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SURGERY AND PATHOLOGY 
 
 OF THE 
 
 THYROID AND PARATHYROID GLANDS 
 
.J! , 
 
THE 
 
 SURGERY AND PATHOLOGY 
 
 OF THE 
 
 Thyroid and Parathyroid Glands 
 
 BY 
 
 ALBERT J. OCHSNKR, A. M., M. D., LL. D.. 
 
 Professor of Surgery in the Medical Department of the University of Illinois, 
 Chief Surgeon to Augustana Hospital and St. Mary's Hospital, Chicago, 
 
 and •; 
 
 RALPH L. THOMPSON, A. M., M. D., 
 
 Professor of Pathology in the St. Louis University School of Medicine, 
 
 St. Louis. 
 
 ft 
 With 57 Illustrations in the Text and 40 Full-1/a.ge Plates, 
 4 of the Plates being in Colors. , 
 
 ST. LOUIS,: 
 C. V. MOSBY COMPANY, 
 
 19 10 J|t i 
 
 I ■ I 
 
 

 Copyright, 1910, by C. V. Mosby "Company, 
 
 £ &} 
 
 
 I ' 
 
TO 
 
 DR. CHARLES H. MAYO, 
 
 IN RECOGNITION OF HIS SPLENDID WORK IN THE 
 DEVELOPMENT OF THYROID SURGERY IN AMERICA, 
 
 THIS VOLUME IS DEDICATED BY 
 
 THE AUTHORS. 
 
PREFACE. 
 
 The great interest that surgeons and pathologists 
 are experiencing in the study and treatment of 
 diseases of the thyroid and parathyroid glands 
 seems to justify the production of the present 
 volume, which has been planned to bring to the 
 practitioner of surgery and medicine the result of a 
 study of the work of those who have given much 
 time to the development of this special field. It 
 also includes the clinical and technical personal ex- 
 perience in the surgical treatment of a large number 
 of patients suffering from diseases of the thyroid 
 gland which have come under the care of the senior 
 author during the past twenty years. It has seemed 
 proper to give special emphasis to details which 
 have practical value in the diagnosis and treatment 
 of exophthalmic goitre, because in this matter this 
 book will probably have its greatest field of use- 
 fulness. 
 
 In the chapter on thyroid pathology the attempt 
 has been made to simplify as much as possible our 
 understanding of goitre. A basis for a clinical and 
 pathological correlation of the symptoms and mor- 
 phological changes in the thyroid gland in exoph- 
 thalmic goitre has been offered by Dr. Louis B. 
 Wilson', and we have taken full advantage of his 
 excellent study of the subject. We are also in- 
 debted to Dr. Wilson for several illustrations which 
 accompany the text. The organization of surgical 
 clinics has made possible, by the proper relationship 
 of surgeon, internist and pathologist, not only the 
 
6 PREFACE 
 
 most satisfactory treatment, but also the most 
 advanced pathological study of this disease that we 
 are able to offer at the present time. 
 
 An apology for the compilation of the main facts 
 regarding the parathyroid glandules here presented 
 is not necessary. These vital organs have been too 
 long neglected, both in medical text books and in 
 medical teaching. Most students have never seen 
 the parathyroid glandules, and there is no text book 
 that devotes more than a brief paragraph to these 
 bodies — organs that are necessary for the mainte- 
 nance of life. In fact, until the excellent chapters of 
 Dr. George Dock appeared in Osier's Modern Medi- 
 cine even the more exhaustive books had practically 
 disregarded these glandules. 
 
 The author of this section of the book wishes to 
 express his indebtedness to Professor Ludwig Pick, 
 Director of the Pathological Institute, Friedrichs- 
 hain, Berlin, for assistance and stimulation which 
 has led to the accomplishment of much of the 
 original work by the author that is included in 
 these chapters. 
 
 The section of the book on the thyroid gland, with 
 the exception of the chapter on pathology, is written 
 by the senior author ; this chapter and the section on 
 the parathyroid glandules are by the junior author. 
 
 A. J. Ochsner. 
 R. L. Thompson. 
 
CONTENTS. 
 
 PART I. 
 
 Chapter • 
 
 I. 
 
 Chapter 
 
 II. 
 
 Chapter 
 
 III. 
 
 Chapter 
 
 IV. 
 
 Chapter 
 
 V. 
 
 Chapter 
 
 VI. 
 
 Chapter 
 
 VII, 
 
 Chapter 
 
 VIII. 
 
 Chapter 
 
 IX, 
 
 Chapter 
 
 X. 
 
 Chapter 
 
 XI 
 
 THE THYROID GLAND. 
 
 The Surgical Consideration of the Thyroid 
 
 Gland ' 9 
 
 The Pathology of the Thyroid Gland ... 14 
 
 Diagnosis 36 
 
 Non-Surgical Treatment 77 
 
 Anaesthesia 90 
 
 Dangers of Operation 110 
 
 Indications for Operation on the Thyroid 
 
 Gland 119 
 
 Thyroidectomy 126 
 
 Other Operations on the Thyroid Gland . . 163 
 
 Prognosis in Exophthalmic Goitre .... 178 
 
 Heredity in Goitre ......... 191 
 
 PART II. 
 
 THE PARATHYROID GLANDULES. 
 
 Chapter XII. Introduction — Historical — Function . . . 199 
 
 Chapter XIII. Anatomy 209 
 
 Chapter XIV. Embryology and Histology 227 
 
 Chapter XV. The Pathologic Histology of the Parathyroid 
 
 Glands 243 
 
 Chapter XVI. Cysts and Tumors 268 
 
 Chapter XVII. Relation of the Parathyroid Glands to Post- 
 operative Tetany 281 
 
 Chapter XVIII. Surgical Accidents in Man Due to Removal 
 
 of the Parathyroid Glandules 311 
 
 Chapter XIX. The Relation of the Parathyroid Glands to 
 
 Medical Tetany . 318 
 
 Chapter XX. Parathyroid Therapy 334 
 
PART I. 
 
 CHAPTER I. 
 
 THE SURGICAL CONSIDERATION OF THE 
 THYROID GLAND. 
 
 INTRODUCTION. 
 
 The first decade of the present century has added 
 the treatment of the diseases of the thyroid gland 
 to the surgical side of our art. This applies more 
 especially to that form of disease which had been 
 most discouraging heretofore, and which now is one 
 of the most satisfactory conditions in the field of 
 major surgery — namely, the disease generally known 
 in America as exophthalmic goitre. 
 
 • Although the diagnosis is practically never diffi- 
 cult at the time at which these patients come into 
 the care of the surgeon, still it has seemed to be of 
 great importance to discuss extensively the diagnosis 
 and differential diagnosis, and with this the history, 
 etiology, symptomatology and physical findings. 
 
 The treatment, after-treatment and prognosis will 
 be considered in detail, and special care will be taken 
 in making clear the points in the technic that seem 
 of importance in making the operative treatment 
 safe and the results immediately and ultimately 
 successful. 
 
10 THYROID GLAND 
 
 In the search for support for the various ideas in- 
 corporated in this volume in the literature of the 
 subject there have been encountered in the original 
 and in abstracts and references nearly twelve hundred 
 monographs, articles and case reports, less than ten 
 per cent, of these being surgical. 
 
 It would be quite useless to enumerate these and 
 
 many others which a further search of the literature 
 
 would reveal, and consequently only those have been 
 
 added to the bibliography that have aided very 
 
 materially in the development of the surgical side 
 
 of the subject. 
 
 history. 
 
 The surgical history of the diseases of the thyroid 
 gland is extremely meager before the last quarter 
 of the past century, when the remarkable work of 
 Theodor Kocher attracted the attention of the entire 
 surgical world by his practical demonstration — first 
 in a few, then in hundreds and later in thousands of 
 cases — that thyroidectomy, if performed skillfully, is 
 not the extremely dangerous operation that the 
 earlier surgeons had pictured. 
 
 He eliminated the principal dangers — namely, those 
 from anaesthesia, sepsis, hemorrhage, shock, hyper- 
 thyroidism, cachexia strumipriva, injury to the re- 
 current laryngeal nerve and injury to the para- 
 thyroid glands- — and gave us relatively an exceedingly 
 safe surgical procedure. In many of these features, 
 and especially in many of the details, much impor- 
 tant support came from other sources. 
 
 Moebius supplied a most important element for 
 the rational surgical treatment of the important 
 class of exophthalmic goitre by his logical and con- 
 
HISTORY 11 
 
 vincing studies, which made it clear that in this dis- 
 ease there is absorption of an excessive amount of 
 substance secreted by a diseased gland, which enters 
 the general circulation through the lymphatic system. 
 
 This important element will be referred to at 
 length at the proper place. In connection with this 
 part of the history of this subject it is proper to 
 state that Rehn pointed out just a quarter of a 
 century ago the splendid effect of surgical treat- 
 ment on exophthalmic goitre, and Tillaux had 
 pointed out similar results four years earlier in the 
 year 1880, although he had no definite theory by 
 which he could explain the great benefit obtained 
 by excision of the gland. There can be no doubt, 
 however, that the surgical treatment of exoph- 
 thalmic goitre resulted directly from the surgical 
 work of Kocher in simple goitre and the pathological 
 and physiological explanation of Moebius. 
 
 In this as in most other instances, the benefit of 
 operative treatment of exophthalmic goitre was 
 first observed accidentally in cases in which the 
 goitre was removed, not to cure this disease, but to 
 relieve pressure or deformity. 
 
 To the development of the technic much has been 
 added by the work of Dr. C. H. Mayo, of this country, 
 who has the largest personal experience in the treat- 
 ment of exophthalmic goitre at the present time. 
 
 The subject of exophthalmic goitre in its clinical 
 aspect dates back much further than the entire sub- 
 ject does in the surgical aspect. As early as 1786, 
 more than one and a quarter centuries ago, Parry 
 described this disease clearly, and in the year 1800 
 an Italian physician of the name of Flajani de- 
 
12 THYROID GLAND 
 
 scribed a disease much less clearly which undoubted- 
 ly represented the same condition. In the year 1828 
 Adelmann directed attention to the goitre heart. 
 
 In the year 1835 Graves described this disease in 
 his lectures, which were published in book form 
 eight years later — hence the name of Graves' disease. 
 This description was so clear that it was accepted as 
 typical by English speaking physicians throughout 
 the world. 
 
 In 1840 v. Basedow described this disease in Ger- 
 many, and since then it has been known as morbus 
 Basedowii, although the term was not formally 
 adopted until 1858, following the suggestion of 
 Hirsch. 
 
 From the standpoint of symptomatology and 
 diagnosis the observations of Charcot in 1856, those 
 of v. Graefe in 1864, those of Stellwag in 1865, those 
 of Marie, beginning in 1856 and continuing for a 
 period of forty years, seem to be of special impor- 
 tance, and will be considered fully in the discussion 
 of that portion of our subject. In 1873 Gull de- 
 scribed myxcedema. In 1882 Kocher established the 
 fact that this condition can be brought about regu- 
 larly by removing the entire thyroid gland — hence 
 his introduction of the term cachexia strumipriva. 
 The most important historical data regarding this 
 portion of our subject, however, seems to be that 
 Moebius was able in 1886 to permanently establish 
 the fact that exophthalmic goitre is a "form of 
 poisoning of the body through a diseased activity of 
 the thyroid gland," and not a disease due to some 
 primary lesion of the central nervous system, es- 
 pecially the medulla oblongata; neither a disease 
 
HISTORY 13 
 
 due to a pathological condition of the sympathetic 
 nervous system, nor a form of hysteria. It is a disease 
 due to a pathological development in the thyroid 
 gland itself. From the surgical standpoint the cor- 
 rectness of this theory had already been proven by 
 the cure of many patients suffering from this disease 
 whenever the diseased gland has been removed. 
 There are two publications, one published in France 
 by Tillaux in 1880 and the other in Germany by 
 Rehn in 1884, which seem of specially great his- 
 torical interest. The establishment of technic which 
 ensures safe and permanent surgical treatment 
 belongs to our contemporary surgeons. 
 
CHAPTER II. 
 
 THE PATHOLOGY OF THE THYROID GLAND 
 
 The function of the thyroid gland is to furnish 
 an internal secretion, which is not only important, 
 but indispensable, for the building up and mainte- 
 nance of the organism. A lack of this material 
 leads to nutritional disturbances (myxcedema or 
 cachexia), and its overproduction to nervous phe- 
 nomena (exophthalmic goitre) . Therefore, in a study 
 of this organ we are most interested in the condi- 
 tions which give rise to a diminution, an increase, 
 or a perversion of this important function. 
 
 A new field for study was offered in the experi- 
 mental problems that suggested themselves in con- 
 nection with thyroid function, which was opened by 
 the discovery of Kocher and of Reverdin, that ex- 
 tirpation of the thyroid was followed by severe 
 cachexia. At first these experiments were compli- 
 cated by a lack of knowledge of the parathyroid 
 glands, but that subject has now been made clear 
 by a more exact study of the latter organs, which 
 will be discussed in other chapters. Then came the 
 observation of the efficacy of mouth administered 
 thyroid extracts as a substitute for the gland itself, 
 and then the discovery that the thyroid possessed a 
 marked power of regeneration when transplanted — 
 sufficient, indeed, to act permanently for a removed or 
 diseased organ. 
 
< 
 
 Oh 
 
THE PATHOLOGY OF THE THYROID GLAND 15 
 
 Our knowledge of hyperthyroidism has been in- 
 creased by the ability to study glands removed at 
 various stages of Graves' disease, but the compli- 
 cated phenomena that occur in connection with the 
 reaction of thyroid diseases on the organism as a 
 whole still offer a rich field for investigation that 
 may well lead us into a consideration, not only of 
 cretinism and exophthalmic goitre, but also of such 
 conditions as certain neuroses, psychoses and der- 
 matoses, rickets and osteomalacia, obesity, and allied 
 conditions. 
 
 Anatomy. The thyroid gland consists of two 
 lateral lobes, connected by a narrow strip called the 
 isthmus. Each lateral lobe is somewhat pyramidal 
 in form, and possesses an antero-external, inner and 
 posterior surface. These surfaces come together, 
 forming the apex, over the upper posterior part of 
 the body. The lower end of the lateral lobe is thick 
 and rounded. The isthmus usually crosses the second 
 and third rings of the trachea. It varies in size, and 
 is sometimes absent. A projection may extend up 
 from either the isthmus or one of the lateral lobes, 
 which is known as the pyramidal process of the 
 gland. The inner surface of the lateral lobes lies 
 against the trachea, the cricoid cartilage and the 
 lower part of the thyroid cartilage, and reaches 
 back to the oesophagus. 
 
 Considerable variation is found in the gross blood 
 supply of the thyroid gland. In general, however, 
 we find the superior thyroid artery approaching the 
 gland at the upper pole, and the inferior thyroid 
 artery approaching from beneath the gland. These 
 main arteries (superior and inferior thyroid) run 
 
16 
 
 THYROID GLAND 
 
 along the margin of the gland and form anastomoses, 
 which vary considerably m different thyroids (as has 
 been described in detail by Landstrom). Branch- 
 ing of the large arteries is mostly upon the surface 
 of the gland; only smaller branches penetrate the 
 tissue. Small arteries pass between the lobules, and 
 give off branches which supply the lobule; these, in 
 turn, divide to supply the individual follicles. The 
 follicular arteries end in a capillary network. The 
 
 Fig. 1. Scheme showing the origin of the different branchial 
 epithelial bodies. 1, 2, 3, 4, 5, branchial grooves, a, median thyroid, 
 b, lateral thyroids, c, thymus, dl, outer parathyroids. 6.2, inner 
 parathyroids. 5, rudimentary parathyroid of Getzowa. (Modified 
 from Aschoff.) 
 
 veins follow the same course as the arteries to the 
 surface of the gland. They are rich in anastomoses. 
 The lymph spaces in the thyroid are found out- 
 side the capillary network which surrounds each 
 follicle. They connect with larger trunks which run 
 between the lobules into still larger ones between 
 the lobes, and, following the course of the blood 
 vessels, finally form a rich lymphatic network 
 
THE PATHOLOGY OF THE THYROID GLAND 17 
 
 beneath the capsule of the gland. The further 
 lymphatic drainage is usually described as following 
 out the blood vessels, one trunk passing upward and 
 the other passing downward. 
 
 The thyroid gland arises from a median unpaired 
 evagination of the epithelium of the front wall of 
 the throat in the vicinity of the second visceral arch. 
 This detaches itself from its place of origin and 
 wanders down the neck, to merge finally with the 
 second points of origin, which are from the epithelium 
 of the fourth visceral cleft, and which wander up- 
 ward somewhat and form a portion of the lateral 
 thyroid bodies. 
 
 At first the proliferating cell masses form a net- 
 work of solid cords, which later become separated 
 into round masses, with a lumen. The cells arrange 
 themselves as a lining to the lumen, which finally 
 becomes somewhat enlarged and, through secretion 
 of the cells, filled with colloid. These mature, rounded, 
 closed spaces are called follicles. In the adult 
 thyroid the epithelial cells lining the follicles may 
 be columnar, cuboidal, or flat. The colloid varies in 
 amount and staining reaction, as will be described 
 later on. The follicles are surrounded by connective 
 tissue, carrying blood and lymphatic vessels, as has 
 been described. The capsule, as well as the lobular 
 partitions of the gland, is made up of dense con- 
 nective tissue. 
 
 Between the follicles, especially in the new born, 
 one finds frequently rests of foetal tissue, appearing 
 in strands and small masses. It is from these cells 
 that the so-called foetal adenoma are supposed to 
 arise, 
 
18 THYROID GLAND 
 
 Abnormalities of Development. Either a part of 
 the thyroid or the whole gland may be lacking. 
 The pyramid or the isthmus not infrequently pre- 
 sents unusual forms, or there may be complete lack 
 of development of these parts, as well as absence of 
 one of the lateral lobes. Aplasia, or complete ab- 
 sence of the thyroid gland, gives rise to sporadic 
 cretinism or congenital myxcedema, in contradis- 
 tinction to the endemic variety found in certain re- 
 gions, in which the gland, present at birth, later 
 undergoes atrophy. 
 
 Accessory thyroid nodules are frequently found, 
 sometimes lateral to the thyroid, but more commonly 
 in the neighborhood of the hyoid bone, or they may 
 be below the gland as far down as the aortic arch, 
 behind the sternum. Rarely they are found within 
 the larynx or trachea. The accessory thyroids are 
 of the same histologic structure as the thyroid gland 
 itself; goitre and tumors may develop from them, 
 just as from the main gland. 
 
 Failure of closure of the thyroglossal duct may 
 give rise to cysts, fistulae or tumor formation. 
 
 Circulatory Disturbances. The thyroid gland has 
 an extremely rich blood supply — so rich, in fact, 
 that when its vessels are overfilled (hyperemia) the 
 gland may be notably increased in size. This great 
 development of blood vessels which the gland pos- 
 sesses, combined with its proximity to the larger 
 neck vessels, caused some of the older authors to 
 believe that the thyroid was a sort of safety valve 
 for regulating the circulation of the brain. 
 
 Of more interest is the physiologic active hyperae- 
 mia of the gland, which stands in close relation- 
 
THE PATHOLOGY OF THE THYROID GLAND 19 
 
 ship to the genital organs, especially of the female. 
 A visible enlargement of the gland may occur in 
 connection with menstruation, during pregnancy, 
 after coitus, and especially after defloration. Cases 
 have also been reported where a distinct goitre was 
 
 Fig. 2. Old, simple, diffuse, symptomless goitre. Epithelium 
 degenerated and the distended follicles filled with thick, stainable 
 colloid. Calcareous degeneration in places. (Louis B. Wilson.) 
 
 present during the period of conception, which sub- 
 sided with the beginning again of menstruation. 
 This sexual hyperemia of the thyroid is so constant 
 that in certain southern countries zealous mothers 
 measure the neck of the bride before and after the 
 marriage night. 
 
20 THYROID GLAND 
 
 Haemorrhage is more frequently found in goitre 
 than in the normal thyroid, although any trauma of 
 the thyroid may .result in haemorrhage into the acini 
 or into the stroma of the gland. 
 
 Infarction and embolism of the thyroid can be 
 practically disregarded owing to the free anasto- 
 moses in this organ. 
 
 Passive congestion of the thyroid may occur, but 
 it rarely causes changes of importance. Destruction 
 of the blood supply of the gland, as by ligation of 
 the thyroid arteries, leads to atrophy of the thyroid. 
 This ligation of the thyroid arteries was first prac- 
 ticed for the treatment of goitre by Wolfler in 1886. 
 The possibility of leaving in the neck a beginning 
 malignant growth instead of a simple goitre was an 
 objection urged at once by von Bergmann against 
 this operation. 
 
 Inflammation. Primary acute inflammation of 
 the thyroid gland (thyroiditis) is almost never seen. 
 Acute inflammation of a goitrous gland may be 
 occasionally observed. In general septicaemia, with 
 involvement of various organs, the thyroid is rarely 
 included, as it is one of the most resistant of all the 
 tissues. However, in connection with certain in- 
 fectious diseases, acute inflammation of the thyroid 
 has been described. So we find an occasional rare 
 case of thyroiditis reported following such infections 
 as puerperal fever, influenza, typhoid fever, diph- 
 theria, erysipelas, orchitis, acute articular rheuma- 
 tism and similar infections. 
 
 These acute inflammations, when they do occur, 
 are usually purulent. Pus accumulation (abscess) 
 is found in the majority of these cases. Rupture of 
 
THE PATHOLOGY OF THE THYROID GLAND 21 
 
 the abscess and healing by cicatrization may occur, 
 or simple resolution may take place. Sometimes 
 abscesses may rupture into the trachea, oesophagus 
 or mediastinum, causing death. 
 
 Gangrene as a result of acute infection has occurred, 
 but such an outcome is extremely rare. Perhaps 
 seven or eight such cases have been reported. Also 
 sufficiently rare to be of interest are the few cases 
 where thyroid destruction by acute inflammation 
 has been sufficient to cause symptoms of myxoedema. 
 
 Chronic Inflammation. Chronic interstitial thy- 
 roiditis may be found in very young individuals 
 (primary infantile atrophy) or in older individuals 
 without giving rise to any symptoms of hypothy- 
 roidism. In such cases the gland is diminished in 
 size and the parenchyma is replaced to a greater or 
 less extent by connective tissue. 
 
 The atrophy of old age is to be distinguished from 
 the sclerosis due to a chronic inflammatory process, 
 although the increase in stroma and decrease in 
 colloid and epithelial elements gives practically the 
 same histologic picture. 
 
 The thyroid has been found atrophic in sclero- 
 derma (Hektoen) and in icthyosis (Moore and War- 
 field). 
 
 Tuberculosis. Tuberculosis of the thyroid is a 
 comparatively rare finding, but careful search of the 
 gland will sometimes reveal tubercular foci in con- 
 nection with cases of wide-spread general tubercu- 
 losis, especially acute miliary tuberculosis. Fraenkel 
 found the thyroid involved six times in fifty cases, 
 the lesions usually appearing as miliary tubercles, 
 although rarely a large caseous nodule was found. 
 
22 
 
 THYROID GLAND 
 
 The tubercles arise in the interstitial tissue between 
 the follicles. The latter are compressed, stellate 
 at times, with their walls pressed together, and their 
 content and lining epithelium degenerated or lost 
 altogether. 
 
 Ruppanner has recently described, in addition to 
 
 Fig. 3. Very early ; mild Graves' disease. Sections show small 
 intra-alveolar parenchyma increase, with small amount of thin secre- 
 tion. (Louis B. Wilson.) 
 
 the interstitial form, an intrafollicular tubercular 
 process in the thyroid, and also differentiates between 
 miliary and chronic tuberculosis of the gland. 
 
 Syphilis. Syphilis of the thyroid gland is much 
 more rare at the present day than it Was formerly. 
 
THE PATHOLOGY OF THE THYROID GLAND 23 
 
 Practically the only instances seen now are in con- 
 nection with visceral syphilis of infants, in which 
 the thyroid may show pea-sized, or smaller, gum- 
 matous nodules, grayish red or grayish yellow in 
 color, with typical microscopic structure, such as 
 new formation of connective tissue, with lymphoid and 
 plasma cell infiltration and destruction of paren- 
 chyma, but showing less tendency to necrosis than 
 the tubercular nodules. 
 
 Certain cases of general thyroid enlargement in 
 connection with tertiary syphilis have been reported, 
 which disappeared under syphilitic treatment, but 
 recurred with the other symptoms on discontinu- 
 ance of the treatment. 
 
 Degeneration and Infiltration. While various 
 forms of degeneration may occur in the normal 
 thyroid, these processes are much more frequently 
 met with in goitre, and are sometimes so marked as 
 to give the title of the degeneration to the goitre — - 
 e. g., "calcified goitre," a term that is lacking in the 
 true significance of the process. 
 
