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Tuberculosis of the thyroid gland
TUBERCULOSIS
OF THE THYROID GLAND* T. BANFORD
JONES,
ROCHESTER, UBERCULOUS infection of the thyroid gIand is a rare condition. AIthough of late severa excelIent reports have appeared in the literature, the incidence of thyroid tuberculosis is stiI1 \-et->- IO\\-. Quite naturaIIy the earliest reported c’nses were those discovered at postmortem examination, the majority 01‘these being cases of miliary tuberculosis in which the infection was so acute and o\.erwheIming that a11organs \vere invoIved. E\,en so, it \vss noted by pathoIogists that only a very smaII percentage of such cases shelved thyroid invoIvement and this obser\,ation Ied to such statements as that of Virchow that “the presence of a goiter was proof that the subject was not Some pathologists even went tuberculous.” so far as to say that the thyroid gIand by tubercuIosis. \vas ne\-er invaded \F’ith the deveIopment of surgery of the thyroid gland and the coincident thorough examination of gross and microscopic tissue removed at operation, the pathoIogic processes to which the thyroid is subject ha\-e become better known and more cnrefuIIy studied. It I\-ouId seem that with an increase in the number of glands studied the number of cases of tubercuIous involvement wouId increase RISO but this has not been the case. Thus reported 9 cases of in 191: Mosimanl tuberculosis of the thyroid from CriIe’s of Iess an incidence clinic, representing and than I per cent. In 1920, Plummer Broders” reported onI)- 7 cases from the h,layo Clinic. An excellent rcvielv of the subiect \vas presented I~)- CoIIer and Huggins:’ in 1926 in which the)- summarized aII reported cases, adding 5 of their own, ~1hich represented the total number of cases of thq-roid tuberculosis encountered in I zoo thyroid cases treated by operation. In looking o\‘er the literature on the subiect
N. Y.
2 additional cases4’Z not included in their report, were discovered. Since 1926 there have appeared severa reports: Higgins6 reported 5 additiona cases from CriIe’s cIinic betbveen the years of 192 I 1926; an incidence of 0.13 per cent in the total series i incIuding I 9 I 7 report by %losiman i ; Smith and Leech7 reported 3 cases encountered in some 1500 thyroid operations ant1 100 autopsies in the Lahey clinic, an incidence of 0.25 per cent; Askmazy and E. Marcuse each reported 2 cases. The 2 cases reported in the present communication are the only case‘s encountered in 67 thwoid operations since the opening of the chnic two years ago, ;ln incidence of 3 per cent.
T
* Submitted
h%.D
CASE I r&X). 1%‘. G., male, aged sistb-~,lemoriaf \\-as admitted to Strong I;)ur, I fospital April 18, 1927 complaining of :I lump in the neck. A small tumor the six of a \\-afnut rvas first noticed three months before acfmission. This increased rapidly in size and there with \\as some ct)-spfx~gia for six months hoarseness for three or four \veclis. l’llcrc were no svmptoms of hyperthyroidism. The main physkaf findings aside from the local t:oncfition were undernourishment, arteriosclerosis v ith 200,’ 100). rmphysenia, hypertension (B.P. cardiac hypertrophy, prostatic flppertrophy, left inguinaf hernia and bilatcraf varicose veins. The thyroid showecf little if any generalized enlargement but there was a prominent tumor over the isthmus 5 to 7 cm. in clinmctc~r. This tumor mox-cd on cfegfutition, \\as tense, encapsulated, non-ffuctuant, not painful ancf tfle skin was not adherent. The \Ihole tumor was freely moveal~fe up and cloxvn but not fateralI?-. A Jxx?OperativC di:~gnOsis Of :i&!nOinz~ Of tlic thyroid with hemorrhage :1n(1 cystic degeneration was made. Operation 152s performecf 11‘. l3. .I ., April 20, 1920) uncfcr I per cent procaine ancsthcsia. The usual necklace incision ~\:Is nlatlc. ‘rhe riljbon muscles \\cre cfensefy adherent to the :~ntl the ficfcl of operation presented tumor
for publicxtion 029
February
25,
1929.
