Reprinted from The Medical and Surgical Reporter, June 24th, 1893. 
Cystic Goitre With Cases in Prac- 
tice. 
A. BRITTON DEYNARD, M. D., 
New York. CYSTIC GOITRE WITH CASES IN PRACTICE. 
A. BRITTON DEYNARD, M.D., New York* 
DEFINITION. 
Any enlargement of the thyroid gland 
containing a cyst. 
CLASSIFICATION. 
Clinically we meet single or multiple 
cysts. Where vessels predominate in 
morbid action we have vesicular or caver- 
nous cysts. They contain sometimes pure 
blood. Where connective tissue increases, 
fibroid development takes place; produc- 
ing the fibro-cystic formations whose con- 
tents in appearance vary from grumous to 
gray-looking serum. 
Calcareous degeneration takes place in 
the cyst wall or septae when multiple, but 
this is rare. As exophthalmic goitre, or 
Graves' disease, may accompany this and 
every form of thyroid enlargement, it is 
most probable they are only different 
manifestations of one and the same dis- 
ease. 
ETIOLOGY. 
The cause, like that of goitre itself, is 
an unsettled problem. It is found in the 
frozen North and under the tropics. 
Humboldt mentions its prevalence in 
South America among those of most 
varied environments, as to soil and climate, 
and a recent traveler, Vincent, alludes to 
its prevalence there, particularly among 
the Venezuelians. Over sixty per cent, 
of the inhabitants of the Indian Punjaub 
are said to be affected with goitre. That 
it is due to a high percentage of mag- 
nesian lime in solution in the water can- 
not be maintained. That it may be a 
mycosis there is some reason to believe. 
Klebs suggests organisms. He sees a 
relationship in changes taking place in 
the enlarged spleen of intermittent, and 
goitre. No inflamatory change in vessels, 
but a lessened resistance pressure of 
vessel walls of spleen and thyroid 
gland. 
PATHOLOGY. 
The thyroid is a vascular, ductless, and 
true epithelial gland. There takes place 
a defective maintenance of structure, 
increase of fluids and organizable products, 
and oozing of coloring matter. Colloid 
metamorphosis occurs in cell contents and 
then it liquifies. Virchow thinks that 
colloid of this gland commences in the 
free fluid of its follicles after having been 
let loose by the destruction of the cells. 
Cell walls atrophy and connective tissue 
forms capsule or capsules of cyst or cysts. 
Hemmorrhage occurs which colors contents 
of cysts, and hence fluid is generally 
grumous in appearance. Under the 
microscope are seen detritus, fatty de- 
generation cells, and cholesterine. Al- 
bumen is always found in cyst contents, 
and according to Conheim1, the thyroid 
is the typical seat for the development of 
the so-called alkali-abumen; albumnose 
and meucin. Cysts may develop in cases 
where little colloid degeneration is seen. 
instructor Post Graduate Medical School, Assis- 
tant Surgeon Manhattan Eye and Ear Hospital. 
Fellow of the Academy of Medicine, etc. 
1 Conheim's Pathology. 3 
Follicles are distended by albuminoid 
fluid, and cells undergo changes. Fatty 
degeneration most common. 
SYMPTOMS AND DIAGNOSIS. 
The symptoms depend on the presence 
■of tumor and the pressure made by it. 
The most common fibro-cystic have ir- 
regular outlines, firm consistency, and 
fluctuating cysts. Dyspnoea is present 
generally, but size of growth does not 
always determine its extent. Pressure on 
veins may lead to passive hypersemia of 
the brain and tidal tinnitus is sometimes 
present, anaemia constant and prominence 
of eyes sometimes. It is generally seen 
in young women, and a hypodermic 
syringe, used as an exploring needle and 
aspirator, makes diagnosis easy. The 
presence of so marked an enlargement 
over the thyroid region and such an as- 
semblage of symptoms could only be con- 
founded with an aneurism or malignant 
growth. The former does not move 
vertically during deglutition and after 
-cysts have formed in cancers, evidence of 
the disease in adjoining glands would 
present itself. 