 Slight parenchymatous changes have been de- 
 scribed in connection with acute infectious diseases, 
 but the thyroid is so variant in its histology that it 
 is difficult to state when such changes are actually 
 present. Thus Torri described hypersecretion of 
 colloid and. new formation of epithelium, which goes 
 on to progressive changes if the disease is long con- 
 tinued, in connection with acute infections. 
 
 Hyaline degeneration is of little importance, and 
 fatty change is rarely observed, save in degenerated 
 areas, especially of goitres. The epithelium of the 
 thyroid normally contains some fat (Erdheim). 
 
24 THYROID GLAND 
 
 Calcification, and at times ossification, is seen, par- 
 ticularly in old age. In goitre, calcified areas are 
 very common. Old cyst walls may be completely 
 infiltrated with lime salts. 
 
 Amyloid infiltration may be found in connection 
 with cases of amyloidosis, but is much less often 
 present in the thyroid than in the liver, spleen and 
 other parenchymatous organs. It is found, when 
 present, deposited in the walls of the arteries and in 
 the stroma of the gland. 
 
 Hypothyroidism. Lack of thyroid function, as 
 brought about by congenital defect or degeneration', 
 or removal of the thyroid gland, is followed or ac- 
 companied by certain disturbances, the most com- 
 mon of which are swelling of the subcutaneous 
 tissues, falling of the nails and hair, stupidity, idiocy 
 and skeletal disturbances. The various cases that 
 come under this head lend themselves to the fol- 
 lowing classification (Ewald). 
 
 1. — Endemic Cretinism, a chronic disease found 
 in regions where goitre is endemic, manifesting itself 
 through skeletal deformity, skin and subcutaneous 
 tissue changes, lack of genital development, diminu- 
 tion in intellect and sense function. Such cases 
 show changes in the thyroid gland, consisting of 
 partial or complete degeneration, which maybe either 
 atrophic or goitrous in its inception, or, as Getzowa 
 has described, cases are found in which atrophic 
 areas and goitrous degenerated nodules alternate 
 in the same gland. 
 
 2. — Sporadic Cretinism, a similar condition to the 
 above, due to congenital absence of the thyroid 
 gland (thyroaplasia) . 
 
THE PATHOLOGY OF THE THYROID GLAND 25 
 
 3.— Infantile myxoedema, due to acquired loss or 
 perversion of thyroid function in the early years of 
 life, and therefore showing greater or less severity of 
 symptoms, according to the amount of functional 
 disturbance of the gland. Under this head may be 
 included the abortive cases of myxoedema (myxoe- 
 deme f ruste) . 
 
 4. — Adult myxoedema, a spontaneous hypo, or 
 athyreosis of adults. In these cases the thyroid gland 
 is usually diminished in size and atrophic, pale yel- 
 lowish white in color, firm in consistence. Micro- 
 scopically the parenchyma is replaced by dense 
 fibrous tissue. Degenerated epithelial cell nests, 
 small cysts containing fat and cholesterin, and areas 
 of lymphoid and plasma cell infiltration may be 
 found. In addition to the changes in the thyroid, 
 peculiar changes are found in the corium (thicken- 
 ing and fracture of the connective tissue fibres, in- 
 filtration with gelatinous like material). 
 
 5. — Operative myxoedema (cachexia strumipriva 
 or thyropriva), a condition due to the operative 
 (complete) removal of a goitre or the normal thyroid 
 gland. This latter condition has been fully dis- 
 cussed in the chapters on the parathyroid glands. 
 
 Hypertrophy (Goitre). Although we can not al- 
 ways make a sharp distinction between new growth, 
 in the tumor sense, and hypertrophy, especially in 
 the circumscribed forms as they occur in the thyroid 
 gland, still the ordinary goitre (struma) probably 
 best lends itself to the above classification. 
 
 We recognize two main foims of hypertrophy or 
 simple goitre : 1, diffuse; 2, nodular. 
 
26 THYROID GLAND 
 
 In diffuse goitre we have a uniform enlargement 
 of the thyroid gland, or perhaps one lobe of the gland 
 is frequently considerably more enlarged than the 
 other, but presents no circumscribed nodules differ- 
 ing in structure from the rest of the lobe. Occasion- 
 ally, however, a more rapidly proliferating area may 
 be encountered in such a thyroid than is shown in 
 the adjoining tissue, but such areas are not sharply 
 bounded. 
 
 This diffuse type of hypertrophy may show itself 
 in two forms: (a) Colloid goitre. In this type the 
 amount of colloid is so greatly increased that the 
 follicles of the gland are often greatly dilated, and the 
 epithelium lining the same more or less flattened, or 
 finally completely destroyed, by the pressure of the 
 increased colloid content. The septa between neigh- 
 boring follicles may be broken through by strong 
 pressure and subsequently absorbed. If sufficient 
 dilatation and confluence of follicles is brought about 
 by this process, we can finally have the appearance 
 of considerable sized cysts (cystic colloid goitie). 
 
 (b). Parenchymatous goitre. This type of hyper- 
 trophy consists of a glandular proliferation that is 
 more in the order of a new formation in the tumor 
 sense. Solid cell masses and cords, together with 
 connective tissue, form follicles much in the same 
 manner as they are built up in the foetal thyroid. 
 The colloid content is usually scant, or may be alto- 
 gether lacking. The epithelium lining the follicles 
 may be cylindric, and sometimes forms papillary 
 projections into the lumina of the follicles. By en- 
 largement of the follicles and continued papillary 
 ingrowth into the same, we may have a variation of 
 
THE PATHOLOGY OF THE THYROID GLAND 27 
 
 type, which has been designated papillary cystic 
 goitre. 
 
 These two types of diffuse goitre just described 
 are widely different in regard to their clinical signifi- 
 cance. In the first type (a) the functioning epithe- 
 
 Fig. 4. Acute stage of Graves' disease. Sections show increased 
 alveolar parenchyma, papillae formation, and a large amount of non- 
 staining secretion. (Louis B. Wilson.) 
 
 lium of the gland is more or less completely destroyed 
 and the colloid usually non-absorbable ; therefore 
 such goitres are not associated with hyperthyroid- 
 ism. In the second type (b), on the contrary, we 
 
28 THYROID GLAND 
 
 have an increased amount of functioning tissue, and 
 it is from such goitres that hyperthyroidism (Graves' 
 disease) arises. 
 
 Marine and Lenhart have shown that in the dog 
 one can carry a thyroid gland through a variety of 
 stages of goitre. By partial removal of a thyroid, 
 for example, one may produce an active hyper- 
 plasia, as was originally shown by Halsted. This 
 hyperplastic type of gland may be reduced to a simple 
 colloid type by the administration of iodine. By 
 means of partial removals, together with withholding 
 and giving iodine, one may follow the process of 
 reversion of a hyperplasia to colloid, produce again 
 a second hyperplasia, and finally obtain a secondary 
 reversion to colloid in the same animal. It is in- 
 teresting to note that these authors find that an 
 actively proliferating thyroid (hyperplasia) may re- 
 vert to a pure colloid goitre within a month. 
 
 Nodular goitre is characterized by the occurrence 
 in the thyroid gland of circumscribed nodules, vary- 
 ing in number and size, between which either normal 
 or completely degenerated or atrophic thyroid tissue 
 appears. Even the smallest (microscopic) nodules 
 show a distinct connective tissue capsule. The 
 nodules may present the typical picture described 
 under colloid goitre, or may be of the parenchyma- 
 tous type. Sometimes in the same gland nodules 
 of both types may appear. In these nodules various 
 degenerative processes are frequently encountered, 
 such as hyaline and fatty change. A nodule may 
 undergo complete connective tissue transformation 
 (fibrous goitre), or lime salts may be deposited in 
 the same (calcified goitre) . Through breaking down 
 
THE PATHOLOGY OF THE THYROID GLAND 
 
 29 
 
 and. absorption of the content of such nodules, cysts 
 may frequently arise, which through haemorrhage 
 may show a red brown or deeper brown colored content. 
 A combination of these various degenerative process- 
 es in the same nodule gives rise to the multicolored 
 appearance frequently seen on fresh section of the 
 same. 
 
 Still another variation of the nodular form of 
 goitre is to be found in the so-called foetal adenoma 
 
 Fig. 5. Foetal adenoma of the thyroid, with acini in various 
 stages of development and edge of a large cyst. (Louis B. Wilson.) 
 
 of the thyroid, which consists of encapsuled nodules 
 made up of cells corresponding to the undifferen- 
 tiated cell rests of embryonal thyroid. The develop- 
 ment of these latter nodules may in certain instances 
 give rise to hyperthyroidism. 
 
 Hyperthyroidism (Graves' Disease, Basedow's Dis- 
 ease, Exophthalmic Goitre). In connection with 
 
30 THYROID GLAND 
 
 certain types of thyroid hypertrophy (parenchy- 
 matous goitre, papillary cystic goitre, and sometimes 
 foetal adenoma of the thyroid, according to the class- 
 ification of MacCarty), we have, in addition to the 
 struma, the appearance of certain phenomena, such 
 as exophthalmos, 1 heart palpitation, tremor of the 
 hands, and nervous symptoms, especially of vaso- 
 motor type, in varying degrees of prominence. Au- 
 topsies on such individuals show, in addition to the 
 changes in the thyroid, usually dilatation of the heart, 
 more or less wide-spread fatty muscle atrophy, par- 
 enchymatous myocarditis, and frequently a persist- 
 ent thymus and splenic enlargement. 
 
 It is in the hyperactive thyroid that we seek an 
 explanation for these symptoms, and the recent 
 work of Dr. Louis B. Wilson has shown that there 
 is a definite parallel between the increased amount 
 of functioning tissue and absorbable secretion in the 
 thyroid gland and the degree of severity of the symp- 
 toms. 
 
 So we may have hyperthyroidism result from a 
 simple goitre by increase in function of the thyroid 
 gland; or, on the other hand, by continued activity, 
 degenerative changes may appear in the function- 
 ing cells, and blocking of the lymphatic drainage 
 take place, so that, provided the patient lives long 
 enough, a case of hyperthyroidism can return to a 
 simple goitre. In such cases, however, the heart 
 
 (1) If we take for granted hyperthyroidism as the cause of exophthalmos, we are 
 still considerably in doubt as to how the action is brought about. The phenomenon 
 can not rest on so simple an explanation as increased fatty tissue, congestion or 
 edema within the orbit. Muscular spasm, sympathetic irritation, vasomotor con- 
 gestion and what not have been assumed. A mechanical basis for its occurrence 
 has been offered by Landstroem, who has recently described a new muscle within the 
 orbit. This muscle, which consists of a cylindric band of smooth muscle fibres, has 
 its origin in the orbital septum and its insertion into the equator bulbi. The cone- 
 like insertion is sufficient to pull the eyeball forward and produce exophthalmos under 
 the sympathetic irritation which is assumed as a result of the hyperthyroidism. 
 
THE PATHOLOGY OF THE THYROID GLAND 31 
 
 and nervous symptom may persist as a result of 
 the previous over action of the thyroid for a consider- 
 able time after the thyroid has become quiescent. 
 It is in such cases that Wilson has warned against 
 operative interference. 
 
 The thyroid gland itself in hyperthyroidism while 
 usually increased in size is not necessarily always 
 large, it is firm in consistence, and decidedly vascu- 
 lar, especially in acute cases. 
 
 Microscopically the important change is the paren- 
 chyma increase which may appear within the alveoli 
 as a cellular increase in a single layer, or there may 
 be a reduplication of layers. In many instances 
 this cellular increase is brought about by infolding 
 of the alveolar wall, or papillas formation within the 
 alveoli. In a second type of case there is an actual 
 increase in the number of alveoli (adenoma type). 
 The acute cases also show a considerable amount of 
 thin, non-eosin staining secretion) . The more chronic 
 cases show degenerative changes consisting of des- 
 quamation of the alveolar epithelium and denser 
 staining of the secretion. 
 
 Wilson has been able to classify the pathological 
 findings in this condition very closely with the clini- 
 cal symptoms. Eighty per cent, of his cases showed 
 a remarkable parallel between the pathologic finding 
 in the thyroid gland and the condition of the patient. 
 According as to whether the cases were acute, and 
 mild, moderate or severe, there was a rising increase 
 of functional activity as shown by increased paren- 
 chyma and increased absorbable secretion in the 
 thyroid gland. Cases that had been severe but with 
 remission of symptoms at the time of examination 
 
32 
 
 THYROID GLAND 
 
 showed microscopically beginning degeneration. Cases 
 that had been severe but that had reduced them- 
 selves to the residual stage where only heart and 
 nervous symptoms persisted as a result of the pre- 
 vious intoxication, showed histologically more or 
 less complete degeneration in the thyroid gland. 
 
 The extent of the pathological process in the thy- 
 roid is not always to be brought in line with the 
 
 \\1 
 
 p. 
 
 
 , : J m 
 
 
 
 ^§|n 
 
 'M 
 
 
 j^RKyl 
 
 rm 
 
 Kl) 
 
 >■■- ■* \ 
 
 
 
 
 
 
 We 
 
 
 
 » 
 
 
 
 
 
 
 m?t 
 
 1 ! ™ 
 
 
 Fig. 6. Showing lateral compression of the trachea by a large 
 goitre. 
 
 severity of the symptoms, however, as the patient's 
 ability to neutralize the increased secretion has to 
 be taken into account. 
 
 Tumors. Simple histoid growths, such as fibroma, 
 chondroma, osteoma, etc., may be found in the 
 thyroid gland and show no peculiarities worthy of 
 
THE PATHOLOGY OF THE THYROID GLAND 33 
 
 note in this situation. More complicated structures, 
 including teratoma in which all three germ layers 
 are present, have been found in the gland. 
 
 Sarcoma. Primary sarcoma of the thyroid is 
 very rare; less than a hundred authentic cases have 
 been reported. Most of these cases have appeared 
 in the middle years of life, and have been found more 
 frequently in women than in men. They have also 
 been found more often in an already goiterous gland 
 than in the normal thyroid. 
 
 Histologically these growths may be of almost any 
 sarcoma type, although the round cell and spindle 
 cell varieties are most frequently met with. Giant 
 cell and osteoplastic growths have been described, 
 as well as tumors classified as perithelioma and endo- 
 thelioma. 
 
 The sarcomatous cell growth is infiltrative in type, 
 rarely encapsulated, and sometimes so completely 
 destroys the gland that no recognizable thyroid 
 tissue can be found. These tumors may become so 
 large as to cause dangerous pressure symptoms. 
 Metastasis from such growths may take place by 
 both blood and lymph channels. 
 
 Carcinoma. Primary malignant epithelial new 
 growths are also rare in the thyroid gland. Less 
 than one per cent of all carcinoma has its origin in 
 this location; moreover, the disease is more common 
 in goiterous regions, as cancer develops oftener in 
 struma than in the normal thyroid. The interest- 
 ing work of L. Pick on carcinoma of the trout 
 has emphasized the coincidence of goitre and car- 
 cinoma. The growth is usually of the medullary 
 type, soft in consistence, scant in connective tissue, 
 
34 THYROID GLAND 
 
 and according to its blood content, gray white to 
 dark red in color. Areas showing degeneration 
 and haemorrhages are frequent. Owing to lack of 
 encapsulation the growth may penetrate the trachea 
 or the skin by direct extension. Frequently there is 
 growth directly into the thyroid veins or their 
 branches, emboli from which lead to wide-spread 
 metastases. 
 
 At times the structure of these malignant growths 
 bears a close resemblance to actively proliferating 
 goitre, or even to normal thyroid gland, so that 
 histological differentiation as to malignancy is ex- 
 tremely difficult, or at times impossible; the metas- 
 tatic nodules in the lungs, liver, bone, etc., for in- 
 stance, corresponding almost identically with normal 
 thyroid gland. 
 
 Adenocarcinoma types, with widening of the gland 
 follicles and papillary ingrowths may sometimes 
 appear so that a so called papillary cystocarcinoma 
 is formed. 
 
 In addition to metastasis through direct ingrowth 
 into the veins and subsequent vascular embolism, 
 the lymphatics may be invaded. As a rule greatly 
 enlarged neighboring lymph nodes accompany these 
 growths. The lungs are the most favorable site for 
 metastasis; more rarely other internal organs are 
 included. 
 
 Bone metastases are especially to be noted in con- 
 nection with these malignant thyroid tumors, which 
 apparently find a most suitable opportunity for 
 growth in bone marrow. This favorable influence 
 of bone marrow on thyroid proliferation is borne 
 
THE PATHOLOGY OF THE THYROID GLAND 35 
 
 out by the fact that such a situation is best adapted 
 to successful thyroid transplantation. 
 
 A rare but interesting form of tumor is a malig- 
 nant growth found usually in bone which may 
 metastasize to other organs, but which possesses the 
 typical structure of normal thyroid gland or of 
 simple goitre. Such tumors are made up of typical 
 follicles filled with iodine containing colloid. The 
 thyroid gland in such cases may be free from any 
 tumor growth. Fabris has reported such a case, 
 which was diagnosed Pott's disease, but at autopsy 
 the vertebra were found to be filled with a tumor 
 growth corresponding histologically with thyroid 
 tissue. 
 
 Mixed tumors of the thyroid which have been oc- 
 casionally observed, i. e., growths apparently of 
 both connective tissue and epithelial origin — sarco- 
 carcinoma — are best explained by the experimental 
 tumors of Ehrlich and Apolant. 
 
 Two such cases have been reported by Teacher, 
 and a case of Schmorl's is distinctly of this type. 
 In the latter case an adenoma of the thyroid was 
 removed at operation. After a time the tumor re- 
 curred and this examination showed carcinoma and 
 sarcoma in about equal amount. Finally the patient 
 died from metastases, which presented, histologic- 
 ally, the structure of pure spindle cell sarcoma. 
 
CHAPTER III. 
 DIAGNOSIS. 
 
 The diagnosis of goitre in itself is exceedingly 
 simple because of the definite location of the thyroid 
 gland and its attachment to the trachea which 
 causes it to move upwards with the larynx during the 
 act of swallowing. Normally the form of the thyroid 
 gland is quite regular as shown in our anatomical 
 illustrations and whenever there is a uniform en- 
 largement of the gland, the larger it becomes the 
 easier it is to make the diagnosis. This uniform en- 
 largement of the gland is, however, not the rule and 
 usually the distortion increases with the extent of 
 enlargement. There seems to be no definite rule as 
 to the number of lobes that are to be involved when 
 the enlargement has once begun to become apparent. 
 It is, however, more common to find the middle lobe 
 and one lateral lobe enlarged than to find both 
 lateral lobes affected with the middle lobe in a 
 normal condition. Most commonly one lateral lobe 
 is greatly enlarged, the middle lobe considerably 
 and the other lateral lobe but slightly. 
 
 The differential diagnosis may sometimes be some- 
 what difficult between goitre and branchial cyst but 
 the latter is usually more uniform. There is usually 
 distinct fluctuation present in the latter condition 
 and the normal thyroid gland can be felt usually 
 below the branchial cyst. 
 
DIAGNOSIS 37 
 
 Enlarged lymph nodes due to leukaemia or pseud o- 
 leukasmia are definitely composed of separate more 
 or less spherical glands which are arranged along 
 the anterior or posterior border of the sterno-cleido- 
 mastoid muscle, or in the vicinity of the submaxil- 
 lary, salivary or the parotid glands. 
 
 Moreover, the first nodules usually appear high 
 up in the neck and not in the region of the thyroid 
 gland. 
 
 Diffuse or dissecting lipoma of the neck is likely to 
 begin on the posterior surface of the neck and to 
 progress downwards and forward. 
 
 Lymphosarcoma may occur at any point in the 
 neck usually in front of the sterno-cleido-mastoid 
 muscle. It is only slightly movable, if at all, and 
 neither this nor the preceding two forms of enlarge- 
 ment move up and down with the larynx at degluti- 
 tion. 
 
 Carcinoma in the lymph nodes of the neck will not 
 be mistaken for goitre upon careful examination be- 
 cause the former is always secondary to carcinoma 
 of the mouth, pharynx, nose, scalp, parotid gland 
 or ear or some other tissue. 
 
 Occasionally the primary tumor is very small and 
 in this way it may be overlooked, but even in this 
 case the masses do not rise and fall with the larynx, 
 and the normal gland can usually be outlined in its 
 proper position by making a careful examination. 
 The surgeon is rarely called upon to treat simple 
 goitre until it has advanced to a considerable size 
 so that the growth is a source of annoyance to the 
 patient because of the deformity it produces, or be - 
 
38 THYROID GLAND 
 
 cause of the fact that the pressure from the tumor 
 interferes with respiration or deglutition. Occasion- 
 ally these symptoms exist in cases in which inspec- 
 tion does not reveal an enlargement of the thyroid 
 gland but upon deglutition a tumor will be seen to 
 rise from under the upper end of the sternum. In 
 these cases there is a marked enlargement down- 
 ward of a portion of the middle lobe which presses 
 forward against the sternum and backward against 
 the trachea. In a few instances I have encountered 
 such a lobe projecting inward and downward from 
 the lower end of one of the lateral lobes extending 
 quite behind the upper end of the sternum and giv- 
 ing, rise to severe obstruction to respiration. 
 
 THE DIAGNOSIS OF EXOPHTHALMIC GOITRE. 
 
 There is no disease in which familiarity through 
 repeated contact is of greater aid in making a diag- 
 nosis than in exophthalmic goitre. The earlier ob- 
 servers like Parry, Graves, Basedow, Desmarres 
 and Trousseau placed especial stress upon two ele- 
 ments contained in the name exophthalmos and goitre 
 to which the symptom — which later became the 
 most important of all — tachycardia was soon added. 
 Later many other symptoms which will be described 
 in detail were added from time to time, but we must 
 bear in mind that in England the description of the 
 disease by Parry and Graves, in Germany by von 
 Basedow, in France by Charcot and Trousseau, and 
 in Italy by Flajani had thoroughly established this 
 as a distinct disease before any of the following 
 symptoms had been shown to be present in exoph- 
 thalmic goitre. Recently it has been claimed by 
 
DIAGNOSIS 
 
 39 
 
 several clinicians that a diagnosis of this disease can 
 and must be made in case tachycardia is present 
 which cannot be explained upon any other patho- 
 logical theory in any given case especially if several 
 of the other symptoms, but neither exophthalmos 
 nor goitre are present. When either of these two 
 symptoms is present with tachycardia all authorities 
 agree on the diagnosis. 
 
 Fig. 7. Exophthalmic goitre, lateral view of neck, showing 
 moderate enlargement of thyroid gland. 
 
 This has given rise to a serious objection to the 
 term exophthalmic goitre because it was argued 
 that a disease with a description name should at 
 least in part conform with this description. 
 
 Since the disease has been definitely accepted as a 
 condition, due according to Moebius to an increased 
 pathological activity of the thyroid gland, those who 
 
40 THYROID GLAND 
 
 have most carefully studied the specimens removed 
 by operation have always been able to find some por- 
 tion of the gland with the typical pathological 
 structure of the thyroid gland even in cases in which 
 from external examination the pressure of a goitre 
 could not be definitely demonstrated. In my own 
 cases it was always possible to demonstrate even in 
 the gross specimen some portion that showed the 
 presence of hypertrophy and histologically every 
 case showed typical tissue in some portion. It is 
 true that there is often a marked discrepancy be- 
 tween the extent of the goitre and the degree of 
 tachicardia, tremor, muscular weakness and other 
 symptoms. When one bears in mind, however, that 
 very minute quantities of any one of a number of 
 active drugs with which we are familiar when intro- 
 duced into the circulation produce exceedingly vio- 
 lent symptoms it is easy to understand how the 
 secretion from a very small portion of diseased tissue 
 in the thyroid gland may produce all of the symp- 
 toms of this disease. All of these symptoms may be 
 intermittent. There may be a marked difference in 
 the size of the thyroid gland from week to week, the 
 eyes may be so prominent one day that they will at- 
 tract attention at once at one time and a few weeks 
 later this symptom may be scarcely perceptible. In 
 the same manner the pulse may vary from eighty to 
 one hundred and sixty beats per minute, although it 
 rarely remains under one hundred during the entire 
 day. 
 
 In these cases there seems to be a discharge into 
 the circulation of a considerable quantity of the 
 
DIAGNOSIS 41 
 
 poison at intervals. This may be brought about by 
 mental or by physical influences. 
 
 I have known severe sorrow over the death of some 
 member of the family, excitement over a fire ; a sud- 
 den fright, overwork, both physical or mental, anx 
 iety and fatigue during a political campaign, excite- 
 ment in social life and many other similar conditions 
 to give rise to severe, sometimes fatal exacerbations 
 of this condition. 
 