630
Ame&an Journal of
Surgery
Jones-Tuberculosis
evidence of a diffuse chronic infIammatory process. At this stage of the operation the remark was made bv the operator that the d&uIty of dissection suggested that encountered in tuberculous adenitis. No Iine of cIeavage couId be found between the ribbon muscIes and tumor. After freeing the muscles attempts were made to enucleate the tumor which was identified as arising from the isthmus of the thyroid. During dissection the capsule of the tumor was broken and immediateIy there escaped a thick creamy yeIIow pus containing small caseous particles. No further attempts were made to enucleate the mass. The anterior part of the thick fibrous capsuIe was removed and the posterior aspect was seen to be composed of thyroid tissue, much aItered by inflammatory reaction. AI1 caseous and necrotic tissue was removed and the ribbon muscIes sutured Ioosely in the miclline, and skin tlaps closed with a small subcutaneous drain. The patient had an uneventfu1 postoperative the drain was removed in convalescence; twenty-four hours and there continued to be slight serous drainage. Intensive uItravioIet light therapy was used with considcrabIe improvement. The patient, however, disappeared before the wound was entirely heaIed and attempts to locate him have been unsuccessful. Pathologic report on a very smaI1 piece of tissue showed no thyroid tissue but a diffuse chronic inflammation with areas of necrosis ant1 giant celIs. No tubercles could be identified. However, a guinea pig innocuIated with pus obtained at operation was autopsied May 27 and found to have extensive generaIized tubercuIosis.
CASE II (11,423). J. C., femaIe, aged fiftynine, was admitted to the Strong &IemoriaI HospitaI, November 28, 1927, complaining of “pounding and fluttering over the heart,” insomnia, weakness and fatigue. The present illness began five months before aclmission with the symptoms noted. The palpitation became accentuated eight weeks before admission and the patient \vas sent in the hospitaI for observation by, her physician. The past history was rather Interesting in that twcntyeight years before aclmission the patient had her left breast amputated for “chronic ulceration not carcinoma.” The patient’s mother had “nervous goiter ” and died folIowing operation at the age of seventy. Her father
of Thyroid
NO~EMDER,1920
died at sixty-eight of tuberculosis. One brother died at the age of thirty of tubercuIosis. The patient’s best weight was 168 pounds, tweIve years before admission, her average weight rvas 144 pounds. The positive findings on physical csamination at the time of admission were: emaciand nervousness, slight ation, hyperactivity tremor of eyelids and hands; the thyroid was paIpabIe but not markecIIy enlarged, smooth with no noduIes; a bruit was audibIe over right poIe of thyroid; examination of the chest showed slight impairment of the percussion note in the right interscapular region and at the right apex anteriorIy but the breath sounds were normaI. The heart was negative except for a systoIic murmur at the base, B.P. 145/7$, rate 80. There was slight scIerosis of the radia1 vesseIs. Abdominal, pelvic and were negative. The rectal examinations extremities were negative except for moist skin. The reflexes were slightly hyperactive. Lnboratory findings: R.B.C. 5,380,ooo; W.B.C. 9180; Hb. 90 per cent; N.P.N. 38.7 Roentgen-ray examination of the chest showed an obsoIete tubercuIosis with caIcification of gIands at the hilus. The basal metaboIic rate was pIus 21; the Wassermann reaction was negative; the electrocardiogram was normal. On several occasions the patient cIeveIoped paroxysmal auricuIar GbriIIation. Under treatment with Lugols soIution her symptoms improved, the B.M.R. dropping to plus 9 per cent. The case was diagnosed as one of hyperthyroidism. Operation was performed (December 20, 1927, T.B.J.). The gland appeared sIightIy eniarged, rather friable and quite similar to the usual hyperpIastic gland. A subtotal thyroidectomy was done and the wound cIosed without drainage. The wound heaIed per primam. The second day after operation the patient had an attack of auricular fibriIIation Iasting an hour or two. Eleven days after operation, the basa1 metaboiism rate was minus 15 per cent arising to minus 4 per cent on the eighteenth day. There were transient attacks of auricular fibriIIation during the first week after operation but none thereafter. Patient improved cIaiJy, with considerable diminution of nervousness and was discharged January 7, 1928. PathoIogic report: The specimen consists of part of two Iobes of thyroid tissue 2.4 J>y 3 by 1.5 weighing 12 gm. each, meaty, friable of uniform consistency. Microscopic examination:
NEW SERLKS \‘oI..