TREATMENT. 
The methods used in the following 
cases will best elucidate the principles 
underlying plan of treatment adopted, 
and found effective. 
Case I. Miss 0., get 30, housekeeper, 
was seen in June, 1889, with large globu- 
lar growth in median line of neck over 
thyroid region, and extending on both 
sides as far as the carotid vessels. Patient 
was lymphatic temperament, ansemic and 
suffering from dyspnoea. A hypodermic 
needle passed through the centre of the 
enlargement revealed the presence of a 
fluid cavity, and the syringe used as an 
aspirator brought out some dark-looking 
fluid which did not coagulate on exposure 
to the air. Tr. Iodine, which in the 
experience of the writer had been so effec- 
tive in the treatment of simple hyperplasia 
of the thyroid was injected (10 m.) into 
the lateral lobes several times during the 
summer, and while it lessened the lateral 
lobes in size, it did not relieve the dyspnoea 
or reduce the central enlargement. In 
October following, a seton passed through 
the cyst entrance and exit about two 
inches apart caused considerable reaction; 
temperature 103.° At the end of ten days, 
patient was put to bed, and suppuration 
around cord enabled one to pass a small 
trocar and canula. Through canula re- 
tained in position, injection of sol. acid 
carbolic was used frequently. At the end 
of ten days, constitutional disturbance 
had ceased. The seton and canula were 
removed and a drainage tube introduced. 
This treatment was kept up for six weeks 
when tube was removed. The discharge 
continued of pus for seven weeks and it 
was feared a permanent fistula would re- 
sult, but healing in a month occurred. 
The cyst prominence almost entirely dis- 
appeared, the dyspnoea was relieved, but 
the patient passed out of sight and there- 
fore the ultimate result cannot be 
stated. 
Case II. Miss S., student, set 22, 
brunette, family history good, presented 
herself July, 1890, with large growth 
over thyroid region more marked on right 
side. Patient had pallor and dyspnoea. It 
was stated cyst had been tapped and 
quickly refilled. From the irregular 
form, hard and heavy fibroid formations 
were suspected and afterwards confirmed. 
Drew off with the aspirator a tumbler full 
of grumous-looking fluid. At the end of 
a week it was refilled. Cocaine was in- 
jected under the integument over the 
cyst, and an incision severing tissues 
made. When the dark-colored thy- 
roid gland -was exposed a double corded 
silk seton was passed and repassed through 
the cyst wall. Entrance and exit a half 
inch apart. The ends of the . seton 
strands were separated and tied about six 
millimeters apart on either side with a 
view to cut off circulation in enclosed 
space. Inflammatory symptoms followed 
and temperature went up to 104° on the 
third day. The space enclosed was now 
divided; no hemorrhage following. The 
phenic acid solution for irrigation was used 
and temperature fell to normal gradually 
during'two days. The opening was kept up 
with two large drainage tubes, and the cyst 
cavity healed up, after four weeks, from the 
bottom. The dyspnoea and central enlarge- 
ment disappeared, but the lateral lobes con- 
tinued hypertrophied. Tr. iodine injec- 
tions subsequently reduced the size of the 
lateral lobes somewhat, but whether from 
infrequency (5 times) or from inefficiency I 
am unable to state. At the present time, 
over the situation occupied by cyst, de- 
pression appears and patient is pleased 
with result of treatment. 4 
Case III. Miss G., aet. 28, dressmaker, 
active and intellectual, applied in October, 
1891, for relief from deformity and 
dyspnoea. Patient was cachectic, anaemic 
and the eyes prominent. There was a 
large growth over the region of the thy- 
roid isthmus. Patient had been treated 
for three years off and on with the iodides. 