 In each case it has seemed as though the patient 
 could not quite return to the condition in which he 
 was before the last exacerbation and although the 
 next attack might not be more severe than the pre- 
 vious one still its effect upon the patient seemed at 
 least somewhat more severe. 
 
 MINOR SYMPTOMS. 
 
 Before enumerating the minor symptoms of ex- 
 ophthalmic goitre it will be well once more to insist 
 upon the fact that in the presence of tachycardia 
 together with even the slightest degree of exophthal- 
 mos or enlargement of the thyroid gland, a positive 
 diagnosis of exophthalmic goitre can always be 
 made. 
 
 In some instances the changes in the thyroid gland 
 may be so slight that only some insignificant irregu- 
 larity may be noticed, still upon excision of this por- 
 tion of the gland the pathological condition is so typi- 
 cal that there can be no doubt regarding the correct- 
 ness of the diagnosis when the histological examina- 
 tion has been made. I am so persistent in impressing 
 this fact because this is really the only class of cases 
 which is likely to be overlooked by the clinician who 
 has seen only a small number of well developed 
 
42 THYROID GLAND 
 
 typical cases while these cases are regularly over- 
 looked by those who must depend upon description 
 of the disease for a basis upon which to make a 
 diagnosis. 
 
 Fortunately for the patient one or more of the 
 following symptoms will be found in almost every 
 case so that the diagnosis can be further supported. 
 
 At this point it may be well to direct attention to 
 the fact that cases are frequently encountered in 
 which other conditions may readily be mistaken for 
 a tachycardia. These conditions are always due to 
 other causes. 
 
 Of these the excessive use of nicotin especially in 
 cigarette smokers is the most common cause at the 
 present time. Myocarditis due to chronic alcoholism 
 is another condition which is still more misleading 
 because the alcoholic tremor is almost identical with 
 the tremor of exophthalmic goitre to be described 
 among the minor symptoms. 
 
 Habitual users of the various coal tar preparations 
 form another class which may mislead the clinician 
 in making his diagnosis. The habitual use of a number 
 of pother drugs like strychnine, cocaine, quinine and 
 chloral must be borne in mind in making a diagnosis. 
 Similarly severe anaemia, or marked obesity, or the 
 depression following severe illness, or unusual mental 
 or physicial exertion especially when long continued 
 and accompanied with loss of sleep may give rise to a 
 condition of the heart which may lead to a mistaken 
 diagnosis. Great sorrow, severe fright, long con- 
 tinued worry especially when accompanied with in- 
 somnia, exposure to great heat and in fact any con- 
 dition which severely affects the nervous and circu- 
 
DIAGNOSIS 
 
 43 
 
 latory system may cause a condition of the heart's 
 action which may easily be mistaken for the tachy- 
 cardia of exophthalmic goitre. This condition is fre- 
 quently present after persons have experienced in- 
 juries during railroad wrecks. 
 
 It is well to bear these facts in mind especially 
 because any one of these conditions may be the ex- 
 
 Fig. 8. 
 enlarged. 
 
 Exophthalmic goitre; thyroid gland only moderately 
 
 citing cause of an attack of exophthalmic goitre. 
 Moebius has reasoned this out in the following man- 
 ner : Many patients may possess thyroid glands that 
 are slightly pathological so that there is a slight de- 
 gree of overproduction of normal or possibly abnor- 
 
44 THYROID GLAND 
 
 mal secretion which, however, is either not absorbed 
 or if it is absorbed the quantity is so limited that it 
 does not make any appreciable impression upon the 
 tissues of the body and especially the tissues of the 
 heart. 
 
 The patient may consequently live in an appar- 
 ently normal condition until there is a severe de- 
 pression due to one of the conditions mentioned 
 above whereupon the effect of the thyroid poisoning 
 is felt sufficiently to give definite symptoms, first of 
 tachycardia and later of other typical conditions 
 and' then the presence of exophthalmic goitre is es- 
 tablished. This thyroid poisoning added to the other 
 conditions may be sufficient to make the disease per- 
 manent or it may subdue as the bad results of the 
 acute shock to the general system subside because 
 the amount of thyroid poisoning may not be sufficient 
 even after such an exacerbation to produce typical 
 symptoms. 
 
 It is plain, of course, that such cases must be 
 guarded against a repetition of acute strains of ah 
 kinds as the resistance against thyroid poisoning as 
 has been said above is reduced with each successive 
 exacerbation. 
 
 Another theory may be mentioned at this point 
 namely that there may be an actual increase in the 
 secretion due to the strain which has temporarily 
 been placed upon the nervous and circulatory sys- 
 tems by any one of the conditions mentioned above. 
 Until some one can determine by actual measure- 
 ment the isolated poisonous substance in the circu- 
 lation in patients suffering from exophthalmic goitre 
 it seems unlikely that the correctness of this theory 
 
DIAGNOSIS 45 
 
 will or can be proven although there is much in the 
 course taken by the disease that speaks in favor of 
 the hypothesis. 
 
 For the sake of clearness and brevity the minor 
 symptoms will be first enumerated and then dis- 
 cussed separately. 
 
 LIST OF MINOR SYMPTOMS. 
 
 1 — Tremor; 2 — Muscular weakness; 3 — Nervous 
 excitability ; 4 — Mental deficiency ; 5— Vertigo ; 
 6— Graefe's sign; 7— Stellwag's sign; 8— Moebius' 
 sign; 9 — Paroxysmal dyspnoea; 
 
 10 — Intermittent vomiting without apparent ex- 
 citing cause. 
 
 11 — Intermittent diarrhoea without apparent ex- 
 citing cause. 
 
 12 — Intermittent sweating without apparent ex- 
 citing cause. 
 
 13 — Intermittent mental depression without ap- 
 parent exciting cause. 
 
 14 — Increase of gravity of symptoms upon psychic 
 excitation. 
 
 15 — Increase of gravity upon mental fatigue. 
 
 16 — Increase of gravity upon physical fatigue. 
 
 17 — Increase of gravity upon administration of 
 thyroid extract. 
 
 18 — Increase of gravity upon administration of 
 iodine. 
 
 19 — Emaciation in advanced cases. 
 
 20 — Anaemia in advanced cases. 
 
 21 — Increased lymphocytosis, decreased poly- 
 morphonuclear leucocytosis. 
 
 22 — Oedema of upper and lower eyelids, later of feet. 
 
 23 — Visible pulsations in goitre. 
 
46 THYROID GLAND 
 
 24 — Discoloration of skin especially about nipples 
 and orifices. 
 
 Any one or any group of these symptoms may be 
 prominent early in the course of the disease. They 
 rarely precede the presence of tachycardia but fre- 
 quently the appearance of exophthalmos or marked 
 enlargement of the gland and frequently several of 
 these symptoms have developed to a marked degree 
 before either exophthalmos or enlargement of the 
 thyroid gland can be demonstrated. 
 
 It is in these latter cases in which a thorough 
 knowledge of an acquaintance with these symptoms is 
 of especial importance in making a diagnosis. They 
 should always be carefully noted in all cases in which 
 the three major conditions, tachycardia, exophthal- 
 mos and enlargement of the gland are present in 
 order that the relation of these conditions may be 
 recognized when found associated only with tachy- 
 cardia. 
 
 1 — Tremor. The most important minor symp- 
 tom which can be recognized in all advanced cases 
 is muscular tremor. This was first associated with 
 the disease by Charcot and later by his pupils 
 notably by Marie. The similarity between the tremor 
 of chronic alcoholism and that of exophthalmic 
 goitre further supports the theory of Moebius that 
 the disease is due to a condition of poisoning through 
 toxic substances circulating in the blood and affect- 
 ing the tissues directly. The symptoms can be most 
 easily elicited by having the patient extend an arm 
 at right angles with his body or by standing upon 
 one leg and flexing the other thigh with the knee 
 
DIAGNOSIS 47 
 
 extended. The latter test is of course too severe for 
 advanced cases. Accurate measurements have been 
 made to determine the number of contractions per 
 second, according to Marie, from 8 to 9 oscillations 
 take place per second. 
 
 Although there seems to be much uniformity in 
 the frequency of the oscillations there is a great 
 difference in their severity. In many patients it is 
 
 
 Kjk 
 
 
 > 
 
 \ 
 
 IgjgfM | 
 
 
 
 Fig. 9. Lateral view of large goitre weighing seven pounds giv- 
 ing rise to severe discomfort because of its weight and because of the 
 direct pressure upon the trachea which caused marked obstruction to 
 breathing. It also forced the patient to hold her head in a most un- 
 comfortable position. 
 
 this tremor that first causes them to consult the 
 physician, consequently it is necessary to bear the 
 relation between this symptom and exophthalmic 
 goitre constantly in mind in order not to overlook 
 it and make a wrong diagnosis. In many cases the 
 
48 THYROID GLAND 
 
 tremor remains permanently after it has once ap- 
 peared while in others it may be present at times 
 with varying degrees of severity only to disappear 
 and reappear again at intervals. Sometimes the tre- 
 mor is so marked that a look at the patient from a 
 distance will convince the trained observer that the 
 patient presents this symptom to an extent which 
 will make it necessary only to establish one or two 
 other symptoms to confirm the diagnosis of exophthal- 
 mic goitre, while in other cases the most painstaking 
 examination may barely enable the most acute ob- 
 server to establish the presence Of this symptom. 
 Whenever the symptom is present in any given case 
 it will usually appear in a more marked form when- 
 ever there is an exacerbation of the disease from 
 any other cause. 
 
 This symptom may be confined to the upper or to 
 the upper and lower extremities or it may effect all 
 of the muscles of the body so that one can feel it by 
 placing the hand upon any portion of the patient's 
 body. It has been observed in most of the voluntary 
 muscles. Tremor of the eyes is not uncommon, but 
 not nearly so common as in the extremities. 
 
 It may be so severe that it may become difficult 
 for the patient to do any kind of accurate work with 
 the hands or even to walk with comfort. The tremor 
 in the hands seems to differ from that observed in 
 paralysis agitans in that there is no especial motion 
 of the fingers but rather a wavelike motion or oscil- 
 lation of the separate muscle fibres rather than a 
 contraction of any muscle as a whole. This condition 
 is entirely different from a condition of mus- 
 cular spasms or cramps described by Mackenzie. 
 
DIAGNOSIS 49 
 
 In my own observation the tremor has been ex- 
 ceedingly common in exophthalmic goitre patients 
 while distinct cramps have occurred only in a very 
 small proportion of cases. In quite a proportion of 
 patients who have suffered from exophthalmic goitre 
 for a considerable period the presence of mild con- 
 tractions reminding one of incipient chorea may be 
 observed. These contractions seem to affect especi- 
 ally the head and sometimes also the upper ex- 
 tremities. Since we are familiar with the fact that 
 removal of all of the parathyroid glands invariably 
 results in tetany some authors have attributed the 
 spasmodic contractions just described to a diseased 
 condition of the parathyroid glands. It has been 
 suggested that this condition of the parathyroid 
 glands may be due to the effect upon these glands 
 exercised by the pathological thyroid secretion cir- 
 culating in the blood in exophthalmic goitre, it being 
 supposed that these glands may have been rendered 
 incapable of performing their physiological functions 
 precisely as the muscle fibres have become in- 
 capacitated by direct contact with the same poison. 
 2 — Muscular Weakness. In advanced cases of 
 exophthalmic goitre there is always muscular weak- 
 ness. This may show itself simply in the fact that the 
 patient becomes fatigued more readily than normal, 
 or it may become so serious that the muscles will 
 give out suddenly and the patient may lose 
 complete control of certain muscle groups unex- 
 pectedly and may suddenly drop things held in 
 the hand or it may affect the lower extremities so 
 that the patient suddenly falls to the ground 
 because his legs give way. This condition has been 
 
50 THYROID GIAND 
 
 called paraparesis. It may be only temporary or it 
 may begin in a mild form and increase in severity. 
 Many patients first notice this condition when they 
 find that it is no longer possible for them to change 
 from the sitting to the standing position without 
 lifting the weight of the body with the arms. Con- 
 versely they find in changing from the standing to 
 the sitting posture that unless they steady them- 
 selves with their arms they will suddenly drop down 
 into the seat while they had expected to lower the 
 body gradually. 
 
 This condition must, of course, not be confounded 
 with similar symptoms which are frequently present 
 in patients suffering from hysteria. 
 
 This weakness seems to be due to a condition of 
 the muscle tissue itself caused by the poisoning of 
 this tissue by the thyroid secretion in the blood. 
 
 Although this symptom is usually present quite 
 late in the course of the disease still it has occasionally 
 been the first to attract the attention of the physician. 
 
 It is likely that the same condition affecting the 
 muscles of the orbit has much to do with producing 
 the symptoms of exophthalmos as well as the symp- 
 toms to be described later as Graefe's, Stell wag's 
 and Moebius symptoms. Since Landstrom has given 
 us a more perfect knowledge of the muscles of the 
 orbit it seems certain that the exophthalmos is due 
 especially to the weakness of an unstriped cylinder- 
 formed muscle which had formerly been overlooked 
 both by anatomists and clinicians as well as by 
 pathologists. 
 
 This muscle is under the control of the cervical 
 sympathetic plexus The weakness may be uniform 
 
DIAGNOSIS 51 
 
 throughout the muscles of the body or it may be 
 selective affecting only certain muscles, those in the 
 orbit being affected more often than any of the others. 
 In rare cases the muscles of one side of the body may 
 be affected alone but it is likely that in these cases 
 there are other definite complications like cerebral 
 haemorrhage or circumscribed cerebral anaemia or it 
 may be due to hysteria. 
 
 In connection with the symptoms of exophthal- 
 mos it must, of course, be borne in mind that aside 
 from weakness in the muscles which ordinarily keep 
 the eyeball in place there are other conditions like 
 engorgement of veins which aid in pushing the eye- 
 balls forward. 
 
 There is quite an opportunity for theorizing con- 
 cerning the relation of the weakened condition of 
 various groups of muscles to other secondary con- 
 ditions. The digestive disturbances may be ac- 
 counted for by the weakened condition of the muscles 
 of the stomach and intestinal walls. The same ex- 
 planation may be applied to the diarrhoeas. It seems, 
 however, scarcely necessary to discuss all of these 
 theories in the present work. It is quite possible 
 that the digestive disturbances are quite as much 
 dependent upon the direct effect which the thyroid 
 poison in the circulation has upon the glands se- 
 creting digestive ferments as upon the condition of 
 the muscles of the alimentary canal. 
 
 Although the effects of this poison can be most 
 readily demonstrated in the muscular system still 
 it is not at all likely that any of the other tissues are 
 less seriously affected, and it would consequently not 
 be correct were we to attribute the effects which this 
 
52 ' THYROID GLAND 
 
 disease has upon the digestive apparatus entirely 
 to the impaired muscles of the walls of stomach 
 and intestines. 
 
 3 — Nervous Excitability. From the first obser- 
 vations to the present time the presence of great 
 nervous excitability has been noticed as one of 
 the symptoms almost invariably present in some 
 
 Fig. 10. Shows the same patient as Fig. 9 the enlarged gland 
 overhanging its base to a marked degree. 
 
 form. In fact it was the presence of marked nervous 
 symptoms which caused the greatest amount of 
 opposition against a separate classification of 
 this disease, especially in the French Academy. 
 It was pointed out constantly, that the most 
 marked symptoms of this disease were identical 
 
DIAGNOSIS 53 
 
 with those characterizing hysteria. At this point 
 a symptom dwelt upon especially by Martin B. 
 Tinker should be emphasized. He points to the 
 fact that these patients frequently complain of a 
 symptom which could readily be mistaken for 
 typical globus hystericus and which has often even at 
 the present time caused careful observers to make 
 a diagnosis of hysteria in patients suffering from 
 unquestionable exophthalmic goitre. 
 
 In many of these cases there may be but a very 
 small central lobe which acts in the form of a ball 
 valve and interferes with the patient's breathing and 
 occasionally even with the swallowing of food, or the 
 lateral lobes may have prolongations at their ex- 
 ternal borders which may be directed backward and 
 inward around the posterior surface of the trachea, 
 and this may cause a compression of the latter tube 
 and thus cause difficulty in breathing. Or again, the 
 middle lobe may have an enlargement on its lower 
 border which may be permanently located behind 
 the upper end of the sternum or it may take this 
 position only when the patient's tissues are in a re- 
 laxed condition during sleep. I have had one of 
 these patients come to me with a diagnosis of cardiac 
 asthma whose attacks came on regularly at night 
 after the patient had fallen asleep but which would 
 not occur in case the patient would remain awake 
 for any reason. Many of these patients wander from 
 one sanitorium to another because their symptoms 
 of neurasthenia or hysteria are so marked that the 
 presence of exophthalmic goitre is entirely over- 
 looked. 
 
54 THYROID GLAND 
 
 The fact that the disease comes on so often to a 
 marked degree directly after some severe mental, 
 emotional, or physical strain has served still further 
 to obstruct the diagnosis. It seems, however, that 
 we must agree with Moebius that this simply in- 
 dicates an increase in the abnormal secretion at a 
 time when there was a decrease in resistance. Or it 
 may mean a decrease in resistance in a case that was 
 able to overcome a slight increase so long as there 
 was no abnormal strain. 
 
 I am thus explicit at this point because it is here 
 that most errors are made in diagnosis. In the be- 
 ginning of the disease these patients are especially 
 likely to be moody. They fear something they cannot 
 explain, they are joyous or depressed or they may 
 change from one of these conditions to the other 
 without cause and often without the ability of 
 ascribing their mental or emotional condition even 
 to an imaginary cause. 
 
 Many attempts have been made to make differ- 
 ential tests by the use of electricity which have been 
 exceedingly interesting to those engaged in this 
 research but as the results are entirely speculative, 
 and unreliable from a practical standpoint, it will 
 not be best to give them any space in this volume. 
 
 It is of course plain that there must be a marked 
 increase in the power of the skin as a conductor in 
 patients in whom profuse sweating is one of the 
 marked symptoms but it can hardly be considered 
 of much value to make tests requiring such great 
 technical skill to diagnose cases with symptoms so 
 pronounced that they can readily be recognized with 
 the unaided senses. 
 
DIAGNOSIS 55 
 
 4 — Mental Deficiency. In a proportion of these 
 cases the first symptom noted is some form of mental 
 deficiency. In some instances this may take one 
 form, in others quite the opposite. Some of these 
 patients suffer markedly from melancholia while 
 others are in a constant state of exhilaration, some 
 become quiet and thoughtful while others talk in- 
 cessantly. In a number of instances these patients 
 first consult their physicians because they cannot 
 live in peace with the other members of the family. 
 In only a few instances have I encountered these 
 patients with definite illusions or hallucinations but 
 it is likely that the proportion of such patients en- 
 countered in the neurological practice must be 
 much larger than in a surgical practice. 
 
 It is of course important to bear in mind that an 
 insane person may acquire exophthalmic goitre in- 
 dependently of his insanity and vice versa that a 
 patient suffering from exophthalmic goitre may be- 
 come insane although in the latter case one would 
 naturally be likely to consider the former condition 
 responsible for the latter. On the other hand in- 
 sanity and exophthalmos may both be due to in- 
 creased intracranial pressure especially if this is 
 caused by the presence of a tumor. 
 
 5 — Vertigo. This symptom is not present with 
 any regularity and it has appeared to me to be due 
 largely to the anaemia in these cases and also that in 
 many cases what appears to be vertigo is in fact 
 only a condition of unsteadiness due to general 
 weakness of the muscles which come into use in 
 locomotion. 
 
56 
 
 THYROID GLAND 
 
 The symptom is not of great diagnostic import- 
 ance in itself. Personally, I have never encountered 
 it in any case not sufficiently far advanced to make 
 a diagnosis possible long before this symptom made 
 its appearance. 
 
 Fig. 11. Exophthalmic goitre with very prominent exophthal- 
 mos, the eyes protruding nearly to the point of dislocation. All lobes 
 of the thyroid gland are markedly enlarged especially the right lobe. 
 (By the courtesy of Louis B. Wilson.) 
 
 6 — Graefe's Sign. In the year 1864, v. Graefe 
 •described a definite symptom which had been 
 described independently eight years before by 
 Desmarres in France but neither author seems to 
 have known of the fact that the symptom had been * 
 recognized by the other. 
 
 The former's name has been attached to this 
 symptom because of his long continued interest 
 shown in this subject resulting in the publication of 
 several excellent articles and because he was one of 
 the greatest leaders in his specialty in his day. 
 
DIAGNOSIS 57 
 
 The symptom can be readily recognized even in 
 relatively mild cases but its absence does not war- 
 rant a negative diagnosis in the individual. 
 
 In directing the eye downward, the lower margin 
 of the upper eyelid does not follow the line of vision 
 normally but lags behind or follows in an irregular 
 spastic manner. This clear cut symptom is of real 
 value in making the diagnosis. 
 
 It should always be elicited when present. It is 
 probably due to the weakness of the eye muscles 
 due to the poisoning caused by the hyperthyroidism. 
 Landstrom attributes this symptom also to the 
 diseased condition of the muscle he has described. 
 
 The same explanation will apply to the condition 
 elicited by the tests used to demonstrate Stell wag's 
 sign and the sign of Moebius, so it will not be neces- 
 sary to refer to it again. 
 
 Undoubtedly there are differences in the inherent 
 conditions of these various muscles not only in dif- 
 ferent individuals but also between the various 
 groups of muscles in the same individual which will 
 account for the variations in the results of these 
 various tests*. 
 
 7 — Stellwag's Sign. In close relation to Graefe's 
 sign we must place that first described by Stellwag 
 in 1869. This consits in the fact that especially in 
 cases suffering from marked exophthalmos there is a 
 retraction of the upper eyelid t and at the same time 
 the lid remains much more stationary than it does 
 under normal conditions. There is also a marked 
 decrease in the frequency of winking. 
 
 8 — Moebius* Sign. In 1895, Moebius pointed 
 out the fact that in many cases of exophthalmic 
 
58 THYROID GLAND 
 
 goitre there is an insufficiency of convergence. If the 
 patient is directed to look at the ceiling and then 
 suddenly at his own nose it will be found that only 
 one eye will be directed toward the nose and the 
 other may take any other direction although it 
 usually maintains its axis fairly parallel with the 
 eye that is directed toward the nose. This symptom 
 may also be elicited by having the patient fix an 
 object with his eyes at a distance of several yards 
 then by gradually approaching the face a point will 
 be reached at which only one eye will continue to 
 fix the object. The other eye will cease to see the 
 object. There will be no double vision but the pa- 
 tient will feel a certain degree of strain during this 
 experiment. 
 
 There is no definite distance from the eyes at 
 which the convergence will cease and the distance is 
 not constant in the same patient at different times. 
 
 There does not seem to be any definite relation 
 between the degree of exophthalmos and the de- 
 ficiency indicated by the test. 
 
 This test is not positive in all cases of exophthalmic 
 goitre but it can be elicited in a majority of these 
 cases. 
 
 9 — Paroxysmal Dyspnoea — Bryson's Symptom. In 
 close relation also with the symptoms just de- 
 scribed we must place that of paroxysmal dyspnoea, 
 because it is undoubtedly also dependent largely 
 upon the effect which the thyroid poisoning has had 
 upon the muscles of respiration. 
 
 It is important not to overlook the fact that the 
 dyspnoea may in reality be due to the pressure upon 
 the trachea by the enlarged thyroid gland referred 
 
DIAGNOSIS 59 
 
 to above. Neither must the anaemia and the weakness 
 of the heart be lost sight of in the consideration of 
 this subject. It is likely that in most cases all of 
 these conditions or several of them may act together, 
 then there may be a further exacerbation at times 
 due to a dilatation of the stomach which is not un- 
 common and which would naturally cause more 
 disturbance in these than in other patients. 
 
 Late in the course of the disease, a form of dysp- 
 noea occurs which is not. paroxysmal in character 
 because it is entirely due to the oedema of the lungs. 
 
 10 — Intermittent Conditions Without Apparent 
 Exciting Cause. There are several conditions 
 which come and go intermittently which may be 
 considered together. They may all occur in the 
 same patient at the same time or at different times, 
 or they may occur but once or twice but there is 
 this peculiarity that it does not seem possible to 
 determine a satisfactory exciting cause for their 
 occurrence. 
 
 These conditions are vomiting, diarrhoea, sweating 
 often over circumscribed portions of the surface 
 of the body, and mental depression, all intermit- 
 tent. In many cases there seems to be a general ex- 
 acerbation of the disease whenever one or more of 
 these symptoms appear. 
 