\‘lI,
NO. j
Jones-
TubercuIosis
The sections show thyroid tissue with rather smaI1 acini, in places aImost obliterated. There is considerabIe round ceII infiltration. No marked tufm-cks
hyperplasia. There with giant cells.
are
numerous
DlSCUSSION
In genera1 these cases pathoIogicalIy are quite simiIar to other reported cases. The first case presented the more unusua1 pathoIogic picture, that of a tuberculous abscess. From the appearance of the operative fieId it would seem that at one time the thyroid gland had been the seat of a rather extensive and active inflammation. The second case showed the picture of diffuse invoIvement with some fibrosis and numerous tubercIes but very littIe h)-perpIasia of the gIancI structures. Considerable has been written on the subject as regards the types of pathoIogic picture most often encountered and the types of gIands invoIved, whether normaI, hyperpIastic or adenomatous. Thus Higgins1 feeIs that tubercuIosis of the thyroid gland is most commonIy associated with hyperthyroidism, pointing out that IO of the 14 cases from CriIe’s series showed increased activity. This naturaIIy brings up the question as to whether the tubercuIous infection causes a hyperpInsia of the remaining glanduIar tissue or the hyperpIastic gland is more susceptibIe to tubercuIous infection than a normal gland. Torri,lO and Roger and Gamier” as earIy as 1900 produced tubercuIosis of the thyroid gIand by injecting emulsions of the tub&e baciIii into the thyroid and carotid arteries of guinea pigs and rabbits. The former noted that the infection was Iimited to the injected side, ant1 the outstanding features were the new formation of follicles, proliferation of the epithehum, :[I1 d an increase in colloid. He a1s0noted microscopicaIIy that sections of gIands taken one to three days after injection sho\ved the baciIIi in the coIIoid to be granular and less easily stained than those Iying in the stroma and that sections
of ThJ-raid
A mericnn J,turnz~l (I( Su~gqry
631
of glands taken ten days after injection showed no organisms in the coIloid. He interpreted this as evidence that the colIoid had a definite antagonistic and destructive influence toward the tubercle baciIli. He also noted that the addition of thyroid extract to his cuItures of tubercle bacilli prevented further growth. Since the Iack of colloid in hyperpIastic glands is one of the outstanding features it might seem pIausible to attribute Higgins’ findings to this feature. On the other hand CoIIer and Huggins conclude from their review of reported cases that the hyperplastic gIand is not more susceptibIe to tubercuIous infection. Their survey showed that the majority of reported cases occurred in adenomatous gIands. They also feel that evidence tends to show that tubercuIosis of the thyroid gIand produces no dysfunction other than a tendencv to myxedema by a destruction of gIand -tissue and subsequent fibrosis. No definite statements can be made on these points until further clinica an d experimental e\-idence accumuIates. In considering the different t;spes of pathologic pictures encountered such as difruse miliary tubercIes, “coId abscess,” fibrosis, etc., rt seems that Iittle can be gained by considering the reIative frequency wrth which each type is encountered. AI1 represent tuberculous infection and undoubtedIy the pathologic picture in each case depends on the classical factors influencing infection any\vhere in the body, the resistence of the patient nameIy, and tissue invoIved, the virulence of the organism, etc. CIinicalIy these 2 cases present nothing unusua1 unless it be the suggestive history in the second case. The patient gave a in the family history of tubercuIosis (father and brother died of tubercuIosis), she herself had had a chronic ulcerative Iesion of one breast (not carcinom:~) some years before and the roentgenogram of her chest showed an old tuberculosis of the Iung. Considering this in retrospect it presents an exceIIent setting for tuber-
632
American
Journal
of Surgery
Jones-TubercuIosis
culosis of the thyroid. Here again the cases were quite in accordance with other reported cases in that the diagnosis was not onIy missed but not even considered. In onIy one instance of a11 the reported cases was the diagnosis of tubercuIosis even considered. This naturaIIy brings up the question of differential diagnosis of tubercuIosis of the thS;roid gland and after studying the subJect carefuIIy we are forced to admit that there are no diagnostic points peculiar to this condition alone. The observation made most frequently has been that the gIands are very firm, hard and fixed, in some instances with skin adherent, so as to suggest carcinoma but even these features are not sufIicientIy constant to be of much vaIue. UntiI we have more experience with such cases and deveIop more exact diagnostic methods it seems highIy probabIe that the condition will continue to pass unrecognized unIess discovered
of Thyroid
NO\.EMR~H.
‘r,.q
by microscopic examination of the gland tissue. Although admitting failure in the matter of diagnosis we are better equipped therapeuticaIly, for subtota1 thyroidectomy in these cases gives exceIIent results. Even in the cases with the most extensive tuberculous invasion the majority of wounds heal per primam and symptoms are relieved. It seems, therefore, that nature here, as in so many instances, compensates for our mistakes.
