fruit in the right lobe, ex- tending beneath the sternum. Contents: dark-yellow fluid. Ten years ago, when crossing the Atlantic, she was violently sea- siiik. Lump on right side of neck was noticed shortly after- ward. This continued to 'now steadily, and had increasr in size considerably during the last thirteen months. Noticed for six years. Growth at flrst small, slowly increased until a year before operation ; then grew rapidly, the position becoming somewhat altered. Present for three years; very slow enlargement until a year before operation, when there was a sudden increase in size. Gradual enlargement noticed for a year; then sudden increase in size three months before op- eration. Noticed for twelve years. Present for six years ; more rapid enlargement a few months be- fore operation. Two years ; had enlarged rapidly during the six months preced- ing operation. * F. J. Shepherd, Annals of Surgery, September, 1896. f Cases VI and VII were operated upon shortly after Dr. Shepherd's article in the Annals of Surgtry had gone to press, and consequently are not referred to in that article. h ■ AC' I • W. I. Bradley 8 Before speaking generally upon the subject of these cysts, it will be advisable to record briefly the results of the microscopical examina- tion in each case: Case I. — In this there were t)vo cysts in the right lobe, whose con- tents were reported by Dr. Shepherd to be of the nature of a reddish- brown fluid. The cyst wall did not come into my possession, the mate- rial supplied to me being an ingrowth into the cyst. It presented the characters of somewhat modified glandular tissue; the average diameter of the vesicles appeared to be 15 fi, the largest measuring 60 /n. Owing to the great variation in the size of the follicles, it is only possible to give a rough approximate statement of the average size of the vesicles. Although these figures have been reached by estimating the diameters of fifty or more neighbouring follicles, it is not pretended that they represent more than a general approximation to the average sizp. The majority of the collections of gland cells had no lumen, and were 4=imply clumps of nucleated cells. Some of the vesicles contained a dense colloid material, deeply stained as though by blood pigment, and here nnd there the colloid masses showed a definite concentric appearance. In some, in the middle of the colloid, it was possible to recognise one or more clear transparent crystals, varying in shape from a square to an oblong, and in longitudinal diameter from 10 /x to 55 /it (Plate XV, Fig. 1). As to the exact nature of these crystals, I am not in a position to make any statement; they were unaffected by all the ordinary media employed in hardening and fixation, such as alcohol, MUller't; fluid, and the essential oils. It must be added that the crystals were .ijiy present where there was surrounding interstitial haemorrhage, with a degenerated condition of the epithelium. Corresponding with the irregularity in the size and contents of the vesicles, their epithelium showed great variation in depth. There was periarteritis and also extravesicular (interstitial) haemorrhages; the capil- laries were dilated, and the vesicles widely separated. This presence of dilated capillaries and of hsemorrhages is worthy of note in connection with the reddish-brown character of the fluid contained in the cyst. The above case is unsatisfactory to this extent, that the relation- ship of this intracystic growth to the cyst wall could not be made out, # On IloiinorrKagic Cyait of the Thyroid Gland and because the absence of the cyst wall prevented a fuller study of the case. In the remaining cases the material sent fortunately in- cluded the cyst walls, and thus gave a far more satisfactory insight into the nature of the cysts themselves. Case II. — (Two cysts of the right lobe, the second removed through the posterior wall of the cavity left by removal of the first.) The cyst wall in this case consisted of several irregular overlapping and not perfectly concentric layers of dense fibrous tissue, with inter- spersed occasional short imperfect layers, characterized by the presence of numerous small nuclei. Some of the outermost of these imperfect nucleated layers appeared to merge into more perfect gland tissue; they represented evidently the remains of atrophied lobules or collections of vesicles. Upon the inner surface of the cyst, section showed here and there accumulations of well-developed vesicles 50 /* to JJOO /a in diame- ter, possessing a somewhat flattened epithelium; here and there several vesicles appeared to have run together into a common chamber. There were, in addition, small areas of fibrosis and of calcareous de- posits. The fluid filling the main cyst contained cholesterine crystals and large, round cells filled with fatty globules. The fluid had a glairy, yellowish-brown appearance. ^ Case III. — (Single cyst of right lobe.) As in the case last mentioned, the cyst wall was formed of several layers of fibrous tissue, with intermediate partial layers of atrophied gland tissue. From the wall there projected inward large, firm masses of gland tissue, with vesicles varying in diameter between 50 ^ and 400 fi, having a thin, low epithelium and very little tissue between the individual vesicles. The fluid contents of the cyst were grumous, and contained cholesterine crystals. <:U' Case IV. — (Single cyst of left lobe, the size of a hen's egg.) The cyst wall possessed the same features as those in the last two cases, except that it was not quite so dense, and that here and there in it could be observed flattened masses of colloid. Greatly elongated vesi- cles could also be seen gradually losing their epithelium, and passing into what might possibly be lymph channels (vide Plate XV, Fig. 4). Both on the outer and on the inner side of the cyst wall there was typi- cal gland tissue, the diameter of the vesicles varying between 40 ji and 125 It.. In these masses of gland tissue protruding into the lumen of the 1 ^- W. 1. Bradley • cyst were unmistakable signs of old hsemorrhages (deposits of pigment and cells containing pigment granules). The contents of this cyst were reported by Dr. Shepherd to consist of a yellowish-brown fluid, with blood clots. Case V. — (Single cyst of left lobe, the size of a small orange.) The wall of the cyst in this was much thicker than in the preceding case, and was almost entirely fibrous, though there were evidences of contained atrophied gland