 During these times the thyroid gland is sometimes 
 engorged to a condition which has been aptly com- 
 pared with a lactating breast as compared with the 
 same organ during its inactive stage. That there is 
 an increase in the local blood supply during periods 
 of exacerbation there can be no doubt. 
 
60 
 
 THYROID GLAND 
 
 So far as the gastrointestinal symptoms are con- 
 cerned it is likely that the involuntary muscles 
 suffer quite as much in the walls of the stomach and 
 intestines as do the heart muscles and the muscles 
 in the extremities, and this would readily account 
 for any disturbances in this part of the body .The 
 mental depression has been attributed to the direct 
 effect of the hyperthyroidism upon the tissues of the 
 brain. 
 
 Fig. 12. Exophthalmic goitre with the goitre scarcely percepti- 
 ble but the exophthalmos quite marked but not nearly so prominent 
 as Fig. 11. (By courtesy of Louis B. Wilson.) 
 
 The erratic sweating reminds one very forcibly of 
 hysteria and this symptom has frequently been 
 brought forward in support of the neurotic origin 
 of the disease. It seems, however, not unreasonable 
 to suppose that notwithstanding the fact that satis- 
 factory nerve lesions cannot be demonstrated still 
 
DIAGNOSIS 61 
 
 so general a poison is likely to have some effect 
 directly upon the nerve tissues and that certain 
 branches will be more affected than others. The 
 actual pathological findings in the nervous system 
 have been fully described in the chapters on path- 
 ology. In connection with the condition of intermit- 
 tent mental depression without apparent exciting 
 cause, it is proper to refer to epiliptiform seizures 
 which frequently have been reported. There is no 
 reason why true epilepsy should not complicate 
 exophthalmic goitre but there are cases in which 
 the cortical irritation is undoubtedly directly due 
 to the thyroid poison. It is often difficult to distin- 
 guish between these paroxysms and those due to 
 hysteria which also frequently complicates exoph- 
 thalmic goitre. 
 
 Here again it is necessary to establish the existence 
 of exophthalmic goitre because a mistaken diagnosis 
 might readily give rise to an endless amount of 
 harm to the patient. Undoubtedly, many cases 
 diagnosed as hysteria which are actually suffering from 
 exophthalmic goitre have been made much worse 
 by extended travel, mountain climbing, social di- 
 versions, vigorous hydrotherapeutic treatment or 
 by the various other methods often employed in 
 the treatment of patients suffering from hysteria. 
 I have personally encountered a number of these in- 
 stances. 
 
 11 — Conditions Increasing Gravity of Disease. 
 A number of conditions regularly serve to in- 
 crease the gravity of exophthalmic goitre some- 
 times to an alarming or even to a fatal extent, and 
 it is consequently important that these should be 
 
62 THYROID GLAND 
 
 pointed out with especial emphasis. This is true 
 especially because some of these conditions are em- 
 ployed in the treatment of neurasthenia or hysteria 
 and others in the treatment of simple goitre. 
 '^Psychic excitation is extremely harmful. In 
 many instances every symptom is increased with enor- 
 mous rapidity so that the patient loses ground to a 
 marked extent from day today and a week or a month 
 may '^change the case from a hopeful to a hopeless 
 condition. I have repeatedly observed such decline. 
 It seems in these cases as though the blood were 
 rapidly filled with a most active poison. Mental 
 and physical exhaustion bring the same results only 
 in^a less violent form. In a number of cases in which 
 the condition was mistaken for neurasthenia and 
 consequently treated by vigorous exercise and mental 
 diversion and social excitement, I have seen these 
 patients become worse rapidly only to improve upon 
 the substitution of absolute rest. 
 
 In order to impress this fact more acutely, I will 
 give an abstract of the history of a case under treat- 
 ment at the present time. A business man, 34 years 
 of age, who had severely overworked for a number 
 of years began to lose a pound in weight each day 
 for a period of ten weeks, he also became severely 
 nervous. Being exceedingly powerful and weighing 
 240 pounds, he did not pay much attention to the 
 loss of weight and strength which he attributed to 
 the fact that he had worked from seven in the morn- 
 ing until one o'clock the following morning during 
 this time. When he began to suffer from dyspnoea 
 he consulted his physician who prescribed a diet, 
 out-door exercise and tonics, and a few weeks later a 
 
DIAGNOSIS 63 
 
 trip in the mountains at an elevation of over 10,000 
 feet with long rides on horseback over mountain 
 trails. The case proved on examination to be a 
 typical exophthalmic goitre. It is plain that the trip 
 would have been extremely harmful if not worse. 
 
 The administration of thyroid extract is sure 
 to have a harmful influence upon these patients 
 although there may be a decrease in the size 
 of the goitre. The decrease in the size of the 
 goitre is especially likely to occur in patients 
 who have suffered from simple goitre for some 
 time before the occurrence of exophthalmic goi- 
 tre. Recently, I have examined a maiden lady 
 of thirty-six years who came for relief of gas- 
 tric ulcer. She had carried a simple goitre for 
 a number of years without any discomfort. Eight 
 months ago she began to suffer from tachycardia 
 and at the same time her eyes began to bulge for- 
 ward. She also lost rapidly in strength. Two months 
 ago she began to suffer from intermittent nausea, 
 pain in the region of the stomach, occasional diarr- 
 hoea, profuse sweating, dysmenorrhea. All of these 
 conditions were attributed by her and her physician 
 to a gastralgia and as the symptoms were increased, 
 to ulcer of the stomach. 
 
 The patient directed the physician's attention to 
 the presence of the goitre, but the latter was so 
 thoroughly engrossed in the care of the stomach 
 that he gave only incidentally some slight attention 
 to the goitre by prescribing thyroid extract inter- 
 nally and an iodine ointment for external use. Not- 
 withstanding the most painstaking attention to the 
 stomach the patient has lost over three pounds each 
 
64 THYROID GLAND 
 
 week for the last eight weeks. She is now exceed- 
 ingly anaemic and weak, her pulse beats 136 times 
 per minute and she has all of the typical symptoms 
 of exophthalmic goitre described above. This case 
 is not at all isolated. I simply describe it because it 
 was so typical in every respect. 
 
 What I have said of thyroid extract applies to a 
 somewhat slighter extent to the use of iodine in the 
 treatment of exophthalmic goitre. The use of iodine 
 in any form always makes them worse. 
 
 Emaciation and Anaemia. In advanced cases 
 emaciation and anaemia are practically always 
 present but it will hardly be necessary to discuss 
 these symptoms because they are plainly secondary 
 to the malnutrition which is caused by the condition 
 of the gastrointestinal tract described above. 
 
 We have confirmed the findings of Kocher in the 
 examination of the blood that there is an increased 
 lymphocytosis and a decreased leucocytosis but in 
 itself the blood examination cannot determine the 
 diagnosis, it can at most confirm a diagnosis which 
 has already been made from a study of the symptoms 
 described above. 
 
 , Kocher reports careful blood examinations in 
 fifty-eight cases in which he found the number of 
 lymphocytes increased while the polynuclear forms 
 were diminished. The total number of leucocytes 
 was normal or rather below normal. The increase in 
 lymphocytes was sometimes absolute but more com- 
 monly relative. In early cases and in those that 
 have improved under treatment there is usually no 
 increase of lymphocytes. 
 
DIAGNOSIS 65 
 
 Conditions Occasionally Present. There are some 
 other conditions which seem of little importance 
 because they are present only in a very small 
 proportion of cases, but as they are likely to direct 
 the attention of the physician away from the correct 
 diagnosis it seems proper to give them a limited 
 amount of space at this point. Their presence or 
 absence should not affect the diagnosis of exophthal- 
 mic goitre but it is important that their presence 
 be not used to introduce doubt into the correctness 
 of a positive diagnosis. 
 
 Discoloration of the Skin. In some cases there 
 is a marked degree of darkening of the skin es- 
 pecially in the portions exposed to light or to the 
 irritation of certain portions of the clothing like 
 garters and waistbands. 
 
 The mucous membrane is either entirely free or 
 only very slightly affected. In the face the most 
 marked portion is around the eyes. 
 
 The areas about the nipples and the axillary 
 spaces, the lower portion of the abdomen and the 
 inner surface of the thighs are usually darker than 
 the remaining portion of the body. Theoretically it 
 may be supposed that this condition is due to the 
 effect of the thyroid poison upon the suprarenal 
 glands which seems reasonable although it will re- 
 quire much careful study to prove or disprove this 
 theory because it is not likely that the pathological 
 material can be obtained in a sufficiently fresh con- 
 dition in a considerable number of these cases to 
 bring about positive results. 
 
 The pigmentation changes with the severity of the 
 conditions and disappears almost entirely after 
 
66 
 
 THYROID GLAND 
 
 operation if this treatment has been successful in re- 
 moving the typical symptoms of the disease. 
 
 These patients are likely to be mistaken for cases 
 of Addison's disease. It is plain that such a mis- 
 
 Fig. 13. Profile of exophthalmic goitre with but a slight goitre 
 but fairly marked exophthalmos. (By courtesy of Louis B. Wilson.) 
 
 take would probably prove fatal to the patient 
 unless corrected before the degenerative changes had 
 advanced to a hopeless condition. 
 
DIAGNOSIS 67 
 
 There is, of course, no reason why Addison's 
 disease should not occasionally complicate exoph- 
 thalmic goitre, but one should always exclude the 
 latter disease carefully in every case in which the 
 presence of pigmentation may suggest the presence 
 of Addison's disease because in this way valuable 
 time for treatment of the hyperthyroidism may not 
 be lost. It is possible that the pigmentation may be 
 due in these cases to the effect of the thyroid poison 
 upon the suprarenal glands. 
 
 Erythema. This condition although not com- 
 mon should be borne in mind because it is likely to 
 occur early in the disease and thus cause the physi- 
 cian's attention to be directed away from the correct 
 diagnosis unless he is familiar with the fact that it 
 occurs as a complication of exophthalmic goitre. 
 
 Blushing. Occasionally patients suffering from 
 exophthalmic goitre are annoyed by the fact that 
 the slightest mental excitement causes them to 
 blush violently, a symptom which is less uncommon 
 in young women who are suffering from this disease 
 early in its course before marked anaemia has ap- 
 peared. 
 
 Urticaria. In some instances urticaria may occur 
 either spontaneously or upon external irritation. 
 In some instances only one form of irritation will 
 bring about this condition while in others it may 
 be brought about by many forms of external irrita- 
 tion. 
 
 Circumscribed Oedema. In a considerable pro- 
 portion of patients suffering from exophthalmic 
 goitre circumscribed oedema may be observed. This 
 condition may remain for days or weeks or it may 
 
68 THYROID GLAND 
 
 appear suddenly and disappear again within a few 
 hours. It may reappear in the same location or at 
 any other point or it may disappear permanently. 
 This condition can be differentiated from anasarca 
 by the fact that it is not influenced by the position 
 of the part of the body affected and that its is not 
 symmetrical. 
 
 It is undoubtedly related in some way with 
 myxcedema although the histological' sections of 
 tissue which have been removed from these circum- 
 scribed areas are quite different from similar sec- 
 tions made in cases suffering from myxcedema. The 
 tissue in the former is thickened because of the pres- 
 ence of water, in the latter because of the infiltration 
 with a mucoid substance. 
 
 Myxoedema has been observed in some cases in 
 connection with exophthalmic goitre although the 
 presence of this condition would indicate an absence 
 of activity of the thyroid gland while as has 
 been repeatedly stated exophthalmic goitre repre- 
 sents an increase in thyroid activity. This apparent 
 discrepancy in theories has been explained by the 
 supposition that on the one hand the thyroid gland 
 has lost its ability to perform its normal physiological 
 function, while on the other hand a portion of the 
 gland is still active in producing abnormal secretion 
 which when forced into the circulation gives rise to 
 more or less typical exophthalmic goitre. It is most 
 important to bear in mind these conditions because 
 this will enable the physician to recommend treat- 
 ment which is likely to correct both conditions. The 
 treatment indicated for the relief of exophthalmic 
 goitre in these cases must consist in the removal of 
 
DIAGNOSIS 
 
 69 
 
 that portion of the thyroid gland containing the 
 nodules secreting the substance which causes the 
 disease, or the double ligation and section of the 
 superior, inferior, and anterior thyroid veins. 
 Then the myxcedema must be relieved by adminis- 
 tering thyroid extract. Were the thyroid extract 
 
 Fig. 14. Exophthalmic goitre, very early stage, neither the goitre 
 nor exophthalmos well marked. (By courtesy of Louis B. Wilson.) 
 
 administered before the removal of the diseased 
 portion of the thyroid gland, the tachycardia and 
 the other symptoms of exophthalmic goitre would 
 increase probably to a fatal extent. On the other 
 hand were the thyroid gland removed without the 
 
70 THYROID GLAND 
 
 subsequent use of thyroid extract, there would un- 
 doubtedly result an increase in the severity of the 
 myxcedema. In these cases it would be reasonable 
 to remove the diseased thyroid gland and simul- 
 taneously transplant normal thyroid gland from 
 another person. 
 
 Scleroderma. This condition has frequently been 
 observed. Singer believes that there is a definite 
 relation between the condition of the thyroid gland 
 and scleroderma not only in cases in which it has 
 been incidentally observed in connection with goitre 
 but also in all cases in which the patient is suffering 
 from scleroderma independently. 
 
 Alopecia. In a number of cases, either circum- 
 scribed or general, baldness has occurred as a com- 
 plication of exophthalmic goitre and in other cases 
 there has been a loss of eyebrows, eyelashes, axillary 
 and pubic, hair. The beard seems affected less fre- 
 quently than other portions of the body. 
 
 Atrophy of the Mammary Glands. There seems 
 to be a marked shrinkage of the mammary glands 
 early in the course of exophthalmic goitre before 
 the effect upon the patient's general condition is 
 sufficient to produce so marked a local effect. This 
 seems to be coincident with a depression in the 
 sexual vigor of these patients. This condition does 
 not preclude pregnancy, although it is much 
 more common to encounter patients in whom ex- 
 ophthalmic goitre has developed during the period 
 of pregnancy or lactation than those in whom preg- 
 nancy has occurred during the existence of exoph- 
 thalmic goitre. 
 
DIAGNOSIS 71 
 
 A circumscribed oedema of one or both breasts 
 may be mistaken for a hypertrophy but the condition 
 is the same as though it occurred in any other portion 
 of the body. 
 
 Enlargement of Lymph Nodes. In operating for 
 the removal of portions of the thyroid gland one 
 frequently encounters enlarged lymph nodes. It is 
 doubtful if these have any definite relation to the 
 disease. It is important not to mistake them for 
 parathyroid glands. Confounding them with aberrant 
 thyroid glands is of no importance because the re- 
 moval of the latter is immaterial. 
 
 Enlargement of Thymus Gland. Practically, the 
 fact is important that this gland is enlarged in 
 a considerable proportion of cases. At autopsies 
 in patients succumbing to exophthalmic goitre 
 the upper margin of the thymus gland has fre- 
 quently been found to touch the lower end of the 
 thyroid, or in other instances enlarged lymph nodes 
 have been found between the two. In the cases that 
 died after thyroidectomy Capelle found persistency 
 of the thymus gland in 79 per cent. It is possible 
 that there is a lower death rate in cases in which 
 the thymus gland has disappeared because in sta- 
 tistics taken without reference to operative treat- 
 ment the number of persistent thymus glands is 
 always considerably lower. Von Houseman found a 
 persistent thymus in each of four out of eight cases. 
 If this theory should become established, it would of 
 course become necessary to find some way of de- 
 termining the presence or absence of a persistent 
 thymus gland before undertaking the operation. 
 
72 THYROID GLAND 
 
 In its presence it would then become proper to 
 make the operation according to a plan which will 
 be described fully under surgical treatment which 
 would materially reduce the severity of the opera- 
 tion, possibly at the risk of being less uniformly 
 effective. This would have a tendency to leave a 
 safe margin of resistance in this particular class of 
 cases. 
 
 Osteomalacia. This condition is mentioned by 
 many authors all of whom seem to be convinced that 
 there is some relation between it and thyroid dis- 
 ease. Clinically I cannot discuss this condition from 
 personal observation. This may be a coincidence or it 
 may indicate that the condition is quite as rare in 
 those suffering from exophthalmic goitre as it is in 
 others or the condition of the bones may not have 
 been determined with a sufficient degree of accuracy 
 in my cases. 
 
 In a number of cases of fracture in which union 
 failed to take place promptly we have administered 
 thyroid extract but it is impossible to determine 
 positively whether this remedy definitely influenced 
 the healing of these fractures. 
 
 General Appearance of Patients Suffering from 
 Exophthalmic Goitre. Patients suffering from sim- 
 ple goitre need not be especially described because 
 the condition is so apparent that it will require 
 no especial description to enable even the least 
 experienced physician to recognize the condition. 
 The following illustrations, Fig. 7 and Fig. 8, will 
 be introduced simply for the purpose of com- 
 parison. As regards the size of the swelling, it may 
 be so small as to be scarcely perceptible and it 
 
DIAGNOSIS 73 
 
 may be necessary to palpate the neck in order to 
 discover any abnormal condition or again in case 
 the growth is retrosternal it may become necessary 
 to have the patient go through the act of swallow- 
 ing in order to make the enlargement apparent 
 when it rises with the remaining portions of the 
 thyroid gland which may not be enlarged. 
 
 From this size it may vary in other cases to an 
 enormous proportion. Fig. 9 and Fig. 10 illustrate 
 one of these cases in which the gland when removed 
 weighed six pounds and fourteen ounces after the 
 blood had drained away. 
 
 The growth may be sessile with a broad base as 
 shown in Fig. 9 or it may be narrower at the base 
 with its greatest portion projecting down over the 
 chest, or it may arise from one lobe and be pedun- 
 culated. In fact the swelling may take upon itself 
 a large variety of forms and the size may vary 
 enormously. It is surprising how large a goitre a 
 patient will occasionally carry about without seek- 
 ing relief from surgical interference. This was true 
 especially in the portions of Switzerland in which 
 goitres are endemic before Kocher popularized the 
 operation of thyroidectomy. In some instances the 
 growth becomes so large that the patient has to 
 improvise a form of bandage which contains a 
 pouch in front into which the goitre fits and a broad 
 band behind to be buttoned around the neck so 
 that the weight of the tumor is supported partly 
 from the back of the neck instead of pulling entirely 
 on the front. Fortunately for the patients the old 
 fear of operation no longer exists and consequently 
 
74 THYROID GLAND 
 
 relief is usually obtained before so advanced a con- 
 dition has developed. 
 
 In exophthalmic goitre the size of the goitre is 
 rarely an important feature although occasionally 
 one encounters large goitres in connection with this 
 disease. The striking feature in the appearance of 
 these patients is the prominence of the eyes which 
 may vary from a scarcely perceptible prominence to 
 an actual protrusion which may be so marked that 
 
 Fig. 15. Exophthalmic goitre. The exophthalmos and the goi- 
 tre well marked. (By courtesy of Louis B. Wilson.) 
 
 the eyeball may actually be dislocated from its 
 socket so that it hangs down upon the cheek. 
 
 I have personally encountered but one case in 
 which the condition was so extreme but many cases 
 have been reported and I have encountered a num- 
 ber of cases that approached this condition. Fig. 
 
DIAGNOSIS 75 
 
 11 approaches this degree of protrusion. In this 
 case the goitre itself is of considerable size while in 
 Fig. 12 we have quite a. marked protrusion of the 
 eyes while the enlargement of the thyroid is scarcely 
 perceptible from a distance. The same is true in 
 Fig. 13 in which the condition is shown in profile. 
 
 .Figures 14, 15, 16, show various degrees of pro- 
 trusion but in cases like these there is no difficulty 
 in recognizing the condition. It is in cases like the 
 one shown in Fig. 17 in which neither the exoph- 
 thalmos nor the goitre is prominent that the con- 
 dition is likely to be overlooked. 
 
 Complications. Aside from the complications 
 which have been mentioned in connection with the 
 discussion of the major, minor, and incidental 
 symptoms exophthalmic goitre may be complicated 
 with all diseases which a person can acquire who is 
 not suffering from the condition and conversely 
 aside from the fact that a patient with slight re- 
 sistance is more likely to suffer from diseases in 
 general, it may be said that a patient suffering from 
 exophthalmic goitre is no more likely to suffer from 
 any complication than any normal person. 
 
 Contagious and infectious diseases have not been 
 mentioned frequently in connection with this disease 
 but this may be accounted for by the fact that these 
 patients are not likely to be exposed to contagion 
 or infection. An exception should be noted in the 
 fact that relatively a considerable number of these 
 cases suffer from tuberculosis. 
 
 . All other diseases have been mentioned but it is 
 clearly not necessary to enumerate these separately. 
 
76 THYROID GLAND 
 
 It is, however, exceedingly important to bear in 
 mind the fact that the presence of any other disease 
 does not exclude the possibility of its complication 
 with exophthalmic goitre and also that this is a 
 grave complication at all times and one that will 
 require especial attention. An example of the im- 
 portance of this element will become apparent upon 
 studying the report of Gautiers, of Geneva, who 
 found that symptoms of exophthalmic goitre fre- 
 quently develop in apparently latent cases upon the 
 administration of iodide of potassium. The use of 
 this drug is of course especially contraindicated to- 
 gether with the use of thyroid extract in cases which 
 were suffering primarily from simple goitre but in 
 whom exophthalmic goitre developed later. 
 
CHAPTER IV. 
 
 NON-SURGICAL TREATMENT. 
 
 Treatment of Simple Goitre. Although this book 
 should properly not reach beyond the surgical 
 side of this question, it seems important to bear in 
 mind that all forms of non -traumatic and non- 
 malignant diseases of the thyroid gland are primarily 
 medical. 
 
 There is so convenient an opportunity for the 
 surgeon of falling into an error in logic at this point 
 because he comes in constant contact only with those 
 cases that have failed to respond to internal treat- 
 ment that it may appear to him from his own ex- 
 perience that internal treatment always fails to 
 cure goitre because it has always failed in all of the 
 cases that have come under his professional care. 
 As a matter of fact, a much larger proportion of 
 cases never consult a surgeon because they recover 
 spontaneously or they are cured by internal, dietetic, 
 and hygienic treatment. For this reason it seems 
 important to give some attention to this feature be- 
 fore directing attention to the means offered by 
 surgery for the relief of thyroid disease: 
 
 The fact that practically all cases which come to 
 the surgeon for relief of thyroid disease have wasted 
 much time by subjecting themselves to the ineffec- 
 tive efforts of the internist, neurologist or the various 
 electrical and other specialists might readily be con- 
 
78 THYROID GLAND 
 
 strued to mean that all of these methods are useless 
 and that the patients should be at once referred to 
 the surgeon for operative treatment. This conclusion 
 would, however, be quite as wrong as it would be 
 for an internist to conclude that because the few 
 cases he has referred to a surgeon have died follow- 
 ing the operation, therefore surgical treatment is 
 always contraindicated. 
 
 The facts are as follows: More than one-half of 
 all cases of goitre will recover under careful dietetic, 
 hygienic and medicinal treatment which must consist 
 in drinking an abundance of good water which can 
 always be obtained in regions where goitre is ende- 
 mic by distilling it, by carefully regulating the diet, 
 by correcting the conditions of ventilation in homes 
 and especially in sleeping rooms, by insisting upon 
 an abundance of sleep and upon an absence of ex- 
 citement and of mental and of physical fatigue. 
 
 So far the treatment refers as well to simple as to 
 exophthalmic goitre. 
 
 In simple goitre the application of a non-irritating 
 absorbable iodine ointment to the neck seems to be 
 of considerable benefit. Internally general tonics 
 are of undoubted value and from 3 to 5 grains of a 
 reliable thyroid extract given from three to six times 
 daily seems to have a specific value. 
 
 It should be borne in mind that many of the 
 preparations of the thyroid gland in the market are 
 perfectly inert because these have been deprived of 
 their active elements by some faulty process in the 
 manufacture. It is consequently important to use 
 only tested products. 
 
NON-SURGICAL TREATMENT 79 
 
 In case of simple goitres that do not yield upon the 
 treatment just outlined it is well to inject directly 
 into the substance of the gland ninety drops of a 
 five per cent, aqueous solution of pure carbolic acid, 
 a method introduced and practiced for many years 
 by Professor Moses Gunn. It is important to pre- 
 pare this solution carefully by mixing the carbohc 
 acid with boiling water because when mixed with 
 cold water small globules of the strong acid may 
 continue to float in the solution and these will cau- 
 terize the tissues with which they come in contact. 
 This treatment is to be repeated once each week. 
 When more than one lobe of the gland is involved 
 the different lobes should be injected at successive 
 treatments, until all of them have been so treated 
 when two or three of the lobes may be injected at 
 each treatment. If the patient shows marked vertigo 
 or if the urine becomes dark and cloudy the quantity 
 injected shpuld be reduced. It is, however, but rarely 
 necessary to reduce the quantity. In order to deter- 
 mine the fact that the injection is actually made into 
 the gland, the patient should go through the effort 
 of swallowing before the contents of the syringe has 
 been discharged after the needle has been plunged 
 into the enlarged gland. , If the needle is in the proper 
 position the syringe will rise with the act of swallow- 
 ing. It is well for the patient to lie down for a few 
 moments after the injection has been made because 
 there is frequently a little vertigo directly after the 
 solution has been injected into the gland. During 
 the administration of many hundreds of these in- 
 jections, I have never seen any harmful effects. 
 