2.
OF THE THYROID GLAND* T. BANFORD
JONES,
ROCHESTER, UBERCULOUS infection of the thyroid gIand is a rare condition. AIthough of late severa excelIent reports have appeared in the literature, the incidence of thyroid tuberculosis is stiI1 \-et->- IO\\-. Quite naturaIIy the earliest reported c’nses were those discovered at postmortem examination, the majority 01‘these being cases of miliary tuberculosis in which the infection was so acute and o\.erwheIming that a11organs \vere invoIved. E\,en so, it \vss noted by pathoIogists that only a very smaII percentage of such cases shelved thyroid invoIvement and this obser\,ation Ied to such statements as that of Virchow that “the presence of a goiter was proof that the subject was not Some pathologists even went tuberculous.” so far as to say that the thyroid gIand by tubercuIosis. \vas ne\-er invaded \F’ith the deveIopment of surgery of the thyroid gland and the coincident thorough examination of gross and microscopic tissue removed at operation, the pathoIogic processes to which the thyroid is subject ha\-e become better known and more cnrefuIIy studied. It I\-ouId seem that with an increase in the number of glands studied the number of cases of tubercuIous involvement wouId increase RISO but this has not been the case. Thus reported 9 cases of in 191: Mosimanl tuberculosis of the thyroid from CriIe’s of Iess an incidence clinic, representing and than I per cent. In 1920, Plummer Broders” reported onI)- 7 cases from the h,layo Clinic. An excellent rcvielv of the subiect \vas presented I~)- CoIIer and Huggins:’ in 1926 in which the)- summarized aII reported cases, adding 5 of their own, ~1hich represented the total number of cases of thq-roid tuberculosis encountered in I zoo thyroid cases treated by operation. In looking o\‘er the literature on the subiect
N. Y.
2 additional cases4’Z not included in their report, were discovered. Since 1926 there have appeared severa reports: Higgins6 reported 5 additiona cases from CriIe’s cIinic betbveen the years of 192 I 1926; an incidence of 0.13 per cent in the total series i incIuding I 9 I 7 report by %losiman i ; Smith and Leech7 reported 3 cases encountered in some 1500 thyroid operations ant1 100 autopsies in the Lahey clinic, an incidence of 0.25 per cent; Askmazy and E. Marcuse each reported 2 cases. The 2 cases reported in the present communication are the only case‘s encountered in 67 thwoid operations since the opening of the chnic two years ago, ;ln incidence of 3 per cent.
T
* Submitted
h%.D
CASE I r&X). 1%‘. G., male, aged sistb-~,lemoriaf \\-as admitted to Strong I;)ur, I fospital April 18, 1927 complaining of :I lump in the neck. A small tumor the six of a \\-afnut rvas first noticed three months before acfmission. This increased rapidly in size and there with \\as some ct)-spfx~gia for six months hoarseness for three or four \veclis. l’llcrc were no svmptoms of hyperthyroidism. The main physkaf findings aside from the local t:oncfition were undernourishment, arteriosclerosis v ith 200,’ 100). rmphysenia, hypertension (B.P. cardiac hypertrophy, prostatic flppertrophy, left inguinaf hernia and bilatcraf varicose veins. The thyroid showecf little if any generalized enlargement but there was a prominent tumor over the isthmus 5 to 7 cm. in clinmctc~r. This tumor mox-cd on cfegfutition, \\as tense, encapsulated, non-ffuctuant, not painful ancf tfle skin was not adherent. The \Ihole tumor was freely moveal~fe up and cloxvn but not fateralI?-. A Jxx?OperativC di:~gnOsis Of :i&!nOinz~ Of tlic thyroid with hemorrhage :1n(1 cystic degeneration was made. Operation 152s performecf 11‘. l3. .I ., April 20, 1920) uncfcr I per cent procaine ancsthcsia. The usual necklace incision ~\:Is nlatlc. ‘rhe riljbon muscles \\cre cfensefy adherent to the :~ntl the ficfcl of operation presented tumor
for publicxtion 029
February
25,
1929.