A hypodermic needle determined the con- 
tents of a cavity in growth and the con- 
tents shown by aspirating consisted of a 
liquid resembling serum and blood. After 
a hypodermic of cocaine as in the last 
case, a bistoury was used and cyst opened 
as if it were an abscess. The hemorrhage 
was profuse, but venous in character, and 
easily controlled by packing the cyst 
cavity with borated cotton and compress. 
The second day this was removed, and 
the bleeding which was free quite ceased 
after applying saturated solution chromic 
acid to cavity and repacking. There were 
no constitutional symptoms and my associ- 
ate Dr. J. H. McCullough, who assisted and 
attended to subsequent treatment, informs 
me that suppuration hastened by poultices 
took place, and healing as desired. I 
saw the patient one year after. The 
growth was not apparent; the patient 
much improved in health and grateful for 
treatment. 
Case IV. Miss H., jet. 20; student; 
was first seen June, 1888, with simple 
parenchymatous goitre of medium dimen- 
sions. A hypodermic of tr. iodine in six 
weeks reduced the thyroid to normal size. 
In October, 1891, patient presented her- 
self with large growth over the thyroid 
region. She was very anaemic, eyes pro- 
truding, and had dyspnoea and stupidity. 
The presence of a liquid cavity was deter- 
mined with the hypodermic syringe, and 
its contents shown to resemble grumous 
fluid. Cocaine was used and an opening 
made down to the cyst wall. This was 
opened with bistoury. Hemorrhage was 
copious, but with fingers in wound some- 
what under control. Adjoining cysts to 
the one opened were determined upon and 
septas severed. Packing with cotton and 
compress stopped bleeding. The second 
day chromic acid was applied to the inside 
of cavity repacked. No constitutional 
disturbance followed and my associate Dr. 
J. H. McCullough, who was present and 
attended subsequently,reports no incidents 
of importance. I saw patient one year 
after and the central enlargement had 
disappeared. There was no prominence 
of eyes nor dyspnoea. The general health 
of the patient was greatly improved. The 
lateral lobes were somewhat enlarged, but 
the results were satisfactory to the patient. 
CONCLUSION. 
It is quite unnecessary to state that the 
dangers of such treatment was made 
known to the patients. They were under- 
taken as a duty rather than as an antici- 
pated pleasure. All the precautions that 
go along with modern surgery: cleanliness, 
etc., were observed as far as practical. 
Prof. Depuis reports cases treated with 
trocar, canula, and tr. iodine. Canulaleft 
no wound while healing. Billroth reports 
a death from suppuration and septicaemia 
after injection of alcohol. With an open 
wound there is less danger from septicae- 
mia, and it is more under control. In- 
cision is to be preferred to excision of the 
cyst owing to difficulties attending the 
operation and dangers following, such as 
shock, etc. Removal of gland is con- 
demned by more recent writers owing to 
the danger of a development of a con- 
dition first described by Sir Win. Gull, 
and afterwards by Dr. Ord named 
myxoedema. A state in which meucin is 
developed in the connective tissue, and 
higher phychological centres become less 
responsive. This is, doubtless, the 
cachexia strumipriva of the German 
writers. The few cases of myxoedema 
seen by the writer resembled forms of 
cretinism. Cutting out a portion of the 
isthmus of the thyroid, first practiced by 
Sidney Jones, is said to be efficient treat- 
ment, but in those cases the anatomical 
identity of isthmus could not be recog- 
nized, owing to degeneration malforma- 
tions. The hemorrhage is free, but 
except in haemophilia under eontrol with 
the packing and caustic as described. 
That there is danger from air and blood 
clot entering the veins there is no doubt, 
but in all surgery involving veins of the 
neck the risk can be lessened by pressure 
below the seat of incision. It is said that 
that those who follow the service of the 
gynecologist or the ophthalmologist learn 
how much traumatism the abdomen or 
the eye can stand, and it is hoped from a 
perusal of this paper some reader may 
better estimate how much meddling the 
cyst of the thyroid in some cases will 
stand with benefit to their possessors.