80 THYROID GLAND 
 
 In cases which can be cured by this method, there 
 is usually a marked improvement by the time the 
 patient has received from six to ten injections. In 
 the meantime the treatment with tonics, thyroid 
 extract and hygienic and dietetic methods should be 
 continued. In many cases in which the latter treat- 
 ment alone without the injections made no impres- 
 sion the patients have recovered fully after this 
 
 Fig. 16. Exophthalmic goitre. Both exophthalmos and goitre 
 are sufficiently advanced to be easily recognizable but cases of this 
 degree are very frequently overlooked. 
 
 treatment was added. It seems important to insist 
 upon the use of distilled or pure spring water in all 
 patients who continue to live in the vicinity in which 
 they acquired the goitre. 
 
 In simple goitre in regions where this disease is 
 not endemic fully fifty per cent, of all cases will re- 
 
NON-SURGICAL TREATMENT 81 
 
 cover by the use of hygienic, dietetic and medicinal 
 treatment and more than one-half of the remaining 
 cases will recover if the injection treatment is added 
 to the other treatment. The remaining twenty-five 
 per cent, will resist every form of treatment except 
 excision which will be considered later. In countries 
 where goitre is endemic these methods seem less 
 useful probably because it is so much more difficult 
 to eliminate the exciting cause. Electricity has been 
 employed in the form of x-ray exposure and by the 
 application of practically every form of this agent, 
 Undoubted improvement has been noted in patients 
 subjected to this form of treatment but it is diffi- 
 cult to determine just how much can properly be 
 attributed to the action of the electricity and how 
 much should be attributed to the benefits from 
 concurrent diet, hygiene and medication. 
 
 The cases that do not yield to any of these forms 
 of treatment should then properly be considered 
 surgical in character and should receive relief through 
 operative interference provided the patient suffers 
 because of the presence of the deformity or because 
 of obstruction to breathing or swallowing or discom- 
 fort from pressure either because of the location or 
 the size of the goitre. 
 
 That there is a certain proportion of cases of simple 
 goitre which will not yield to any form of non- 
 surgical treatment there can be no doubt and it is 
 this class of cases that come under the observation 
 of the surgeon, after all other means have been tried 
 and which gives him the impression that none but 
 surgical treatment is indicated for the relief of 
 patients suffering from goitre unless he is in a po- 
 
82 THYROID GIvAND 
 
 sition to observe the much larger proportion of cases 
 also which never come to his department because 
 non-surgical treatment has eliminated them. The 
 varieties of non-exophthalmic goitres which are most 
 likely to yield to non-surgical treatment will be con- 
 sidered further with the discussion of the pathology 
 of goitre. 
 
 The reason for discussing the medical treatment so 
 briefly is of course apparent but I wish to be em- 
 phatic in stating that all non-malignant and non- 
 traumatic diseases of the thyroid gland should first 
 be considered medically because with the rise of 
 thyroid surgery it would otherwise be certain that 
 many patients would be subjected to operative treat- 
 ment quite unnecessarily. More than one-half of all the 
 patients who have come to me for examination dur- 
 ing the past twenty years have recovered promptly 
 upon the use of non-surgical treatment and the 
 proportion of cases that are curable without opera- 
 tion coming to the surgeon for advice must neces- 
 sarily be much smaller than that coming to the 
 internist for the same purpose. It is doubtful whether 
 one could come upon some permanency of cure fol- 
 lowing the non-surgical treatment of these cases in 
 countries where goitre is endemic. 
 
 That the results of non-surgical treatment are 
 permanent where they are primarily effective in 
 this vicinity, I have had an abundance of opportunity 
 to confirm, because I had the care of many of these 
 cases while serving as the assistant of Prof. Moses 
 Gunn, who introduced the carbolic acid treatment, 
 and I have followed many of these cases for a period 
 of twenty-five years. It would be interesting to fol- 
 
NON-SURGICAL TREATMENT 83 
 
 low these cases statistically in some of the great in- 
 ternal clinics but I have failed to encounter any 
 important records. It seems that no one has followed 
 these cases after their recovery for the purpose of 
 reliable statistics to compare with the results ob- 
 tained in cases treated surgically. 
 
 Non-Surgical Treatment of Exophthalmic Goitre. 
 The use of rest especially as well as other hygienic 
 and dietetic measures applies even to a greater 
 extent to the non-surgical treatment of exoph- 
 thalmic goitre than to the treatment of simple 
 goitre. There are, however, two very distinct differ- 
 ences. It is far more important that these cases be 
 subjected to early surgical treatment in case the non- 
 surgical treatment proves futile than is the case 
 with simple goitre. In exophthalmic goitre prolonged 
 non-surgical treatment in cases in which there is no 
 improvement always results in serious degenerative 
 changes. These progress to a point at which surgical 
 treatment is no longer possible because the patient's 
 power of resistance has been dissipated to a hopeless 
 degree so that a fatal result must be expected after 
 an operation . Or the patient may still have a sufficient 
 degree of resistance to recover from the operation 
 which may serve to stop the progress of the disease 
 so that there is no further degeneration of any of 
 the tissues which suffered as a result of the thyroid 
 poisoning before the operation, but the degree of 
 degeneration may have advanced so far that the 
 power of recuperation may be entirely or almost 
 entirely lost. Such cases may continue to live for 
 many years following the removal of the diseased 
 gland without any increase in symptoms which 
 
84 Thyroid gland 
 
 would indicate that the thyroid poisoning is still 
 active but they will remain weak. If they are de- 
 pendent upon their own efforts for their support 
 they invariably become public charges. If they have 
 independent means they are usually extremely un- 
 happy because they are not able to follow the pur- 
 suits or pleasures which they enjoyed during their 
 lives before acquiring exophthalmic goitre. Even if 
 surgical treatment is employed early there is usually 
 not a complete recovery according to the investiga- 
 
 I 
 
 Fig. 17. Represents a case of exophthalmic goitre in which 
 both the exophthalmos and the goitre are so slight that they will usually 
 not be discovered until the diagnosis is suggested by the presence of 
 other symptoms like tachycardia, tremor or muscular weakness. 
 
 tions of Landstrdm. Although the patients may be 
 apparently quite well a careful examination of the 
 heart will usually demonstrate at least a slight 
 defect. 
 
 Treatment. Rest is the most important element 
 in the treatment of exophthalmic goitre and in the 
 after-treatment following operations, and it should 
 
NON-SURGICAL TREATMENT 85 
 
 be borne in mind that this refers quite as much to 
 mental and emotional as to physical rest. 
 
 The mental condition of these patients often 
 causes them to become intensely interested in social 
 or religious affairs or in other matters such as litera- 
 ture or music. I have encountered an instance in 
 which the patient, a delicate woman, became almost 
 insanely interested in card playing. The particular 
 subject in which these patients waste their energies 
 is probably largely accidental and due to environ- 
 ment but it is equally harmful and must be stopped 
 without making too severe an impression upon the 
 patient's emotions. In post operative cases this is 
 plainly much easier of accomplishment than in cases 
 that have not been operated. That it is of the very 
 greatest importance to secure rest for these patients 
 there can, however, be no doubt. This must be in- 
 sisted upon for many months after the patient has 
 apparently recovered without regard to the mode of 
 treatment that has been employed in any given case. 
 
 Such patients should be guarded as much as 
 possible against severe sudden or continued strains 
 that can be avoided but that must be accepted in 
 the life of other persons. This would apply especially 
 to pregnancy which has resulted in a large propor- 
 tion of abortions according to Schmauch and in the 
 death of a considerable number of mothers, although 
 according to Charcot, the surviving mothers are 
 likely to recover from the exophthalmic goitre. 
 
 Specific Medication. In a condition which is 
 clearly due to a definite poison circulating in the 
 blood, the treatment must logically consist either 
 in removing the source of the poison, thyroidectomy, 
 
86 THYROID GLAND 
 
 or in the introduction of some medium which will 
 make this poison harmless after it has been intro- 
 duced. A number of attempts have been made to 
 find a substance which will have a neutralizing effect 
 upon this poison. Moebius has introduced the serum 
 of thyroidectomized goats known as "antithyroidin," 
 which is administered internally in doses of from 20 
 to 60 drops every eight to twelve hours at first reg- 
 ularly and later at intervals of several days. Much 
 stress has been laid upon giving a meat free diet con- 
 sisting mainly of vegetables, fruits, eggs and milk 
 and that the use of table salt be reduced to a minimum. 
 
 Beebe and Rogers have prepared and administered 
 a serum which in early cases has given good results 
 when used in connection with rest, hygiene and 
 proper diet. This serum seems to be of especially 
 great value in acute cases with very severe symptoms. 
 
 Forschheimer highly recommends the use of hydro- 
 br ornate of quinia in doses of five grains, administered 
 four times daily in gelatine coated pills, either with 
 or without the addition of one grain of ergotin. He 
 has usually observed improvement within 48 hours 
 after beginning this treatment, which he continues 
 until the patient is normal. He has observed cures 
 within three months from the beginning of the treat- 
 ment while in one case he continued the treatment 
 uninterruptedly for a period of three years. The 
 patient recovered without experiencing any harmful 
 effects from the use of the remedy. In case a patient 
 does not improve from the use of the quinine hydro- 
 bromate in forty-eight hours he adds one grain of 
 ergotin to each dose. 
 
NON-SURGICAL TREATMENT 87 
 
 He has observed the following effects of this treat- 
 ment: 1. The tachycardia disappears. 2. The 
 thyroid gland diminishes in size. 3. The tremor and 
 the exophthalmos diminishes and later disappears. 
 The first change usually takes place within 48 hours 
 after beginning the treatment which must be con- 
 tinued until all symptoms have disappeared. In 
 nine out of twelve patients of fully developed cases 
 the treatment was entirely successful, the failures 
 were in the very violent forms primarily or in f oud- 
 royant relapsing cases. In forty-five cases of all 
 varieties of severity treated by this method there 
 were five failures. 
 
 A large number of other drugs have been recom- 
 mended and discarded which cannot be discussed. 
 Kocher has used sodium phosphate with the hope 
 of stimulating elimination. 
 
 It seems reasonable to hope that at some time a 
 remedy may be introduced which will thoroughly 
 neutralize the thyroid poison in the blood. It is 
 possible that in favorable cases this is accomplished 
 by the hydrobromate of quinia. 
 
 In the meantime it will be necessary to remove the 
 cause in a large proportion of these cases by perform- 
 ing thyroidectomy. 
 
 Iodine. For many years the internal and external 
 use of various forms of iodine as well as the hypo- 
 dermic injections into the enlarged thyroid gland in 
 simple hypertrophy has obtained so fixed a position 
 in the minds of practitioners of medicine that it has 
 been difficult to impress upon them the fact that in 
 exophthalmic goitre this remedy is almost always 
 certain to do harm although it may cause the goitre 
 
88 THYROID GLAND 
 
 to decrease in size. The manner in which patients 
 become worse is by an increase of the hyperthyroid- 
 ism and with this the increase in all of the important 
 symptoms of exophthalmic goitre but especially the 
 heart symptoms. 
 
 Lanz, and many of his followers, have claimed 
 constant improvement in patients who lived largely 
 on milk from thyroidectomized goats. This would 
 virtually represent another form of serum therapy. 
 Many other observers have reported improvement 
 from the use of a liberal diet of milk either alone or 
 with other food. 
 
 Thymus gland has been given in the hope of ob- 
 taining in this manner a kind of antibody. The re- 
 sults do not seem to have been encouraging. 
 
 Strophanthus, belladonna and arsenic are mention- 
 ed by most authors but discredited by more. Re- 
 liable statistics are lacking with all of these. 
 
 Thyroidectomy. General Considerations: Within 
 a quarter of a century this operation has changed 
 its position entirely in the minds of the surgical pro- 
 fession. At the beginning of this period, it was looked 
 upon as one of the most dangerous of all major oper- 
 ations and at the end of this short space of time, we 
 look upon it as one of the safest of major operations. 
 This change is due largely to the skill and genius of 
 Professor Kocher whose enormous experience en- 
 abled him early to speak with authority upon this 
 subject, pointing out methods, recognizing dangers, 
 simplifying technic and in thyroidectonry for ex- 
 ophthalmic goitre pointing out the importance of 
 operations in repeated stages doing at any one time 
 
NON-SURGICAL TREATMENT 89 
 
 only as much as the individual patient under con- 
 sideration could safely bear. 
 
 His views have been supported on all sides by 
 surgeons whose wide experience has insured excel- 
 lent surgical judgment. 
 
 Dangers of Thyroidectomy. The following dan- 
 gers of thyroidectomy should not be overlooked 
 1, anesthesia; 2, shock; 3, haemorrhage; 4, hyper- 
 thyroidism; 5, infection; 6, recurrent laryngeal nerve 
 injury; 7, injury to parathyroid glands; 8, air em- 
 bolism; 9, collapse of trachea and consequent as- 
 phyxia. 
 
CHAPTER V. 
 
 ANAESTHESIA. 
 
 Accidents from anaesthesia have not been 
 uncommon during operations upon the thyroid 
 gland. There are several reasons why this should 
 be the case. In many of these cases respiration 
 has been impaired for a considerable period of 
 time before the operation so that even during sleep 
 the patient has felt the necessity of being prepared 
 for emergencies of asphyxiation so that the sleep 
 has become habitually light. Under deep anaesthesia 
 the patient is no longer able to use his muscles to 
 guard against this difficulty and before the anaes- 
 thetist notices anything wrong the patient may be 
 in serious trouble. Moreover, 'the operation is at a 
 point where the anaesthetist can readily watch the 
 work of the surgeon unless some precaution is used 
 to prevent this and consequently the administra- 
 tion of the anaesthetic may not receive as close at- 
 tention as is proper. Again, especially in cases of 
 exophthalmic goitre the heart has suffered very 
 severely as a result of the disease and consequently 
 the toxic effect of the anaesthetic is more serious than 
 in other cases. The manipulations in form of pressure 
 and traction upon the trachea and larynx often in- 
 crease the flow and accumulation of mucus which 
 interferes with respiration. Many authors, especially 
 Landstrom, consider general anaesthesia the greatest 
 
ANAESTHESIA 91 
 
 danger in operations, especially for the relief of 
 exophthalmic goitre and they consequently insist 
 upon operating only under local anaesthesia. Moebius 
 on the other hand thinks that the harm done the 
 sensitive nervous system of these patients is much 
 greater than the harm of a carefully administered 
 anaesthetic. Crile also points out the fact that mental 
 excitement greatly increases all symptoms and that 
 consequently local anaesthesia should not be prac- 
 ticed. 
 
 Remedies Against Dangers from Anaesthesia. In 
 many cases it is wise to give the patient a hypo- 
 dermatic injection of one-quarter of a grain of morphia 
 and one one-hundredth of a grain of atropine half 
 an hour before operation. 
 
 There are two methods which may be employed 
 to prevent difficulties from this source. 
 
 1. Local anaesthesia. In order to use local anaes- 
 thesia successfully it is necessary to have a number of 
 hypodermic syringes which can be sterilized and 
 which are in good working condition. The solution 
 to be used should be freshly prepared and should of 
 course be sterile. 
 
 All preparations should be made quietly and with 
 as little annoyance or excitement as possible for the 
 patient. 
 
 • Unless the patient's confidence can be gained be- 
 fore the administration of the local anaesthetic is 
 begun, it is much better not to attempt it because 
 the patient will imagine that she is suffering and 
 this will be of almost as much harm to her as actual 
 pain. It is consequently especially important if local 
 anaesthesia is employed in operations for exophthal- 
 
92 THYROID GLAND 
 
 mic goitre that this condition be achieved. This is 
 very largely a personal matter. Many surgeons have 
 the full confidence of their patients in all of their 
 undertakings and for them it is not a difficult matter 
 to employ this method. 
 
 Moreover, in institutions in which many of these 
 operations are performed patients encourage e^ch 
 other and the new arrivals are impressed with the 
 fact that it is really a very simple matter and when 
 they have once become convinced of this fact, it is 
 an easy matter to carry out any plan. 
 
 Choice of Anaesthetic. Cocain in one per cent, 
 solution has been used in many cases or to this may 
 be added one-half per cent, of adrenalin chloride 
 (1 to 1000). This is preferred by many surgeons be- 
 cause it reduces the amount of oozing of blood from 
 the wound surface during the operation. Landstrom 
 condemns the use of adrenalin because he has ob- 
 served severe haemorrhage after its effect upon the 
 tissues had worn off. 
 
 A two per cent, solution of novacain has been 
 recommended by others and again others recommend 
 the use of a one -half per cent, solution of beucaine 
 which is a synthetic preparation which does not 
 degenerate upon boiling. If adrenalin is used in 
 connection with this preparation, however, it must 
 be added after boiling has been completed. The ad- 
 dition of adrenalin chloride to beucaine makes the 
 anaesthesia last from four to eight times longer than 
 beucaine alone which is active for about fifteen minutes . 
 
 All of these substances should be dissolved in 
 normal salt solution; eight parts of sodium chloride 
 in 1000 parts of distilled water, sterilized by boiling. 
 
ANAESTHESIA 
 
 93 
 
 A syringe armed with a fine needle filled 
 with any one of the above solutions is employed. 
 The needle is inserted into the skin at any point 
 along the proposed line of incision, enough of the 
 solution is forced into the skin to form a bleb 
 one c. m. in diameter. Then the needle is pushed 
 on into the skin along the proposed line of incision 
 
 Fig. 18. Anterior view~of patient already anaesthetized and in 
 position for operation with the head elevated, the towels a, b, c in 
 place, also pad of eight thicknesses of gauze placed over mouth and 
 nose to prevent patient from breathing or coughing into her own 
 wound. The assistant is holding the jaw upward and extending the 
 neck. 
 
 and more of the fluid is forced into the skin until 
 the entire line of incision forms a continuous row 
 of blebs from one to two c. m. in width. A small 
 puncture is now made in the line of incision with a 
 
94 THYROID GLAND 
 
 large sharp needle, a Hagedorn being preferred, or a 
 fine, sharp narrow-bladed scalpel, and now the sharp 
 needle of the syringe is exchanged for a long, blunt 
 needle with an opening on the side near its distal end. 
 This needle is introduced through the needle 
 puncture and passed upwards along the inner border 
 of the sterno-mastoid muscle and a small amount of 
 the fluid is forced into the tissues along the course of 
 the needle. With a little practice it is possible to 
 anesthetize the tissues so thoroughly that there is 
 absolutely no pain upon making the skin incision 
 and this will give the patient much confidence so 
 that if the remainder of the operation is carried out 
 with a sufficient amount of gentleness, the amount 
 of suffering will be at least bearable and will soon be 
 forgotten after the operation is completed. 
 
 It is this enforced gentleness in the manipulation 
 of the tissues during the operation which is really 
 of the greatest value to the patient because the 
 patient cannot and will not submit to the violent 
 manipulations which the surgeon might inflict upon 
 the tissues were the patient under the influence of a 
 general anaesthesia. Surgeons who are habitually 
 violent in their technic will undoubtedly have better 
 results if they make their thyroidectomies under 
 local anaesthesia. 
 
 The operation may also be performed under local 
 anaesthesia by means of Schleich's infiltration with 
 very weak solutions but the tissues appear so un- 
 natural as a result of this infiltration that the diffi- 
 culties are greatly increased. 
 
 Moreover, the wounds seem to be much more pain- 
 ful after the effect of this local anaesthesia has dis- 
 
ANAESTHESIA 95 
 
 appeared than after operations performed under 
 general anaesthesia. 
 
 For several years the fact that Kocher had per- 
 formed so large a number of thyroidectomies with 
 local anaesthesia and that others notably Landstrom 
 had attributed a large proportion of the mortality 
 following this operation to the use of general anaes- 
 thesia has caused many of the more recent authors 
 to treat the question of anaesthesia in these cases 
 as settled in favor of local anaesthesia. The following 
 facts should, however, not be overlooked; first, that 
 real harm is done to the patient by the mental strain 
 due to undergoing an operation without being un- 
 conscious as pointed out, particularly by Crile, and 
 Moebius, and second, the fact that in Mayos' Clinic 
 and in Crile's and in my own, general anaesthesia has 
 been practiced in a much larger number of cases 
 of thyroidectomy than local anaesthesia has been 
 employed in any other clinic with the exception of 
 Kocher's, and that we have had a mortality quite 
 as low as the lowest that has been recorded in the 
 clinics where local anaesthesia is being practiced. 
 Of course, it should be borne in mind that careless 
 general anaesthetization must be absolutely con- 
 demned in these cases. I would also add that probably 
 no general anaesthetic except ether and that only 
 when given by the drop method, is at all safe in 
 exophthalmic goitre. It may be an advantage to 
 precede the administration of ether by the hypo- 
 dermatic administration of one-fourth of a grain of 
 morphine and one one-hundredth of a grain of 
 atropine. 
 
96 THYROID GlyAND 
 
 Ether Anaesthesia. It has been found that all 
 patients not suffering from asphyxia at the time, of 
 operation do well if ether is administered in the foi- 
 ling manner: 
 
 After protecting the patient's eyes by the appli- 
 cation of a piece of guttapercha tissue covered ex- 
 ternally with a thick layer of cotton, an ordinary 
 wire mask such as is usually employed in the admin- 
 istration of chloroform, is covered with four to six 
 layers of gauze or two layers of rather thick stockin- 
 ette material. This is placed over the patient's nose 
 and mouth, then the anaesthetist begins to count and 
 requests the patient to repeat the numbers after him 
 slowly. The anaesthetist repeats some number with 
 three figures slowly, after the patient has repeated 
 this number the anaesthetist repeats the next number 
 either upwards or downwards and the patient again 
 repeats this. This plan is continued until the patient 
 has been very thoroughly anaesthetized, the ether 
 being dropped slowly but constantly upon this mask. 
 By using this open mask there is never any danger 
 of asphyxiation. By following this particular plan 
 of counting, the patient's attention will be fixed 
 upon the anaesthetist's voice. While the anaesthetist 
 repeats the next number of three figures the patient 
 has sufficient time to thoroughly fill his lungs by 
 taking a deep inspiration. He does this uncon- 
 sciously and unintentionally in the preparation for 
 repeating the next number. While he repeats this 
 number of three figures he unintentionally exhales 
 fully and is in condition again to fill his lungs thor- 
 oughly by the next inspiration. Ordinarily this will 
 result in from eight to twelve inspirations per minute. 
 
ANAESTHESIA 97 
 
 The regularity and monotony of the performance 
 has an excellent effect upon the patient's nervous 
 system and in presence of a rapid pulse there is 
 usually a marked improvement in the character of 
 the pulse by the time the anaesthesia has been com- 
 pleted. In fact we have observed a marked differ- 
 ence in cases in which this method was employed 
 and in those in which the patient was directed to 
 count independently from one upwards. The patient 
 should always be completely anaesthetized before 
 she is disturbed by washing the field of operation 
 preparatory to beginning the operation. If the 
 patient is disturbed before full anaesthesia has been 
 reached, a stage of excitement is likely to be caused 
 which will necessitate the use of a much larger amount 
 of the anaesthetic before full anaesthesia has been 
 reached. 
 
 After the patient is fully anaesthetized, the neck 
 which has been carefully prepared the previous 
 evening is again washed with alcohol. A piece of 
 gauze saturated with alcohol is placed over the 
 neck, the towels and sheets separating the field of 
 operation together with a considerable portion of 
 the surrounding area from the remaining surface 
 of the body are then adjusted. This requires but a 
 few moments, during which time the administration 
 of the ether is continued. 
 
 Whenever everything is ready for the operation 
 to begin the ether mask is removed and a pad com- 
 posed of eight layers of sterile gauze is placed trans- 
 versely across the face thoroughly covering nose 
 and mouth and preventing the patient from breath- 
 ing or coughing into her own wound. 
 