630
Ame&an Journal of
Surgery
Jones-Tuberculosis
evidence of a diffuse chronic infIammatory process. At this stage of the operation the remark was made bv the operator that the d&uIty of dissection suggested that encountered in tuberculous adenitis. No Iine of cIeavage couId be found between the ribbon muscIes and tumor. After freeing the muscles attempts were made to enucleate the tumor which was identified as arising from the isthmus of the thyroid. During dissection the capsule of the tumor was broken and immediateIy there escaped a thick creamy yeIIow pus containing small caseous particles. No further attempts were made to enucleate the mass. The anterior part of the thick fibrous capsuIe was removed and the posterior aspect was seen to be composed of thyroid tissue, much aItered by inflammatory reaction. AI1 caseous and necrotic tissue was removed and the ribbon muscIes sutured Ioosely in the miclline, and skin tlaps closed with a small subcutaneous drain. The patient had an uneventfu1 postoperative the drain was removed in convalescence; twenty-four hours and there continued to be slight serous drainage. Intensive uItravioIet light therapy was used with considcrabIe improvement. The patient, however, disappeared before the wound was entirely heaIed and attempts to locate him have been unsuccessful. Pathologic report on a very smaI1 piece of tissue showed no thyroid tissue but a diffuse chronic inflammation with areas of necrosis ant1 giant celIs. No tubercles could be identified. However, a guinea pig innocuIated with pus obtained at operation was autopsied May 27 and found to have extensive generaIized tubercuIosis.
CASE II (11,423). J. C., femaIe, aged fiftynine, was admitted to the Strong &IemoriaI HospitaI, November 28, 1927, complaining of “pounding and fluttering over the heart,” insomnia, weakness and fatigue. The present illness began five months before aclmission with the symptoms noted. The palpitation became accentuated eight weeks before admission and the patient \vas sent in the hospitaI for observation by, her physician. The past history was rather Interesting in that twcntyeight years before aclmission the patient had her left breast amputated for “chronic ulceration not carcinoma.” The patient’s mother had “nervous goiter ” and died folIowing operation at the age of seventy. Her father
of Thyroid
NO~EMDER,1920
died at sixty-eight of tuberculosis. One brother died at the age of thirty of tubercuIosis. The patient’s best weight was 168 pounds, tweIve years before admission, her average weight rvas 144 pounds. The positive findings on physical csamination at the time of admission were: emaciand nervousness, slight ation, hyperactivity tremor of eyelids and hands; the thyroid was paIpabIe but not markecIIy enlarged, smooth with no noduIes; a bruit was audibIe over right poIe of thyroid; examination of the chest showed slight impairment of the percussion note in the right interscapular region and at the right apex anteriorIy but the breath sounds were normaI. The heart was negative except for a systoIic murmur at the base, B.P. 145/7$, rate 80. There was slight scIerosis of the radia1 vesseIs. Abdominal, pelvic and were negative. The rectal examinations extremities were negative except for moist skin. The reflexes were slightly hyperactive. Lnboratory findings: R.B.C. 5,380,ooo; W.B.C. 9180; Hb. 90 per cent; N.P.N. 38.7 Roentgen-ray examination of the chest showed an obsoIete tubercuIosis with caIcification of gIands at the hilus. The basal metaboIic rate was pIus 21; the Wassermann reaction was negative; the electrocardiogram was normal. On several occasions the patient cIeveIoped paroxysmal auricuIar GbriIIation. Under treatment with Lugols soIution her symptoms improved, the B.M.R. dropping to plus 9 per cent. The case was diagnosed as one of hyperthyroidism. Operation was performed (December 20, 1927, T.B.J.). The gland appeared sIightIy eniarged, rather friable and quite similar to the usual hyperpIastic gland. A subtotal thyroidectomy was done and the wound cIosed without drainage. The wound heaIed per primam. The second day after operation the patient had an attack of auricular fibriIIation Iasting an hour or two. Eleven days after operation, the basa1 metaboiism rate was minus 15 per cent arising to minus 4 per cent on the eighteenth day. There were transient attacks of auricular fibriIIation during the first week after operation but none thereafter. Patient improved cIaiJy, with considerable diminution of nervousness and was discharged January 7, 1928. PathoIogic report: The specimen consists of part of two Iobes of thyroid tissue 2.4 J>y 3 by 1.5 weighing 12 gm. each, meaty, friable of uniform consistency. Microscopic examination:
NEW SERLKS \‘oI..