tissue. Externally, the gland tissue showed u chronic interstitial thyroiditis, and in places merged imperceptibly inio the cyst wall. In addition, the capsule exhibited patches of calcareous de> generation; in the middle of one such patch the remains of an artery showing obliterating endarteritis could be distinguished. The papilloma- like ingrowths into the cyst showed dilated vesicles tilled with a clear homogeneous colloid material; the vesicular epithelium was greatly flat- tened, and exhibited areas of atrophy with communication between the vesicles. There were the remains of old hsamorrhages with pigment de> posits, and more recent haemorrhages causing rupture of the vesicular epithelium, so that the blood was both intravesicular and extravesicular. The contents of the cyst were reported by Dr. Shepherd to consist of a straw-coloured fluid. Case VI. — (Single enormous cyst of the left lobe of the siie of a turnip.) The wall of this cyst, which had of late grown rapidly, was compara> tively thin, and in its immediate neighbourhood was found nonnal thy> roid tissue, the vesicles averaging about 25 fi in diameter. All around the inner aspect of the wall was similar tissue in fair quantities form- ing an inner lining, and showing here and there a hemorrhagic focus. At one place a large papillomatous mass projecting inward showed thy- roid tissue of a similar nature, with, however, much fibrous tissue and great compression of the vesicles. According to Dr. Shepherd's report, the contents consisted of a dark-brown, thickish fluid, and from the pos- terior wall there projected several papilloma-like patches the size of walnuts. Case VII. — (Large soft cyst of right lobe, extending beneath the sternum over the vessels arising from the arch of the aorta; the cyst in consequence could not be shelled out in its entirety.) The wall of the cyst was very similar to that of the preceding case. From the inner aspect there was thyroid tissue projecting, with vesi- $ On Ilmmorrhagio Cyats qf' the Thyroid Gland cles generally large, varying from 40 ^ to 250 /i, the average diameter being calculated to be about 75 ft,. Here the interHtitial fibrous tissue was much increased, the colloid in the follicles was shrunken, and there were marked evidences of multiple haemorrhages, both intravesicular and extravesicular. The contents of the cyst were reported by Dr. Shepherd Case VIII.-^The eighth specimen receiVed from Dr. Shepherd was -;„ ^^ . ^^^^ of a different nature. While at the operation the case appeared to be c|^^;i;^''.$.4;>i ■ one of multiple large cysts with colloid contents affecting both lobeij upon microscopic examination ox the dense colloid material enucleate^; it was found that this was made up of thyroid tissue, with vesicles rangi-t^iv ing from 25 /i up to 030 /* in diameter, the average being about 50 /*. The vesicular epithelium was greatly flattened, and consisted of little more than small rounded nuclei. Thus the case was one of multiple nodular or lobular overgrowths, or, more correctly, aberrant growths of the gland tissue. I have since received a similar specimen removed by Dr. J. Bell from a patient in this hospital. • /;w>;^>ii , vfi,., ;>;-;: .. Taking into consideration all of the varioiiis featurbs presented by these large fluid cysts, it will be seen that the contents differ mark- edly from those of the ordinary vesicles of the thyroid gland. They are fluid, and in general present evidences of containing blood or derivatives from the blood; they vary from a straw-coloured fluid (as in Case V), through greenish brown (Case I), to a dark-brown, grumous fluid (as in Case VI); or, again (as in Case IV), actual blood clots may be present. It is of importance to note that when, as in Case VI, the growth immediately before the operation had been rapid and the cyst wall was thin, there was found the most abundant evidence of recent effusion of blood; when, on the other hand, as in Case V, the wall was thick and, judging from the calcareous deposits within it, the cyst was of long standing and quiescent, the contents showed least evidence of admixture with blood, consisting simply of a thin straw-coloured fluid. With regard to the nature of the cyst wall, this is of a somewhat peculiar character. Although very definitely fibrous in composition, its nature is not sharply defined. The layers composing it are not .-m ^*-: yi v^M^'^^'il Ml.".. ' ■!. ' > -•.' . >< / ^ W.I. Bradley •• 7 tnily coiu'cntric; hero niul there between them occur masses of small cells, which, by comparison with the tissue immediately outside the wall, are soon to Iw clearly the atrophied remains of gland tissue (vide Plato XV, Fig. 4). These features explain why it is that in enuclea- tion the cysts are found not to bo sharply defined from their sur- roundings, and permit successive irregular layers to be partially peeled off. The wall, in fact, passes gradually into the bands of interstitial ' • •., ..... tissue running between the surrounding collections of vesicles, and ■k " vv.-Xr.-A-'^-r- .^t.. ^. , ■ 5 -4. Portion of the capsule of the thyroid cyst removed from Case V. x 10. * ' " E, external aspect; I, internal aspect; W, W, cyst wall of varying thickness. 1, Fine layer of thyroid tissue oovering inner wall of cyst; 2, 2, naass of thyroid tissue pro- jecting into lumen of cyst; 8, 3, large and healthy thyroid vesicles; 4, dense fibroid mass (atheromatous) with some calcification; S, 6, small areas of haemorrhage with pigmentation ; 6, atrophied glandular tissue included between the layers of the cyst wall ; 7, fibrons band or layer passing from the cyst wall to partially cover the projecting mass of thyroid tissue. evidently represents not so much a new formation of fibrous tissue around the cyst as a compression of the surrounding thyroid tissue. In the older cysts, judging from the thickness of the wall, it would appear that there had been a certain amount of new fibrous tissue j^*vv formation. Upon its inner aspect also the wall differs ^videly from that of i>f uy -■r" On HcBrnorrhagic Cysts of the Thyroid Gland an ordinary retention cyst; it is not lined either with well-developed epithelium or with the remains of ;l tch tissue, while between the contained fluid and the fibrous envelope is to be found irregularly distributed a greater or less amount of intact gland tissue. The appearances here presented differ widely from what is to be observed in the ordinary parenchymatous goitre. In the latter the cysts are gener