98 THYROID GLAND 
 
 The lower end of the table is now depressed from an 
 angle of 30 degrees to 45 degrees so that the patient 
 is in the inverted Trendelenburg position. This re- 
 sults in a sufficient cerebral anaemia so that the 
 operation can be readily completed without the ad- 
 ministration of any additional anaesthetic. This 
 position has the further advantage of reducing the 
 hemorrhage to quite a marked extent. In order 
 to keep the respiration unobstructed an assist- 
 ant lifts the lower jaw forward so that the 
 lower incisor teeth become engaged in front of the 
 upper ones. At the same time he holds the gauze 
 pad in place as shown in Fig. 19, so that there can 
 be no infection from the mouth or nose. A small 
 pillow placed under the patient's shoulders causes 
 the anterior surface of the neck to become prominent 
 and the traction by the assistant exaggerates this 
 at the same time that it facilitates the patient's 
 breathing. 
 
 There are several very distinct advantages in ad- 
 ministering the anaesthetic in this manner. 1. The 
 patient is relieved of all nervous and mental irritation 
 and depression. 2. The amount of anaesthetic re- 
 quired is exceedingly small. 3. The heart's action 
 improves under this form of administration of ethei . 
 4. The administration of anaesthetic having ceased 
 before the operation is started, the surgeon can con- 
 centrate his entire attention upon the operation 
 itself. 5. There is no possibility of infection from 
 mouth or nose or by the anaesthetist during the oper- 
 ation. 6. The patient exhales so much of the ether 
 taken before the operation is completed that nausea 
 and vomiting practically never occur. 7. Upon 
 
ANAESTHESIA 99 
 
 lowering the head, at the completion of the operation 
 the patient awakens fully almost immediately. 8. It 
 is usually possible to give these patients sips of hot 
 water to drink shortly after the operation which is 
 an advantage after operation for exophthalmic 
 goitre. 9. These patients do not inspire mucous 
 which is often very troublesome when the anaesthetic 
 is continued throughout the operation. 10. They are 
 able to sit up at once when they return from the 
 
 Fig. 19. Lateral view of patient anaesthetized and in position 
 to begin operation. A pillow has been placed under the shoulders in 
 order to extend the neck. The assistant holds the jaw forward, ex- 
 tends the neck and holds the gauze pad covering the patient's mouth 
 and nose. The patient's hair is carefully covered by a towel (b) and 
 the body is covered completely with a sterile sheet and towels, only 
 the neck being exposed. 
 
 operating room which still further protects them 
 against bronchitis and pneumonia. 
 
 It seems important to be thus explicit because 
 when these details are carried out one of the greatest 
 difficulties in the way of thyroidectomy for the re- 
 
100 THYROID GLAND 
 
 lief of exophthalmic goitre is eliminated in a very 
 safe and simple manner. One point must be insisted 
 upon which might readily be overlooked, the task 
 of lifting the patient's jaw forward must be entrusted 
 to a reliable, intelligent and trained assistant and 
 not to any one who may accidentally be available and 
 is unfit for any other duty. In one instance, I have 
 observed an almost fatal asphyxia because this 
 assistant relaxed his hold upon the lower jaw after 
 the gland had already been removed. This permitted 
 the tongue to fall back into the pharynx and to ob- 
 struct the respiration completely. The surgeon did 
 not know this had happened until he noticed a 
 deep cyanosis in the flap. Then he immediately 
 drew forward the tongue, lowered the head of the 
 table and performed artificial respiration. Fortu- 
 nately the patient had not advanced in her disease 
 to the stage of advanced myocarditis, a condition 
 so commonly found in connection with exophthalmic 
 goitre and consequently the patient recovered which 
 would have been quite unlikely in a more advanced 
 case. 
 
 Rectal Anaesthesia. The advantages of this 
 method must be apparent if further experience does 
 not show harmful effects. 
 
 The following advantages are claimed for the 
 method by those who have employed it. 
 
 1. The amount of ether employed is very much 
 smaller than by the inhalation method. 
 
 2. There is no stage of excitation. 
 
 3. There is no irritation of the respiratory mucous 
 membranes. 
 
ANAESTHESIA 101 
 
 4. The anaesthetist does not approach the field 
 of operation. 
 
 5. Besides being out of the way he also is unable 
 to infect the wound. 
 
 6. The patient awakens almost at once after the 
 anaesthetic is stopped. 
 
 7. There is said to be less nausea and vomiting 
 probably because the patient has not swallowed 
 quantities of mucous saturated with ether. 
 
 8. There is no depressing effect upon the heart. 
 
 It is, however, to be remembered that all of these, 
 advantages are also obtained if the method is em- 
 ployed which has just been described of thoroughly 
 anaesthetizing the patient by the inhalation method 
 and then stopping the anaesthetic and. elevating the 
 head during the operation. 
 
 Method of Application. It is most important 
 that the colon be empty at the time of administra- 
 tion of ether by rectum, because the presence of 
 faeces will prevent the rapid absorption of ether and 
 the openings in the tube through which the ether 
 fumes are introduced, may become clogged and thus 
 the introduction in sufficient quantities may be pre- 
 vented. 
 
 In order to secure an empty colon, two ounces of 
 castor oil, preferably in beer foam, should be given 
 twenty-four hours before the operation, twelve hours 
 later the patient should receive a large cleansing 
 enema of soap suds and normal salt solution and the 
 latter should be repeated three hours before the 
 operation. In the meantime, no food should be given 
 except broths and gruels in order that there may not 
 be any fresh accumulation. 
 
102 THYROID GLAND 
 
 Technic. The patient is placed upon the table 
 the surface of the neck thoroughly prepared and 
 then covered with a piece of sterile gauze saturated 
 with alcohol. The hair is covered and a gauze pad is 
 placed across the mouth and nose as described in 
 Fig. 19, in fact the preliminary preparation is 
 identical with that employed if the operation is 
 to be performed under ether anaesthesia by inspira- 
 tion. An assistant also draws the lower jaw forward 
 as described above, and holds it in that position 
 throughout the operation. 
 
 An ordinary soft rubber rectal tube with an opening 
 at the end is then introduced into the rectum slowly 
 a distance of eight or ten inches. The tube should 
 be thoroughly lubricated in order to prevent annoy- 
 ance by friction. The gas contained in the rectum is 
 thus permitted to escape in order to facilitate the 
 absorption of ether. The rectal tube is then attached 
 to the tube through which the ether fumes are pump- 
 ed into the rectum. The colon is then slowly filled 
 with ether fumes and then the rectal tube is once 
 more disconnected in order that the remaining in- 
 testinal gas which was not evacuated primarily may 
 escape. This procedure may be repeated several 
 times, care being taken that the ether fumes are not 
 injected too rapidly for fear of causing too great 
 distension or irritation. At first some gas may escape 
 along the side of the rectal tube but this can soon be 
 prevented by injecting only just enough gas to fill 
 the colon. There may be slight colicky pains at first 
 but the patient will soon become accustomed to 
 the sensation. If the castor oil and the enema have 
 acted satisfactorily, there will be no annoyance from 
 
ANAESTHESIA 103 
 
 defecation or clogging of the rectal tube. The full 
 anaesthesia will occur in from five to fifteen minutes 
 and the operation can be performed with the con- 
 sumption of from one to three ounces of ether. When 
 the operation is completed to the point of suturing 
 the external wound, the apparatus is detached from 
 the rectal tube and the accumulated gas in the colon 
 will be permitted to escape. If the patient is slightly 
 conscious of the application of the skin sutures, the 
 consequent deep breathing will facilitate the excre- 
 tion of most of the ether contained in the blood 
 through the expired air. It also facilitates the ex- 
 pulsion of any ether fumes which may still remain 
 in the colon. This can be further facilitated by mak- 
 ing gentle abdominal massage. 
 
 The patient must be observed throughout the 
 period of administration with the same care as when 
 ether is given through the respiratory tract. Cyanosis 
 will almost never occur if the lower jaw is held for- 
 ward as indicated in Fig. 19. The pulse and respira- 
 tion will indicate the progress of the anaesthesia. 
 It is rarely necessary to disconnect the rectal tube 
 from the apparatus and to make abdominal massage 
 to force the ether fumes out of the rectum during the 
 operation, but in case of necessity this could be 
 readily done. If the head is elevated after the opera- 
 tion is begun almost no anaesthetic will be required 
 during the actual progress of the operation. 
 
 Apparatus. Various forms of retainers have been 
 invented for producing the ether fumes utilized in 
 this form of anaesthesia. A simple deep bottle con- 
 structed on the general plan of wash bottles used in 
 chemical laboratories seem to suffice perfectly pre- 
 
104 THYROID GLAND 
 
 ferably mounted on a stand which can easily be 
 moved without breaking the bottle or its attach- 
 ments. The bottle contains a rubber stopper with 
 two holes one of which contains a glass tube whose 
 lower end is even with the stopper and whose upper 
 end is attached to a rubber tube which at its other 
 end contains a glass tube for attachment to the 
 rectal tube. The other hole contains a glass tube 
 with bulb -shaped lower end containing many small 
 perforations and reaching to the bottom of the bottle. 
 The upper end of this tube projects through the upper 
 surface of the rubber stopper a sufficient distance to 
 permit the attachment of a rubber tube the other 
 end of which is attached to a bulb with which air 
 can be forced into the bottle. The bottle should be at 
 least thirty centimeters deep so that the air can be 
 forced through a considerable column of ether. The 
 bottle is filled with ether to a point five cm. from 
 the lower surface of the cork, the upper portion of 
 the bottle being left as a gas space. 
 
 This bottle should be immersed in a vessel con- 
 taining water at a temperature of from 80° to 100° F. 
 according to various clinicians the boiling point of 
 ether being 98.6 F. A thermometer placed in the 
 water is to be added and a stop-cork at the lower 
 part will make it possible to remove the water when 
 the temperature has become too low. 
 
 According to another method which has also been 
 frequently used and apparently with equally satisfac- 
 tory results the arrangement for blowing through the 
 ether is dispensed with ; a simple flask being employed 
 containing a rubber cork fitted with a glass tube 
 whose lower end is even with the lower end of the 
 
ANAESTHESIA 105 
 
 rubber stopper. To the upper end of this a glass tube 
 is attached which in turn is attached to the rectal 
 tube by means of an intervening glass tube. Some 
 surgeons prefer to have this attachment made by 
 means of an intervening rubber tube which is fitted 
 with a stopcork so that the flow of the ether fumes 
 may be interrupted at any time. 
 
 The flask containing the ether is then immersed 
 in a waterbath at a temperature, of 105° F. which 
 will cause ether to evaporate with sufficient rapidity 
 to bring about the anaesthesia. In case the amount 
 evaporated is not sufficient the temperature may be 
 increased. If the evaporation is too rapid, the flask 
 may be raised out of the waterbath either partly 
 or completely until it again becomes desirable to 
 increase the amount of ether fumes. 
 
 The method is so simple that any one who has 
 seen it applied once can readily administer ether 
 in this way, but it seems worth while to be explicit 
 in the description of this method because it has not 
 as yet received practical application to a sufficient 
 extent to become familiar by demonstration. By 
 substituting a good sized thermos bottle for the con- 
 tainer of the warm water, with a rubber cork that 
 fits closely around the upper end of the bottle con- 
 taining the ether, the apparatus can be still further 
 improved because the water will then maintain a 
 fairly uniform temperature throughout the opera- 
 tion and the slight decrease in temperature will be 
 rather an advantage than a disadvantage. 
 
 Spinal Anaesthesia. A few enthusiasts have de- 
 scribed methods by which spinal anaesthesia may be 
 employed in thyroid operations. It is plain that no 
 
106 THYROID GLAND 
 
 one whose judgment has not been impaired by the 
 desire to accomplish that which is unusual would 
 expose a patient already so severely handicapped to 
 the direct application of cocaine to the upper por- 
 tion of the spinal cord. I simply mention this method 
 to express the opinion that it should never be em- 
 ployed in these cases. 
 
 High Spinal Anaesthesia by the use of Stovaine 
 and Neutral Sulphate of Strychnine. During the past 
 eighteen months Prof. Thomas Jonnesco has tried 
 high spinal analgesia for many different operations 
 upon the head and neck in more than 150 cases with- 
 out any fatality and without any serious after effect. 
 It therefore seems proper to describe this method, 
 although it does not seem wise at the present moment 
 to recommend it in operations for goitre as the ex- 
 perience is still limited. 
 
 The following directions are taken from Prof. 
 Jonnesco's article in the British Medical Journal: 
 
 The Preparation of the Solution. The solution 
 must be made at the time when the operation is to 
 be performed as follows: The necessary quantity 
 of stovaine is introduced into a glass tube provided 
 with an india rubber stopper, and sterilized in the 
 autoclave. The substance need not be sterilized 
 since it is itself antiseptic, and some of its properties 
 would be destroyed by heat. 
 
 The strychnine solution is made by dissolving 5 
 c. c. of neutral strychnine sulphate in 100 grams of 
 sterilized (not distilled) water in a glass-stoppered 
 bottle previously sterilized; 1 c. c. of the solution 
 will contain 5 mg. As the strychnine takes some 
 time to dissolve, it is better to prepare this solution 
 
ANAESTHESIA 107 
 
 a little before the time when it has to be used. With 
 an ordinary Pravaz syringe provided with a needle 
 for lumbar puncture, 1 c. c. of the solution of strych- 
 nine is drawn up and is injected into the tube 
 containing the dose of stovaine judged to be neces- 
 sary for the puncture about to be made. The tube 
 is corked again, and shaken, and the salts are dis- 
 solved. The same syringe is then filled with the 
 contents of the tube and is " held with a sterilized 
 compress and removed from the needle while the 
 puncture is being made; 3 c. c. of stovaine is the 
 usual dose for adults. 
 
 Upper Dorsal Puncture. Upper dorsal punc- 
 ture between the first and second dorsal vertebrae 
 is easily performed; the landmark is the vertebra 
 prominens with the visible and tangible protuber- 
 ances of the spinous processes of the second and third 
 dorsal vertebrae. When the patient's head is strong- 
 ly flexed, so that the chin touches the sternum, the 
 protuberances are very marked, and the spaces 
 they bound are enlarged. The patient being placed 
 in this position, the surgeon marks with the fore- 
 finger of his left hand the space between the first 
 and second dorsal vertebrae, and the needle, held 
 between the finger and thumb of the right hand, is 
 pushed in, following the upper border of the spinous 
 process of the second dorsal vertebra. 
 
 The Injection. As soon as the escape of cerebro- 
 spinal fluid renders it certain that the arachnoid 
 space has been entered, its further loss should be 
 stopped, for I am convinced that the escape of more 
 than a certain quantity of fluid is rather harmful 
 -than useful. The loss of too much fluid (1) may 
 
108 THYROID GLAND 
 
 cause signs of faintness, pallor of the face, sweat- 
 ing, etc. ; and (2) by suddenly diminishing the 
 quantity of cerebro-spinal fluid may cause too rapid 
 diffusion of the anaesthetic, which is undesirable 
 and may be mischievous. As soon, then, as a few 
 drops of fluid escape, the needle is closed with the 
 forefinger of the left hand, while with the right the 
 syringe filled with the anaesthetic mixture is adapted 
 to the needle. The liquid must be slowly injected 
 so as not to produce an undue impact upon the spinal 
 cord. 
 
 Position of Patient after Injection. "The posi- 
 tion to be assumed by the patient after the in- 
 jection, so as to ensure analgesia of the region to be 
 operated upon, is a cardinal point, for by attention 
 to it we can favor the distribution of the liquid in 
 the desired direction. If with the higher dorsal 
 injection it is desired to obtain analgesia of the head 
 and neck, the patient is made to lie on his back if 
 the operation is to be on the throat, the head should 
 be a little raised ; if on the face or skull, he should lie 
 horizontally; if on the upper limb or thorax bent 
 slightly forward. If after four or five minutes 
 the analgesia of the head or of the neck is not com- 
 plete, the patient's head should be lowered below 
 the level of the body for three or four minutes." 
 
 Morphin and Hyoscin. A number of surgeons 
 have administered from one-sixth to one-third of a 
 grain of morphin with one one-hundredth of a grain 
 of hyocin hypodermically from twenty to forty 
 minutes before beginning the administration of ether 
 in order to reduce the quantity of the latter drug 
 required. 
 
ANAESTHESIA 109 
 
 In the same manner one one-hundreclth of a grain 
 of atropin has been combined with the morphin for 
 the same purpose. There is no doubt but that both 
 of these combinations will reduce the amount of 
 ether required, but whether this advantage is suffi- 
 cient to balance the disadvantage of subjecting these 
 patients to the effect of these powerful drugs does 
 not seem clear. 
 
CHAPTER VI. 
 
 DANGERS OF OPERATION. 
 
 Shock. Until Billroth and Kocher demonstrated 
 the fact that shock can be very largely eliminated 
 from this operation, the surgical profession laid great 
 stress upon this element and this fear has caused 
 many surgeons, even to the beginning of the present 
 century, to hesitate before recommending this oper- 
 ation to their patients. Kocher's statistics and his 
 daily demonstrations to surgeons from all parts of 
 the world, and again the results of his many disciples, 
 have served to dispel this fear. In America, the 
 work of C. H. Mayo has served especially to bring 
 about similar results more particularly in the sur- 
 gery dealing with exophthalmic goitre. If the surgeon 
 proceeds systematically with a thorough knowledge 
 of the regional anatomy to be encountered in this 
 operation, if he is reasonably skillful so that he can 
 complete the operation in a comparatively short 
 time, if he has the ability of working without un- 
 reasonably traumatizing the tissues and if he is 
 careful to secure the vessels before they are severed 
 in order to minimize the loss of blood, then he need 
 not fear the element of shock. To this should be 
 added good judgment in selecting the proper time 
 for operation especially in exophthalmic goitre. 
 
 Haemorrhage. In connection with prevention of 
 haemorrhage we are again indebted to Kocher for 
 
DANGERS OF OPERATION 111 
 
 the greatest progress. He pointed out the import- 
 ance of keeping the field free from blood and demon- 
 strated a method with the use of his director and his 
 reliable haemostatic forceps by means of which this 
 could be very readily accomplished. These will be 
 discussed and illustrated in connection with the 
 technical description of the operations. 
 
 It is important to bear in mind that the veins are 
 usually dilated to many times the normal size and 
 that consequently great care must be exercised be- 
 cause a tear in the walls of one of these vessels will 
 result in the loss of a considerable amount of blood. 
 Moreover, it is not only the loss of the blood that is 
 to be deplored but the fact that the field of operation 
 is obscured and consequently the progress of the 
 operation is retarded and successive vessels to be 
 grasped may be overlooked causing unnecessary 
 haemorrhage. Besides this, Kocher claims that the 
 blood itself in these cases has a considerable degree 
 of toxicity so that the patients whose wound surfaces 
 have been free from blood make a better recovery 
 than those in whom the surfaces have been drenched 
 with blood. Of course, excessive haemorrhage always 
 increases the shock in three ways: 1, by prolonging 
 the operation; 2, by increasing the amount of man- 
 ipulation and 3, by the loss of blood itself. 
 
 Hyperthyroidism. Whoever has operated fre- 
 quently for the removal of thyroid glands must have 
 become impressed with the real danger to the patient 
 from postoperative hyperthyroidism due either to 
 the absorption of thyroid secretion pressed out of 
 the gland and into the circulation during the opera- 
 tion or of thyroid secretion or toxic blood absorbed 
 
112 THYROID GLAND 
 
 from the wound surface. It seems that all surgeons 
 who have operated for many years can recall numer- 
 ous instances from the early cases while their later 
 experience has been relatively free from this com- 
 plication. Moreover, a number of surgeons have re- 
 ported a greater number of patients suffering from 
 hyperthyroidism while they operated under ether or 
 chloroform anaesthesia, than after changing to local 
 anaesthesia. It seems clear that under local anaes- 
 thesia what might be called violent surgery is not 
 possible, because the patient would not submit to it 
 while awake even though the tissues might be numb- 
 ed to a considerable extent by the use of local 
 anaesthetics. It is often difficult, when the patient 
 is thoroughly anaesthetized, to conduct every step 
 of the operation not only the part accomplished by 
 the surgeon but that carried out by the assistants 
 without unduly traumatizing the tissues. 
 
 In this connection it may be well to refer to the 
 value of drainage for from one to three days after 
 the operation. There is usually a considerable amount 
 of oozing of blood and serum and where a layer of 
 the posterior portion of the gland is left in place to 
 protect the recurrent laryngeal nerve and the par- 
 athyroid glands there is always some thyroid secre- 
 tion that exudes into the wound and it seems well to 
 insist upon making some provision which will rapidly 
 carry these fluids beyond the absorbing surfaces. I 
 have seen violent hyperthyroidism in two of my own 
 cases in which it had seemed unnecessary to provide 
 for free drainage. I am confident that in both of 
 these cases this calamity might have been prevented 
 by the use of free drainage to be described later. 
 
DANGERS OF OPERATION 113 
 
 Above all things it seems important to be gentle in 
 the manipulation of the thyroid gland itself. 
 
 Injury to Parathyroid Glands. A study of the 
 discussion of the parathyroid glands in the later 
 chapters of this book convinces the reader that in- 
 jury of these glands must not occur during opera- 
 tions upon the thyroid gland. In the early days of 
 thyroidectomy these injuries were numerous as 
 shown by the statistics already quoted. As soon as 
 the importance of these glands was generally recog- 
 nized these calamities virtually disappeared because 
 as will be shown in connection with the discussion 
 of the surgical anatomy involved, it is an exceedingly 
 simple matter to avoid injuring these important 
 structures. In the meantime it is, however, impor- 
 tant always to bear in mind the fact that this is 
 really a vital organ from the standpoint of the 
 clinical surgeon and that nothing can be more im- 
 portant than a careful study of all that is known 
 about this structure. The anatomical position of 
 these glands made their removal almost certain dur- 
 ing the early operations because they are so inti- 
 mately attached to the posterior surface of the 
 capsule of the thyroid gland, but it is this very fact 
 which has made it so easy to preserve these glands 
 since their importance has been recognized. That 
 these glands can be restored by transplantation has 
 been demonstrated many times in animals and von 
 Eiselsberg, who reports one successful case in the 
 human patient, thinks that it is justifiable to 
 take a gland from a donor only when one can be 
 certain that he has three other healthy glands or 
 virtually only in cases operated for cyst of one lobe 
 
114 THYROID GLAND 
 
 of the thyroid gland. Pool also reports a most inter- 
 esting case and discusses the subject thoroughly. 
 
 Infection. In preantiseptic days this was the 
 most feared of all complications because an infection 
 usually resulted in a septic mediastinitis which in 
 turn proved fatal to the patient. The infection could 
 readily extend along the vessels of the neck into the 
 mediastinal space. 
 
 Since the introduction of aseptic surgery this 
 danger has practically disappeared in the hands of 
 surgeons who are otherwise qualified to undertake 
 the operative treatment of goitre. At the present 
 time hospitals in which such operations are perform- 
 ed are so perfectly equipped and assistants and 
 nurses are so thoroughly trained that infections from 
 implements, instruments, sponges, dressings and the 
 hands of operator or assistants or nurses is almost 
 impossible. 
 
 There are two sources which are always present 
 which cannot be so absolutely eliminated unless es- 
 pecial stress is laid upon certain precautions and 
 unless the attention of everyone is especially directed 
 to these details. I refer to the difficulty of protecting 
 the patient against infection from her own mouth 
 and nose and the difficulty one often experiences in 
 keeping the surrounding areas together with the 
 ears and hair of the patient thoroughly covered 
 throughout the operation to prevent infecting some- 
 thing by contact with these parts and later bringing 
 the infected object in contact with the wound. 
 
 Unless an intelligent assistant is especially en- 
 trusted with keeping mouth and nose covered 
 throughout the operation and unless this is his only 
 
DANGERS OF OPERATION 115 
 
 duty with the possible addition of keeping the lower 
 jaw forward it may easily happen that the patient 
 may cough or breathe infectious matter into her own 
 wound. As difficult as it may seem to protect the 
 patient against incidental contact infection so easy 
 it becomes when all details have been systematically 
 arranged. 
 
 It is not at all important that these details be uni- 
 form in the work of different surgeons but it is ex- 
 ceedingly important for each surgeon to develop 
 some satisfactory system which is regularly carried 
 out in all of his operations upon the thyroid gland. 
 
 Injury to the Parathyroid Glands and the Re- 
 current Laryngeal Nerve. This danger is es- 
 pecially enumerated only because in the early 
 operations upon the thyroid gland it was not at all 
 uncommon, which will be readily understood when 
 we come to consider the surgical anatomy involved. 
 Fortunately the same precautions which serve to 
 protect the parathyroid glands will serve to prevent 
 the injury to the recurrent laryngeal nerve. 
 