\‘lI,
NO. j
Jones-
TubercuIosis
The sections show thyroid tissue with rather smaI1 acini, in places aImost obliterated. There is considerabIe round ceII infiltration. No marked tufm-cks
hyperplasia. There with giant cells.
are
numerous
DlSCUSSION
In genera1 these cases pathoIogicalIy are quite simiIar to other reported cases. The first case presented the more unusua1 pathoIogic picture, that of a tuberculous abscess. From the appearance of the operative fieId it would seem that at one time the thyroid gland had been the seat of a rather extensive and active inflammation. The second case showed the picture of diffuse invoIvement with some fibrosis and numerous tubercIes but very littIe h)-perpIasia of the gIancI structures. Considerable has been written on the subject as regards the types of pathoIogic picture most often encountered and the types of gIands invoIved, whether normaI, hyperpIastic or adenomatous. Thus Higgins1 feeIs that tubercuIosis of the thyroid gland is most commonIy associated with hyperthyroidism, pointing out that IO of the 14 cases from CriIe’s series showed increased activity. This naturaIIy brings up the question as to whether the tubercuIous infection causes a hyperpInsia of the remaining glanduIar tissue or the hyperpIastic gland is more susceptibIe to tubercuIous infection than a normal gland. Torri,lO and Roger and Gamier” as earIy as 1900 produced tubercuIosis of the thyroid gIand by injecting emulsions of the tub&e baciIii into the thyroid and carotid arteries of guinea pigs and rabbits. The former noted that the infection was Iimited to the injected side, ant1 the outstanding features were the new formation of follicles, proliferation of the epithehum, :[I1 d an increase in colloid. He a1s0noted microscopicaIIy that sections of gIands taken one to three days after injection sho\ved the baciIIi in the coIIoid to be granular and less easily stained than those Iying in the stroma and that sections
of ThJ-raid
A mericnn J,turnz~l (I( Su~gqry
631
of glands taken ten days after injection showed no organisms in the coIloid. He interpreted this as evidence that the colIoid had a definite antagonistic and destructive influence toward the tubercle baciIli. He also noted that the addition of thyroid extract to his cuItures of tubercle bacilli prevented further growth. Since the Iack of colloid in hyperpIastic glands is one of the outstanding features it might seem pIausible to attribute Higgins’ findings to this feature. On the other hand CoIIer and Huggins conclude from their review of reported cases that the hyperplastic gIand is not more susceptibIe to tubercuIous infection. Their survey showed that the majority of reported cases occurred in adenomatous gIands. They also feel that evidence tends to show that tubercuIosis of the thyroid gIand produces no dysfunction other than a tendencv to myxedema by a destruction of gIand -tissue and subsequent fibrosis. No definite statements can be made on these points until further clinica an d experimental e\-idence accumuIates. In considering the different t;spes of pathologic pictures encountered such as difruse miliary tubercIes, “coId abscess,” fibrosis, etc., rt seems that Iittle can be gained by considering the reIative frequency wrth which each type is encountered. AI1 represent tuberculous infection and undoubtedIy the pathologic picture in each case depends on the classical factors influencing infection any\vhere in the body, the resistence of the patient nameIy, and tissue invoIved, the virulence of the organism, etc. CIinicalIy these 2 cases present nothing unusua1 unless it be the suggestive history in the second case. The patient gave a in the family history of tubercuIosis (father and brother died of tubercuIosis), she herself had had a chronic ulcerative Iesion of one breast (not carcinom:~) some years before and the roentgenogram of her chest showed an old tuberculosis of the Iung. Considering this in retrospect it presents an exceIIent setting for tuber-
632
American
Journal
of Surgery
Jones-TubercuIosis
culosis of the thyroid. Here again the cases were quite in accordance with other reported cases in that the diagnosis was not onIy missed but not even considered. In onIy one instance of a11 the reported cases was the diagnosis of tubercuIosis even considered. This naturaIIy brings up the question of differential diagnosis of tubercuIosis of the thS;roid gland and after studying the subJect carefuIIy we are forced to admit that there are no diagnostic points peculiar to this condition alone. The observation made most frequently has been that the gIands are very firm, hard and fixed, in some instances with skin adherent, so as to suggest carcinoma but even these features are not sufIicientIy constant to be of much vaIue. UntiI we have more experience with such cases and deveIop more exact diagnostic methods it seems highIy probabIe that the condition will continue to pass unrecognized unIess discovered
of Thyroid
NO\.EMR~H.
‘r,.q
by microscopic examination of the gland tissue. Although admitting failure in the matter of diagnosis we are better equipped therapeuticaIly, for subtota1 thyroidectomy in these cases gives exceIIent results. Even in the cases with the most extensive tuberculous invasion the majority of wounds heal per primam and symptoms are relieved. It seems, therefore, that nature here, as in so many instances, compensates for our mistakes.
2.