Rarely the parts supplied by the bra chial plexus of nerves show the result of pressure upon that plexus, and we meet with paralysis of certain muscles of the arm, numbness of the fingers and other portions of the upper extremities. Such disturbances occur in growths of large size tending to spread downward beneath the clavicle and sternum.
It is rather remarkable that there is rarely any description of disturbances of deglutition; it would seem that, where there are large growths in the neck, the oesophagus easily adjusts itself to one or other side.
Apart from these symptoms due to local pressure, there are other symptoms which have been too much neglected, to be made out more especially in younger women, and of the same class as the psychoses seen in exophthalmic goitre. There may be no palpitation nor tachy cardia and no exophthalmos, but, as Dr. Shepherd has pointed out to me in con nection with the numerous cases occur ring in the neighborhood of Montreal, very frequently the patients are of a nervous disposition, fearful, and unable to settle down to sustained work; tremors are very rarely observed. An interesting fact, however, is to be made out: that, upon enucleation of the cysts or enlarged adenomatous masses in the gland, the nervous condition almost immediately becomes so much improved that evi dently these symptoms are allied to those of hyperthyroidism and exophthalmic goitre.
Subjects of goitre become insane about nine times as frequently as normal sub jects. The degenerative and puerperal forms of insanity predominate in goitrous ewes. Goitrous patients, with curable forms of insanity, recover as frequently as do non-goitrous; nor is there any special difference in the duration of the disease. The thyroid gland, they con clude, has a direct action upon the cen tral nervous system. Marzocchi and An tonini (Review of Insanity and Nervous Dis., June, '92).
Still more rare, though occasionally recorded in those especially of middle life, is the supervention of symptoms pointing to atrophy of the gland-tissue and the definite development of myxco dema. The heavy appearance and dis position of many middle-aged goitrous subjects is very probably due to relative incompetency of the thyroid. It must
be kept in mind that such symptoms of disturbed function of the gland deserve to be carefully sought out and recorded, for up to the present time little or noth ing has been systematically accomplished either to distinguish the functional dis turbances brought about by one or other form of "ordinary" goitre or to co-ordi nate the symptoinatology of ordinary and exophthalmic goitre.
Diagnosis.—If we leave out of account the enlargement of accessory thyroid bodies, the diagnosis of goitre (apart from that of the various forms of this condition) is a relatively simple matter, and from the position of the thyroid and the ease with which it can be palpated there is little likelihood of mistaking the persistent enlargement of this organ for any other condition. Where accessory thyroids are enlarged, it is practically impossible to arrive at an exact conclu sion as to the nature of the enlargement, unless, indeed, this takes on the char acter of malignancy, and then the evi dence of secondary growth affecting the bones, recognizable in sonic rare cases, world give a certain amount of support to the belief that the primary growth in the neck region originated in the thyroid tissue.
Between the forms of goitre, save as between benign and malignant, up to the present time very little stress has been laid upon differential diagnosis. If, in the first place, the whole of the lobe or the gland be uniformly enlarged, it is necessary to differentiate between the vascular and general hyperplastic goitres and the condition of acute suppurative interstitial thyroiditis. This last condi tion is rare, and the evidence of sepsis alone and the local evidence of inflamma tion will distinguish this from other forms.
Vascular goitre is characterized by the fact that pressure upon the organ leads to marked diminution in its size, the organ soon returning to its former di mensions after the pressure has been re moved. In its slighter conditions simple hyperaemia of the gland leads merely to the rounding of the neck. In the very rare condition of struma aneurismatica there is marked pulsation, and upon aus cultation arterial murmurs are to be made out.