 The injury may occur by cutting the nerve at the 
 point at which it passes between the posterior sur- 
 face of the thyroid gland and the trachea ; or it may 
 be caused by crushing with haemostatic forceps in 
 attempting to grasp the inferior thyroid vessels or 
 their branches. What has been said regarding pre- 
 vention of haemorrhage should be repeated here. If 
 all the vessels are caught before they are severed the 
 field of operation will not be obscured and other 
 structures will not be injured. As a result of this 
 injury, there is a paralysis of the vocal cord on one 
 side which is, of course, a serious matter. 
 
116 THYROID GLAND 
 
 Air Embolism. The thinness of the vein walls 
 makes air embolism quite unlikely although it must 
 of course be borne in mind in connection with this 
 as with all other operations which are performed in 
 the vicinity of the large veins of the neck. If the 
 precautions mentioned in connection^ with the meth- 
 ods advised for prevention of haemorrhage are carried 
 out there is still less likelihood of the occurrence of 
 this accident. 
 
 Air embolism occurs only when a considerable 
 quantity of air enters a vein at one time. Usually 
 this occurs when the vein walls are cut and the in- 
 cision is held open either artificially as by means of 
 forceps or by surrounding non-elastic structures as 
 in case the vein is surrounded by lymph nodes which 
 have been invaded by carcinoma or infected by 
 tuberculosis. As these conditions are almost never 
 present in cases in which operations upon the thyroid 
 gland are indicated this complication must be ex- 
 tremely rare in connection with thyroid operations. 
 
 Collapse of the Trachea. Almost every surgeon 
 who has frequently operated for the removal of dis- 
 eased thyroid glands has encountered cases in which 
 the trachea has collapsed as soon as it has lost its 
 support due to its attachment to the thyroid gland. 
 The cartilages of the trachea may become exceeding- 
 ly soft and pliable or they may practically disappear 
 as a result of pressure atrophy caused by the enlarged 
 thyroid gland. The patient then shows immediately 
 symptoms of asphyxia. The more violent the efforts 
 at inspiration the more complete will be the obstruc- 
 tion because the anterior wall of the trachea is drawn 
 into the lumen of this tube like a valve and the 
 
DANGER OF OPERATIONS 117 
 
 further it is drawn in the more completely will the 
 valve close the lumen of the tube. If the surface of 
 the wound has been kept fairly free from blood one 
 can easily see the anterior wall drawn in but if there 
 is much blood on the surface of the wound it may 
 not be possible to recognize the condition by direct 
 inspection. In that case it may be confounded with 
 sudden collapse of the patient or if an anaesthetic 
 has been administered throughout the operation the 
 difficulty may be attributed to the anaesthetic; of 
 course, the usual methods of restoring the patient 
 for collapse due to anaesthesia will be quite useless 
 and in the meantime the asphyxia with the weak 
 condition of the patient may result in a fatal ending. 
 Again, it may occur that a large middle lobe may 
 have been lodged behind the sternum and when the 
 latter lobe has been severed from its attachments 
 posteriorly and externally, but is still attached to the 
 middle lobe internally, the traction made may 
 carry the middle lobe upward sufficiently to make 
 severe pressure upon the trachea just behind the 
 upper end of the sternum and this in turn may give 
 rise to asphyxia which may be mistaken for the same 
 condition due to collapse of the trachea. In order to 
 avoid unfortunate results of collapse of the trachea 
 it is best to keep in readiness a reliable mouth gag 
 and intubation apparatus. If this cannot be employ- 
 ed it is well to insert two sharp tenaculae into the 
 collapsed portion of the trachea and to draw the 
 latter forward. 
 
 If this succeeds in giving relief an apparatus must 
 be arranged which will maintain the anterior tracheal 
 wall in this position. If this is not possible a longi- 
 
118 THYROID GLAND 
 
 tudinal incision should be made as in ordinary 
 tracheotomy and a tube, which should always be kept 
 in readiness, should be inserted. If no tracheotomy 
 tube is available it will be an easy matter to make 
 some contrivance which will keep the incision open 
 so air can enter freely. 
 
 This opening should be covered with four thick- 
 nesses of sterile gauze in order to prevent infection 
 which might easily result in pneumonia. If an in- 
 tubation has been used this should be removed on 
 the fifth day in order to reduce as much as possible 
 the injury done by the intralaryngeal pressure of the 
 tube. If the breathing is not free after the tube has 
 been removed it is well to replace the latter for two 
 or three days when the same experiment should be 
 repeated. 
 
CHAPTER VII. 
 
 INDICATIONS FOR OPERATION ON THE 
 THYROID GLAND. 
 
 Indications for Operative Treatment. Primarily 
 the indication for operative treatment of simple 
 goitre must be: 1, inability to relieve the condition 
 by non-surgical means ; 2, distress from pressure upon 
 the trachea; 3, pressure upon the trachea and the 
 oesophagus; 4, pain from pressure; 5, unsightly de- 
 formity; 6, discomfort due to the weight of the en- 
 larged gland; 7, increasing symptoms of exophthal- 
 mic goitre also not yielding to non-surgical treatment. 
 
 1 . As has been stated before a very large propor- 
 tion of all patients suffering from non-malignant 
 diseases of the thyroid gland can undoubtedly be 
 relieved by non-surgical treatment provided this is 
 applied systematically and continued for a consider- 
 able period of time after the patient has apparently 
 recovered. Hygienic and dietetic and medicinal 
 treatment should consequently be systematically 
 employed in each case at its beginning and only after 
 failing after these methods have been carefully em- 
 ployed should the surgical treatment be resorted to 
 and then only if the disease has produced conditions 
 that would warrant the undertaking of an operation 
 requiring a considerable amount of skill and ex- 
 perience. 
 
120 THYROID GLAND 
 
 In many cases there is so marked a degree of pres- 
 sure upon the trachea that the patient cannot 
 breathe with any comfort. This may be constant 
 or it may only occur when the patient is in the re- 
 cumbent position. This may be due to a general 
 pressure from all of the lobes or the middle lobe may 
 contain a circumscribed mass which may press 
 directly upon the trachea and may act like a ball 
 valve applied to the outside of the tracheal tube fre- 
 quently causing the softening of one or more of the 
 tracheal cartilages. This is more commonly due to 
 pressure from a portion of the middle lobe projecting 
 downward behind the sternum. In one instance the 
 patient, a young woman, was unconscious as a re- 
 sult of asphyxia caused by the condition just de- 
 scribed, when I was called to give her relief. Her con- 
 dition was so serious that I at once proceeded to 
 secure local anaesthesia by injecting one per cent, 
 of cocaine solution into the skin. The operation was 
 performed immediately with the greatest possible 
 speed, with the patient in this unconscious asphyx- 
 iated condition. No air seemed to pass in either di- 
 rection past this obstruction until traction was made 
 upon the right lobe which had been freed from its 
 attachments when suddenly a prolongation down- 
 ward from the middle lobe came up from its location 
 behind the sternum. Immediately the patient in- 
 haled deeply and a moment later she spoke of the 
 remarkable relief she experienced. 
 
 In a number of other instances I have observed a 
 similar condition to a less marked extent. This has 
 been observed and described by many other clinic- 
 
INDICATIONS FOR OPERATION 121 
 
 ians and is certainly well worth bearing in mind as a 
 strong indication for surgical treatment. 
 
 In other instances an acute inflammatory enlarge- 
 ment may have the same effect only usually to a 
 more marked and also to a more dangerous extent 
 because of the cedematous condition of the surround- 
 ing tissues. 
 
 Here again the course of the disease will indicate 
 the treatment that should be chosen. If the condition 
 shows a tendency to subside under non-surgical treat- 
 ment the latter should be postponed but if the op- 
 posite is the case incision of the gland is indicated. 
 If a circumscribed abscess is present simple incision 
 will cause the condition to subside. If the inflam- 
 matory condition has resulted in a diffuse inflam- 
 mation it may become necessary to remove one 
 lateral or one lateral end and the median lobe. In 
 this case it will become necessary to perform the 
 operation presently to be described, but great care 
 must be taken not to disturb the tissues low down 
 in the neck in order to prevent infection of the 
 mediastinum and very free drainage must be pro- 
 vided for. 
 
 The abscess of the thyroid gland may be located 
 directly underneath the anterior capsule of the gland 
 when it will be reached easily by making an incision 
 parallel with and along the inner border of the sterno- 
 mastoid muscle over the most prominent portion of 
 the swelling. The incision must be carried through 
 the skin, superficial-fascia, platysma and through the 
 capsule of the gland. If the abscess is in the super- 
 ficial portion of the gland all of the tissues underneath 
 the skin and frequently even the skin will be found 
 
122 THYROID GLAND 
 
 to be oedematous but if it is in the deep portion of 
 the gland the first cedema may not be encountered 
 until the capsule of the gland has been reached. In 
 one instance I have been compelled to advance more 
 than one half the distance through the gland before 
 pus was reached. 
 
 The patient, a woman, twenty-six years of age, 
 who had previously been quite normal suddenly ex- 
 perienced severe pain in the region of the right lobe 
 of her thyroid gland. When seen a few hours later 
 there was a slight amount of redness and very slight 
 swelling. The right lobe of the gland was exceeding- 
 ly tender but there seemed to be no grave symptoms. 
 Six hours later severe symptoms of asphyxia ap- 
 peared so that she was at once sent to the hospital 
 for immediate operation. During a two mile ride 
 symptoms subsided and the operation was postponed 
 as there was only slight difficulty in breathing. The 
 temperature which had reached 103° F. remained 
 below 100° F. the leucocytosis reached 26000 and 
 the general appearance of the patient indicated the 
 presence of a considerable degree of sepsis. On the 
 eleventh day after the beginning of the attack the 
 patient consented to an incision under local anaes- 
 thesia with 1 per cent, cocaine solution. The first 
 pus was reached after more than one-half of the 
 thickness of the thyroid gland had been penetrated. 
 Then a necrotic area 3 c. m. wide by 2 c. m. and 
 5 c. m. deep was exposed, filled with thick yellow 
 pus and necrotic gland tissue. 
 
 One interesting feature in this case was the oc- 
 currence of severe syncope which recurred several 
 times each day during the fourth and sixth days after 
 
INDICATIONS FOR OPERATION 123 
 
 the beginning of the attack and previous to the 
 operation. These attacks were probably due to 
 absorption from the substance of the necrotic thyroid 
 gland together with pressure upon the trachea due 
 to the abscess and to pressure from the surrounding 
 codema. After carefully swabbing out the cavity 
 of the abscess and inserting a gauze drain the patient 
 recovered quite as readily as other cases in which 
 the abscesses were located more superficially. 
 
 Indication for Operation in Exophthalmic Goi- 
 tre. Aside from the indications just described in 
 connection with the treatment of simple goitre the 
 following indications should be borne in mind in 
 connection with the treatment of exophthalmic 
 goitre. 
 
 Whenever improvement in these cases from hy- 
 gienic, dietetic and medicinal treatment together 
 with rest is only of temporary duration then opera- 
 tive treatment is strongly indicated because in these 
 cases the prognosis is usually most excellent if the 
 surgical treatment is employed before the patient has 
 suffered too many recurrences, while the fatal con- 
 clusion is usually only a matter of a relatively short 
 time depending upon the frequency and severity of 
 the attack if non-surgical treatment is continued. 
 Moreover, the recovery after surgical treatment will 
 be much more perfect if the operation is performed 
 before the heart and other organs have suffered 
 severely by these recurrent floodings of the circula- 
 tion with thyroid poison. In simple goitre it is not 
 of much importance except, of course, in the presence 
 of asphyxia, but in exophthalmic goitre the element 
 of time is very important. 
 
124 THYROID GLAND 
 
 Indication for Operation in Malignant Growths of 
 the Thyroid Gland. The indications for the re- 
 moval of thyroid glands containing a malignant 
 growth is the same as in malignant growths in other 
 organs. So long as the growth seems to be confined 
 to the gland so that it seems reasonably safe to sup- 
 pose that it will be possible to prevent a recurrence 
 by removing the entire growth, the indication is, 
 of course, absolute. I have never encountered this 
 condition except in cases in which the malignancy 
 was diagnosed incidentally during the microscopic 
 examination of portions of glands removed for other 
 reasons. 
 
 It is doubtful whether a thyroid gland with all 
 lobes involved in a malignant growth can ever be 
 removed while the tumor is still so completely con- 
 fined to the gland that a recurrence can be prevented. 
 If the tumor is confined to one lobe this is possible. 
 In these cases it is doubtful whether it will be proper 
 to remove the entire thyroid gland only preserving 
 the parathyroids or whether one lobe or only the 
 upper portion of one lateral lobe should be left in 
 order to prevent myxoedema. 
 
 When we come to discuss the operative technic it 
 will be shown that the remarkable arrangement of 
 the blood vessels of the thyroid gland is to be taken 
 into consideration in this as in all other operations 
 upon this organ. Every portion of each lobe seems 
 to be connected vascularly with every portion of 
 the other lobes, hence, it seems doubtful whether 
 any portion may be left safely when any other portion 
 is involved in a malignant growth. 
 
INDICATIONS FOR OPERATION 125 
 
 In removing the entire gland, however, we are 
 certain to cause myxoedema unless accessory glands 
 are present or unless this condition is prevented by 
 transplanting normal thyroid gland into the body 
 or by constantly feeding thyroid glands or thyroid 
 extract. 
 
 All of these facts indicate that the results to be 
 expected are not satisfactory. On the other hand, 
 malignant growths of the thyroid gland may pro- 
 gress with great rapidity and destroy the life of 
 the patient in a few months or they may cause lit- 
 tle distress for a number of years. I have person- 
 ally encountered both forms. I would consequently 
 say that in case it seems possible to make a radical 
 operation when the patient consults the physician, 
 an operation should be performed at once. If it is 
 not possible to do this, then the operation should 
 be performed only if it becomes necessary in order 
 to give relief from pain or asphyxia. 
 
 The technic of the operation to be performed 
 will be discussed in another chapter. 
 
 According to Salzer the transplantation of the 
 thyroid glands is so likely to be successful into 
 patients who have been entirely deprived of their 
 thyroid glands that it seems reasonable to suggest 
 the removal of the entire gland and the simultaneous 
 transplantation of one lobe from another patient. 
 The transplantation is simple and accompanied with 
 so little shock that it can easily be accomplished 
 at the same time at which the complete thyroidec- 
 tomy is performed for the removal of the malignant 
 growth. 
 
CHAPTER VIII. 
 
 THYROIDECTOMY. 
 
 In describing the technic of this operation only 
 those methods will be chosen which I have found 
 reliable. In none of them is there any important 
 feature which is original with me. Every part of 
 every operation to be described has been practiced 
 by other surgeons and has in most instances been 
 described in books or articles in scientific journals. 
 Most of the important features were developed and 
 practiced by Kocher although many of them have 
 been modified in minor details by others. I make 
 this statement at this point in order not to give the 
 impression that because I may be unduly emphatic 
 or enthusiastic in the discussion of certain features 
 that, therefore, these may be my original methods. 
 None of them are my methods except by adoption 
 but all have been thoroughly tested by me in many 
 cases. Those who have faith in my surgical judgment 
 in selecting, adapting and accepting the methods of 
 others may follow these methods with confidence. 
 
 Incision. It is important to bear in mind the fact 
 that in operations upon the thyroid gland the in- 
 cision must be so planned that it will result not only 
 in a proper exposure of the tissues to be manipulated 
 during the operation but also to result in little or no 
 deformity after healing has taken place. It is very 
 important to secure free access to the tissues to be 
 
PLATE II 
 
 HORSE SHOE INCISION, BEING THE TRANSVERSE COLLAR INCISION OF 
 KOCHER EXTENDED UPWARDS AT EACH END ALONG THE ANTERIOR BORDER OF 
 THE STERNO-MASTOID MUSCLE TO (a) AND (b). 
 
THYROIDECTOMY 127 
 
 manipulated during the operation because as will 
 be seen later there are various important structures 
 which must be protected during the operation. 
 
 Moreover, it is important not to traumatize the 
 tissues of the thyroid gland itself for fear of producing 
 hyperthyroidism. It is also important to have a clear 
 view of the field of operation in order to reduce the 
 loss of blood to a minimum because aside from 
 the loss of blood itself there seems to be a cer- 
 tain amount of harm done to the patient if 
 the wound surfaces are severely saturated with 
 blood during the operation, because according 
 to Kocher there is a certain amount of specific 
 toxicity in the blood in these cases. The total 
 amount of traumatism to the tissues is greatly 
 reduced if an ample incision gives free access to all 
 tissues to be manipulated. This is even of greater 
 importance if the operation is performed under local 
 than under general anaesthesia, because the skin is 
 most easily rendered painless, hence a large incision 
 causes no more immediate pain than a small incision, 
 while the pain of the remaining steps of the opera- 
 tion is proportionate with the amount of trauma 
 and that is less with an ample than with a small 
 incision. 
 
 As all of the muscles of the neck are arranged in 
 pairs, it is plain that every incision which is not 
 symmetrical as regards the muscles of the neck must 
 result in a considerable amount of deformity because 
 in these cases aside from the almost imperceptible 
 deformity which is due to the line of incision itself 
 all of the deformity resulting from thyroid operations 
 is due to differences in the muscles on both sides of 
 
128 THYROID GLAND 
 
 the neck which can, of course, be avoided if the 
 muscles on both sides are always treated exactly 
 alike. This, however, is possible if the inverted 
 horseshoe incision, Plate 2, is employed, which was 
 introduced by Kocher and called by him "the collar 
 incision." 
 
 This incision begins at a point a little above the 
 level of the most prominent portion of the larynx 
 and the anterior border of the sterno-cleido mastoid 
 muscle, it extends downward and makes a regular 
 curve across the lower border of the thyroid gland 
 two to three c. m. above the upper margin of the 
 sternum. It then ascends to a corresponding point 
 on the opposite side of the neck making a perfectly 
 uniform symmetrical line. This incision may be 
 varied in length and in the distance of separation of 
 the vertical incisions according to the necessities of 
 the case, but aside from these variations no other 
 incision is required for the removal of any portion of 
 the thyroid gland. Many other incisions have been 
 described all of them taking the anterior edge of the 
 sterno-cleido mastoid muscles as a guide, but I am 
 thoroughly convinced that except for the opening 
 of abscesses none of these incisions will be so satis- 
 factory as the one just described, because none of 
 them give so perfect an approach to the field of op- 
 eration and each one leaves a greater amount of 
 deformity. It is plain, of course, that in many cases 
 it will not be necessary to make the incision nearly 
 so long as shown in Plate 2. If the tumor is con- 
 fined to the middle lobe it may be necessary to 
 make an incision which would cover no more than 
 the middle one-third of this incision. But even 
 
PLATE III 
 
 EXTERNAL CAROTIQ.A.- 
 INTERNAL » A.~ 
 SUPERIOR TMYROIDAr 
 INTERNAL JUGULAR^ 
 COMMON CAROTID A.— 
 
 VA6US.N. 
 
 PHRENIC. N. 
 THYROID GLAND'. — 
 
 STERNO HYOID.M. 
 OMO " M. 
 
 STERNO THYRCHDM, 
 3TERNO MASTOID^.! 
 
 ANATOMICAL DISSECTION THROUGH USUAL INCISION EMPLOYED IN MAK- 
 ING THYROIDECTOMY, EXHIBITING STRUCTURES TO BE CONSIDERED DURING THE 
 OPERATION. 
 
THYROIDECTOMY 129 
 
 in this case the curve should be quite as sym- 
 metrical and the tissues underneath should be 
 treated precisely the same on both sides of the center 
 of the incision. Some of the most troublesome little 
 tumors are located precisely at this point or at the 
 very lowest portion of one of the lateral lobes, and in 
 these cases it is well not to permit any asymmetry in the 
 skin incision because an avoidable postoperative 
 deformity is equally annoying to the surgeon and 
 to the patient. 
 
 The incision is carried through the skin, superficial 
 fascia and platysma myoides muscle and all of these 
 tissues are reflected upwards together as shown in 
 Plate 3, leaving the entire field of operation thor- 
 oughly exposed. In case the operation is performed 
 under local anaesthesia the tissues at the upper angle 
 of the wound should be thoroughly infiltrated with 
 the anaesthetizing solution by passing a blunt needle 
 attached to a hypodermic syringe filled with this 
 solution along the anterior and posterior surfaces of 
 the sterno-cleido-mastoid muscles on both sides and 
 also into the deep tissues along the lateral wings of 
 the thyroid cartilage. As the blunt needle enters 
 these various spaces the anaesthetizing fluid is slowly 
 injected and again as the needle is withdrawn, the 
 quantity injected being in inverse proportion to the 
 strength of the solution employed. This may be 
 done before the primary incision is made by first 
 cocainizing the skin, then making small punctures 
 with a sharp scalpel opposite the upper extremities 
 of the proposed incision and then passing the blunt 
 needle through these openings. It is well to wait 
 five minutes before commencing the operation. 
 
130 THYROID GLAND 
 
 Having exposed our field of operation we will con- 
 sider the anatomical structures to be dealt with and 
 to be protected during the operation. These we have 
 illustrated from dissections on the cadaver adjusted 
 to the various steps of the operation. In our illustra- 
 tions it has been necessary to exaggerate the con- 
 dition somewhat in order to secure clearness, but all 
 of these exaggerations were made in keeping with 
 the actual tissues of the neck. For instance, when 
 the sterno thyroid muscles are exposed in the opera- 
 tion they are covered with fascia, but if this were left 
 in place our illustrations would not be more effective 
 than are photographs made during this stage of the 
 operation while if represented as showing the ex- 
 posed muscle fibres the reader obtains a much clearer 
 idea of the conditions. 
 
 Anatomical Consideration. The following tissues 
 must be borne in mind throughout the operation 
 in order to accomplish the work with the greatest 
 possible facility in the shortest time with the least 
 trauma, and without injury to any important struc- 
 tures and with the prospect of the best possible 
 cosmetic results. 
 
 The gland itself is normally quite small weighing 
 only from 30 to 60 gms. It is somewhat smaller in 
 women than in men and larger relatively in infancy 
 than in adult life. 
 
 The diseased gland may be but slightly larger 
 than the normal gland, sometimes not exceeding 
 100 g. while it may be many times this size. The 
 largest gland I have personally removed weighed 
 3,584 g. after the blood had been drained out of it. 
 
THYROIDECTOMY 131 
 
 This would make the gland about one hundred times 
 the normal weight. 
 
 In considering the location of the gland itself in 
 relation to the surrounding structures we must con- 
 sequently bear in mind not only the normal position 
 and the normal relations, but also conditions which 
 are the results of the change in form of the gland due 
 to irregularities caused by the pathological condition 
 present. In many instances abnormal adhesions are 
 found caused by the previous treatment with in : 
 jections into the gland and the surrounding tissues 
 or to adhesions caused by the presence of infection 
 at some previous time. Plate 3 represents a dissec- 
 tion which was made through an exposure such as 
 one obtains by making the collar incision shown in 
 Plate 2 . It has seemed better to represent this through 
 the same incision that we use in making a thyroid- 
 ectomy than through the ordinary incision employed 
 in the dissecting room, because in this way we have 
 obtained not only the normal relation of the various 
 structures but also the relation of these structures 
 to the wound as it appears in the actual opera- 
 tion. There is the difference of having freed the 
 muscles of their fascia and having carefully exposed 
 all of the other structures, which is neither necessary 
 nor desirable in the actual operation, but which seems 
 necessary in order to impress sufficiently the relative 
 positions of the various structures which must be con- 
 stantly borne in mind during the progress of the 
 operation. What has been said regarding the method 
 of producing Plate 3 applies also to Plates 4 and 5. 
 
 On the right hand side we have the tissues as they 
 appear after the flap has been dissected up together 
 
132 THYROID GLAND 
 
 with the platysma myoides muscle. Of these muscles 
 the sterno-cleido-mastoid muscle will be borne in 
 mind prominently throughout the operation because 
 it serves as a guide to almost every important step 
 taken as will be seen later on in the discussion of the 
 technic. The other three muscles are treated as one 
 structure technically throughout the various opera- 
 tions. When displaced by retractors these muscles 
 are always manipulated as one object. When severed 
 for the purpose of exposing structures they are again 
 treated as one structure and not being freed of the 
 fascia covering these tissues the operator never 
 distinguishes them as separate muscles. On the left 
 side they have been removed entirely in order to 
 expose the underlying structures so that they could 
 be drawn distinctly and accurately. In the operation 
 itself the attachment of these muscles with the un- 
 derlying structures is only disturbed so far as the 
 portion of the gland is concerned which is to be re- 
 moved, all of the other attachments remain intact. 
 So long as the surgeon knows precisely where these 
 important structures are located it is quite unneces- 
 sary to expose them by dissection in order to protect 
 them against injury, but it is of the greatest import- 
 ance primarily to know where these various struc- 
 tures are located and secondarily to carry out the 
 steps which are necessary to prevent injury which 
 will be fully described later. 
 
 The thyroid gland itself can always be recognized 
 readily by its lobulated surfaces. It is an exceed- 
 ingly vascular body. In the living body it has a 
 characteristic purple color which readily distin- 
 guishes it from all surrounding structures. The 
 
PLATE IV 
 
 THE SAME AS PLATE III, WITH THE RIGHT LOBE OF THE THYROID GLAND 
 REMOVED IN ORDER TO BRING OUT THE REMAINING STRUCTURES. 
 
THYROIDECTOMY 133 
 
 branches of the superior thyroid artery and vein 
 cover the upper portion of the gland and over the 
 surface of the lower portion a network of veins com- 
 municating with both, the inferior and the superior 
 thyroid veins can always be distinguished. These 
 veins are especially prominent in cases of exophthal- 
 mic goitre but they can always be seen even when 
 there is little or no enlargement of the gland. In 
 order to make the drawing more distinct only the 
 superior thyroid artery is shown in this drawing, 
 the internal jugular vein and its branches having 
 been dissected away in order to show the important 
 deep structures. The superior thyroid artery can 
 always be distinguished during the operation although 
 its origin from the external carotid artery is but 
 rarely exposed during the operation and the internal 
 carotid artery which is also shown in Plate 3 should 
 not be exposed together with the internal jugular 
 vein when the surgeon lifts one of the lobes of the 
 gland out of its bed. The vagus nerve is exposed 
 occasionally during the operation especially when 
 there are enlargements from the lateral surface of 
 the lateral lobe. Very rarely the phrenic nerve is 
 exposed under similar conditions. At the lower end 
 of this drawing on the left side a thin white line 
 represents the recurrent laryngeal nerve. As will be 
 seen later it is not necessary to expose this nerve 
 during the operation, but in this instance it was 
 exposed for a short distance because of the general 
 dissection which was employed to expose the other 
 structures which have just been described. 
 
 In Plate 4 the internal jugular vein has been left 
 in place and the lobe of the thyroid gland has been 
 
134 THYROID GLAND 
 
 entirely removed not as it would be removed during 
 an operation but for the purpose of showing the 
 blood supply of the gland which must be considered 
 during every operation upon this gland as the most 
 important factor. On the right hand side, the draw- 
 ing represents the same structures as Plate 3 with the 
 addition of the external jugular vein which may. 
 however, be disregarded technically during the opera- 
 tion. Usually it is possible to make the incision in- 
 ternally to this vein but when it is not possible to 
 do this, the latter is simply caught between two 
 pairs of forceps and ligated. The superior thyroid 
 vein is usually located somewhat closer to the 
 superior thyroid artery than shown in this illustra- 
 tion so that very commonly it is possible to ligate 
 the artery and the vein with the same ligature when 
 making thyroidectomy. In this dissection the mus- 
 cles represented on the right side have all been re- 
 moved on the left side with the exception of the 
 sterno-cleido-mastoid which has been reflected. 
 
 In Plate 5 we have represented the structures in a 
 somewhat more diagramatic form in order to give 
 a more general impression of the tissues to be borne 
 in mind. On the left side all of the muscles shown in 
 Plates 3 and 4, on the right side are in place together 
 with the external jugular vein, while on the right side 
 all of the muscles have been reflected so as to ex- 
 pose virtually all of the tissues which are to be con- 
 sidered in the subsequent technic. Most of these 
 structures have already been mentioned in connec- 
 tion with Plates 3 and 4 but it seems worth while to 
 consider them all together in their mutual relations 
 to the external wound. In practice one is but rarely 
 
PLATE V 
 
 STERNO HYOID M.~ 
 OMO » MA- 
 
 STER NO THYROID M 
 MASTOID M 
 
 EXTERNALJU6ULARV. 
 
 EXTERNAL carot ;-■ 
 
 NTERNAL CAROTID A. 
 SUPERIOR TH -' = : : P 
 
 
 
 
 
 
 
 1 A "COMMON CAROTID. A. 
 
 
 
 
 -^Ifi-HI 1 — PHRENICN. 
 
 
 
 
 ^^S^vNTERTiAL J UG L 
 ^.W^f '-?-?INFERIORTKYR0IDA' 
 
 
 ( O'''^^^^^ 
 
 I0 % '' 
 
 
 THYROID GLAND 
 
 
 ! RECURRENT 
 
 
 
 LARYN6EALN. 
 
 
 V 
 
 
 
 p NEUMOQASTRIC.N. 
 
 
 
 
 
 
 INFERIOR THYROID.V. 
 MIDDLE " V . 
 
 
 
 
 
 
 ANATOMICAL DRAWING, SOMEWHAT DIAGRAMMATIC, SHOWING THE MUS- 
 CLES IN PLACE ON THE RIGHT SIDE AND ALL OF THE OTHER ANATOMICAL 
 STRUCTURES TO BE CONSIDERED IN PLACE ON THE LEFT SIDE. 
 
PLATE VI 
 
 INCISION FOR THYROIDECTOMY, WITH SKIN SUPERFICIAL FASCIA AND 
 PLATYSMA RETRACTED UPWARD AND HELD OUT OF THE WAY WITH RETRACTOR 
 (i). HAEMOSTATS ON SEVERED VESSELS AXD SHADOWS SHOWING LARGE 
 BRANCHES OF ANTERIOR JUGULAR VEIN. 
 
THYROIDECTOMY 135 
 
 called upon to operate in cases in which, the relative 
 size of the thyroid gland and the other structures 
 is as it is shown in this figure, which is approximately 
 as it exists in the normal conditions, but this will 
 show how the different structures appear normally 
 and then one can judge the changes from the amount 
 of deformity encountered in each individual case. 
 The enlarged portion of the gland usually simply 
 displaces the various structures by lateral pressure 
 but occasionally these structures are overlapped by 
 some projection from the gland. There is, of course, 
 an infinite variety of these displacements so that it 
 would be useless to describe the individual forms 
 which have been or may be encountered. These 
 drawings may be recommended for careful study, 
 and may be verified in the cadaver with profit be- 
 fore attempting the operation. As the condition is 
 very similar in the cat and in the dog it is wise to 
 operate upon these animals before attempting to 
 perform the operation upon the human patient. 
 
 When one has once become practically familiar 
 with the anatomical structures just described, the 
 technic which follows will acquire a much less com- 
 plicated aspect from that which one would obtain 
 without this familiarity. Although it is true that 
 most of the danger to the patient comes from the 
 fact that operations upon the thyroid gland are per- 
 formed upon patients who would not be good sub- 
 jects for any operation, still the local conditions are 
 such that the danger from the operation will be 
 greatly increased unless the surgeon is perfectly 
 familiar with the structures described in Plates 4 and 
 
136 THYROID GLAND 
 
 5, which will be referred to throughout the discus- 
 sion of the various steps of surgical technic. 
 
 Plate 6 represents the flap of the skin together with 
 the platysma myoides reflected upwards. A number 
 of veins which are located immediately underneath 
 the skin are so small in the normal conditions that 
 they will not require any attention in operations upon 
 the neck but are so large in patients suffering from 
 goitre that they bleed very freely. These should be 
 grasped at once with haemostatic forceps which may 
 be left in place as they do not interfere with the 
 subsequent steps of the operation. Occasionally 
 there is some bleeding from the under surface of the 
 flap which should be controlled by hasmostatic for- 
 ceps and ligatured at once. The edges of the sterno- 
 cleido-mastoid muscles can be seen on either side, 
 and over the surface underneath the fascia there are 
 usually several large veins as indicated by the shaded 
 lines in this figure. These may extend longitudinally 
 over the surface of the gland parallel to each other 
 or they may form a network. They are usually 
 branches of the anterior jugular vein. It is also pos- 
 sible to see the sternohyoid and the sternothyroid and 
 occasionally a portion of the edge of the omohyoid 
 muscles through the fascia as shown in this figure. 
 
 The anterior horseshoe shaped flap is held out of 
 the way throughout the operation by means of the 
 retractor. It is well to fasten the towels to the skin 
 by means of a safety pin as shown in this figure in 
 order to prevent them from slipping up and down 
 over the edge of the wound during the operation. 
 
 Plate 7 represents the same conditions as Plate 6 
 with the addition of illustrating an important step 
 
PLATE VII 
 
 
 
 
 
 s 
 
 
 1 
 
 
 
 
 ft 
 
 .i 
 
 
 
 
 
 
 , j 
 
 
 
 
 
 
 I 
 
 
 
 
 
 
 -• ■' T ;|- -v 
 
 
 
 
 
 
 ^- : • 
 
 
 
 
 
 
 
 ■■\v. 
 
 
 
 1 o« 
 
 
 
 \ 
 
 jWp 
 
 WL^ 
 
 
 
 
 
 ' a'<t-_ 
 
 'z==== ==: '. 
 
 
 1 / 
 
 _ M ... 
 
 
 ____ cfcr: ' 
 
 ' a" > :-ct"~ 
 
 
 ===— 
 
 
 '^ 
 
 
 
 .^r- 
 
 -~-__^^ 
 
 
 ' J - ''■;'' 
 
 i 
 ■ 'ill '" 
 
 ■lit ' 
 
 ', '. '<|;\ 
 
 ' 
 
 
 ! ,-y'" ■■; 
 
 /. / / a 
 
 
 jj$ 2?V^ 
 
 
 
 .THE SAME AS PLATE VI, WITH KOCHEK DIEECTOE (b) INSEBTED UNDEB- 
 NEATH ANTEEIOK JUGULAB VEIN WITH TWO HAEMOSTATIC FOECEPS (a) AND 
 (A') APPLIED. 
 
PLATE VIII 
 
 "^ 
 
 ■/' 
 
 k 
 
 a F 
 
 /j? 
 
 ILm. 
 
 // 
 
 :a\A. 
 
 THE SAME AS PLATE VII, WITH LONG-JAWED KOCHER HAEMOSTATIC FOR- 
 CEPS APPLIED TO STERNO-HYOID, STERNO-THYROID AND OMO-HYOID MUSCLES 
 IN FRONT OF THE RIGHT LOBE OF THE THYROID GLAND. 
 
THYRODECTOMY 137 
 
 in the operation. In order to keep the wound con- 
 stantly free from blood Kocher has introduced a 
 grooved director represented at (b) with its point in- 
 serted underneath the anterior jugular vein. In order 
 to expose the vein the fascia overlying it is split 
 longitudinally and then it is lifted up by means of 
 the blunt pointed end of the Kocher director. Two 
 haemostatic forceps, preferably of the type intro- 
 duced by Kocher and shown at (a) are applied to 
 the vessel as indicated in this figure and then it is 
 severed over the middle of the director. It is well 
 to ligate both ends of the vessels at once in order to 
 keep the surface free from instruments for the con- 
 venience of the subsequent steps of the operation. 
 This leaves the sternohyoid, the sternothyroid, the 
 omohyoid and the edge of the sterno-cleido muscles 
 exposed. All haemorrhage has been controlled either 
 by the application of haemostatic forceps which are 
 still in place or by clamping and ligating. In most 
 cases it will be necessary to apply two pair of forceps 
 to the muscles covering the anterior surface of the 
 gland as shown at (b) and (V) Plate 8. These forceps 
 should again be of the type shown in this illustration 
 which were introduced by Kocher. They should be 
 placed about 2 c. m. apart and parallel with each 
 other and closed just tightly enough to stop all 
 haemorrhage but not sufficiently tightly to crush the 
 muscle. It is usually best to ligate the veins caught 
 in forceps (a) and (a") before the present step of the 
 operation is taken because slight traction upon these 
 forceps sometimes causes a tear in the thin walls of 
 these veins which gives rise to quite a severe haemorr- 
 
138 THYROID GLAND 
 
 hage, and which may seriously obscure the subse- 
 quent steps of the operation. 
 
 The muscle is then cut transversely and the handles 
 of the forceps are turned back as indicated at (b) 
 and (b") which results in the perfect exposure of 
 the entire anterior surface of one lobe of the thyroid 
 gland as shown in Plate 9. The same step will usually 
 have to be repeated on the opposite side, although it 
 is sometimes possible to obtain a sufficiently free 
 exposure by simply retracting the muscles on the 
 opposite side. Forceps (c) and (c") are now applied 
 precisely as (b) and (b") were in Plate 8, so as not to 
 interfere with the nerve supply of the muscles, and 
 the muscles are severed transversely half way be- 
 tween these two forceps. When these are turned 
 back to correspond with (b) and (b") which are at- 
 tached to the corresponding muscles on the opposite 
 side the anterior surface of the entire thyroid gland 
 is perfectly exposed as shown in Plate 10. 
 
 There are several advantages in turning both of 
 these muscles back. It facilitates the operation be- 
 cause with so free an exposure the remaining steps 
 of the operation can be accomplished so much more 
 rapidly that in many cases it is really worth while. 
 It requires only a moment to re-unite the muscles. 
 Moreover, there is an advantage in treating both sides 
 alike because of the resulting symmetry when the 
 operation is completed. Again the amount of trauma- 
 tism to the tissues will be reduced by having free 
 access to the gland. In case the smaller lobe contains 
 nodules of diseased tissues these will be discovered 
 and can readily be removed. In many instances a 
 more thorough operation will be performed if both 
 
PLATE IX 
 
 5w 
 
 / 
 
 / 
 
 
 N 
 
 THE SAME AS PLATE VIII, WITH THE MUSCLES CUT ACROSS BETWEEN FOR- 
 CEPS (B) AND (b') ON THE RIGHT SIDE AND SIMILAR FORCEPS (c) AND (c') 
 APPLIED TO THE MUSCLES OF THE LEFT SIDE. 
 
PLATE X 
 
 </ 
 
 s?3 . V 7* it. / 
 
 THE SAME AS PLATE IX, WITH THE MUSCLES ALSO CUT TEANSVERSELY 
 ON THE EIGHT SIDE BETWEEN FORCEPS (c) AND (c'), EXPOSING THE AN- 
 TEEIOE SUEFACE OF THE GLAND PERFECTLY. 
 
THYROIDECTOMY 139 
 
 lobes are exposed because of the ease with which it is 
 possible, under these conditions, to ligate the in- 
 ferior thyroid artery and vein on the side on which 
 the lobe is smaller. It may be well to advise this ad- 
 ditional step to those who have not yet obtained a 
 great amount of experience in this field of operation. 
 With increased experience one acquires the ability 
 to work with less perfect exposure. 
 
 Plate 1 shows a perfect exposure of both lobes of 
 the thyroid gland with the right lobe somewhat en- 
 larged. The form of retractor shown in Plates 2, 3 
 and 4 is very convenient for exposing the field of 
 operation. Forceps (b), (b') and (c) and (c') serve 
 the double purpose of preventing haemorrhage from 
 the cut ends of the muscles overlying the gland and 
 that of very convenient retractors. Two precautions 
 must be borne in mind. These forceps must not be 
 closed too firmly but just sufficiently to prevent 
 haemorrhage in order not to injure the structure of the 
 muscles, and assistants must not pull too heavily 
 upon them during the operation. A portion of the 
 muscle at least half a c. m. in width must be left 
 projecting beyond the forceps in order to preserve 
 perfectly smooth cut surfaces for suturing when 
 the operation upon the gland itself has been com- 
 pleted. 
 
 The branches of the two superior thyroid arteries 
 communicate very freely with each other which 
 can be demonstrated easily on injected specimens 
 but. even in the living body it is apparent from the 
 arrangement of these branches that this must be 
 the case. At the upper end a narrow band extends 
 upwards in front of the larynx, and is attached to the 
 
140 THYROID GlyAND 
 
 upper edge of the thyroid gland. This structure is 
 usually present and represents the remnant of the 
 duct which communicates between the gland and 
 the oesophagus during foetal life. Occasionally the 
 duct persists but this is very rare. Usually it is 
 simply a small band of connective tissue which may 
 be clamped between two pair of hemostatic forceps, 
 cut and ligated. 
 
 In many cases it is possible to retract the sterno- 
 thyroid, sterno-hyoid and omo-hyoid muscles as 
 shown in Plate 1 1 , without clamping and cutting them. 
 This may be done on both sides of the median line 
 either simultaneously or successively. Some opera- 
 tors with great skill and much experience make this 
 their typical operation and choose the method shown 
 in Plates 8, 9 and 10, only in cases in which for any 
 other reason it does not seem possible to complete 
 the operation without taking this additional step. 
 It is often especially difficult to dislocate the enlarged 
 lobe forward if these muscles are left intact. One 
 also may experience difficulty in controlling the 
 bleeding from the small veins which may be torn in 
 bringing forward the lobe. The ligation of the in- 
 ferior thyroid vessels on the opposite side from the 
 one on which the lobe has been removed is also very 
 much more difficult if these muscles are left intact. 
 There is a marked difference in the strength and 
 elasticity of these muscles in different patients and 
 consequently it is well to treat each case according 
 to the conditions found after making a longitudinal 
 separation of the muscles of both sides. This is 
 usually best accomplished by means of dissecting 
 forceps and scalpel. Separating the posterior surface 
 
PLATE XI 
 
 
 2 -,:•>.. 
 
 2, 
 
 
 ///•'i 
 
 ... 
 
 
 *fri 
 
 Gfl6£_, 
 
 
 
 CH 
 
 
 
 •■-.. 
 
 ^ 
 
 ~N^. 
 
 
 ;-'-'- 
 
 
 " : ":: 
 
 C^" — i 
 
 
 
 
 S 
 
 
 \ 
 
 
 
 >; 
 
 >>.\ 
 
 
 v\.: 
 
 w 
 
 
 V 
 
 
 
 \ " '■ 
 
 
 >\ 
 
 \ 
 
 
 
 
 THE SAME AS PLATE X, WITH THE MUSCLES COVERING THE THYROID 
 GLAND RETRACTED BY RETRACTORS (2) AND (3) INSTEAD OF BEING SEVERED. 
 
PLATE XII 
 
 SHOWS THE SUPERIOR THYROID ARTERY ON THE RIGHT SIDE RAISED ON 
 THE POINT OF A GROOVED DIRECTOR (f) AND CLAMPED WITH HAEMOSTATIC 
 FORCEPS (E) AND (E'), WHILE ON THE OTHER SIDE THE VESSEL HAS ALREADY 
 BEEN SEVERED AND IS HELD BY FORCEPS (e") AND (e'"). 
 
THYROIDECTOMY 141 
 
 of the muscle from its attachment to the thyroid 
 gland is best accomplished by passing the index 
 finger between the anterior surface of the gland and 
 the posterior surface of the muscles on either side. 
 
 In doing this it is best to apply the greater amount 
 of pressure anteriorly against the posterior surface 
 of the muscles in order not to traumatize the sub- 
 stance of the thyroid gland. This step of the opera- 
 tion is only rarely accompanied with haemorrhage 
 which can be controlled at once with haemostatic 
 forceps. The anterior surface of the gland is always 
 covered with a perfect network of large thin-walled 
 veins which should not be injured because they 
 bleed very freely and cover the field with so much 
 blood that the remaining steps of the operation will 
 be greatly retarded. 
 
 Plate 12 shows the same exposure as Plate 10. The 
 haemorrhage has been completely controlled by the 
 application of haemostatic forceps to all of the smaller 
 bleeding points and by applying two haemostatic 
 forceps to each one of the larger vessels before cutting 
 them and then ligating them at once. With the gland 
 fully exposed the actual steps for the removal of the 
 gland may be commenced. A Kocher director is 
 passed underneath the superior thyroid artery and 
 vein either separately as shown at Plate 12, or the 
 two vessels may be taken together. After the end of 
 the director has been passed through underneath 
 one or both of these vessels two pair of haemostatic 
 forceps (e) and (e') are clamped upon this vessel and 
 then the latter is severed over the director between 
 these forceps. The cut ends of these vessels are then 
 turned up as shown at (e") and (e" ') and ligated at 
 
142 THYROID GLAND 
 
 once. Usually the superior thyroid vessels can be 
 treated in this manner between their origin from the 
 external carotid artery and their distribution to the 
 gland but occasionally these vessels divide into 
 various branches early and then it will become neces- 
 sary to ligate two or more branches separately. 
 
 Only in rare cases do we find it necessary to ligate 
 the superior thyroid vessels on both sides in the same 
 patient. It is much more common to ligate one super- 
 ior and both inferior thyroid vessels in the same case. 
 In case it seems advisable to ligate the superior 
 thyroid vessels on both sides it seems best to follow 
 the method of Jacobson to be described fully later. 
 
 After the superior thyroid vessels have been 
 clamped, cut and ligated on one side it is possible 
 to dislocate the enlarged lobe of the thyroid gland 
 forward, a method first introduced by Kocher and 
 called "luxation of the thyroid gland." 
 
 The steps that have just been described and which 
 have been illustrated in Plate 12, may be accomplished 
 without cutting the muscles covering the anterior 
 surface of the thyroid gland. This is shown in Plate 
 13. There is, however, much less space and if the 
 operation is under local anaesthesia the patient 
 suffers greatly from the necessary pulling upon the 
 retractors (3) and (3') and (2) and (2') as shown in 
 Plate 13. Unless the enlargement is confined to the 
 middle lobe or is only moderately large in one of 
 the lateral lobes it seems better when operating under 
 local anaesthesia to secure the exposure of the gland 
 indicated in Plate 12. 
 
 In Plate 14 the step which should have been com- 
 pleted in Plates 12 and 13 of severing the superior 
 
PLATE XIII 
 
 REPRESENTS THE SAME STAGE OF THE OPERATION AS PLATE XII, WITH 
 THE MUSCLES NOT SEVERED BUT RETRACTED BY INSTRUMENTS AT (2) AND 
 (2') AND (3) AND (3'). 
 
PLATE XIV 
 
 THE RIGHT LOBE OF THE GLAND HAS BEEN LOOSENED FROM ITS ATTACH- 
 MENTS TO THE TISSUES EXTERNAL TO IT AND HAS BEEN DISLOCATED FORWARD. 
 
THYROIDECTOMY 143 
 
 thyroid vessels is represented as being under way. 
 The Kocher director (f) is represented as elevating 
 the superior thyroid vein and the haemostatic forceps 
 (e) and (e') have been clamped upon this vessel on 
 either side of the director. The right lobe of the gland 
 has been dislocated forward so that it now rests 
 upon the haemostatic forceps and retractors which 
 appear in the previous figures on the surface. 
 
 It is possible in many cases to carry out this step 
 of the operation before severing the superior thyroid 
 vessels, but there is no advantage in doing this while 
 there are several distinct advantages in first ligating 
 and severing the superior thyroid vessels and then 
 dislocating the gland forward. In this way the ten- 
 sion is removed from these vessels and the vein 
 especially is protected against injury by traction. 
 The manipulations may press some thyroid secretion 
 into the circulation. The anterior jugular vein has also 
 been severed early during the operation and this will 
 be of advantage to the patient in the same direction. 
 Occasionally there is some haemorrhage from the 
 small vessels which are torn when the gland is luxated, 
 and if the superior thyroid vessels have already 
 been disposed of it is much easier to control this 
 bleeding either by pressure or by clamping with 
 forceps than if they have not, because much space is 
 gained in this manner. The luxation can usually be 
 accomplished readily by passing the index finger be- 
 tween the gland and the connective tissue capsule 
 and passing it from above downward at the same 
 time lifting the gland forward. 
 
 In freeing the gland from the surrounding tissues 
 it is again important to direct the pressure of the 
 
144 Thyroid gland 
 
 finger away from the gland instead of pressing to- 
 ward the gland in order not to traumatize the gland 
 for fear of pressing thyroid secretion into the circu- 
 lation thus causing post-operative hyper-thyroidism. 
 Many surgeons prefer not to luxate the gland in 
 this manner, but to dissect the entire gland free from 
 its attachment by sharp dissection with scalpel and 
 dissecting forceps, laying bare all of the tissues, 
 notably the inferior thyroid vessels and the recurrent 
 laryngeal nerve. Landstrdm goes no further than 
 this with his concise dissection and prevents injury 
 to the parathyroid glands by leaving the posterior 
 capsule and a thin portion of thyroid gland tissue in 
 place while a few authors go so far as to demand that 
 the dissection must locate not only these structures 
 but also the inferior parathyroid gland on the side 
 from which the lobe is to be removed. It seems quite 
 plain that it is quite unnecessary to expose the 
 patient to the prolonged operation which is, however, 
 of much greater harm if the patient is kept under 
 general anaesthesia during this period of time than 
 if local anaesthesia is employed. All of the steps 
 which have just been described can be carried out in 
 some patients through a field of operation as indi- 
 cated in Plate 1 5 in which the muscles have been re- 
 traced but not severed. The luxation of the gland 
 is especially difficult in cases in which there has ex- 
 isted an inflammation of the gland or a parathyroid- 
 itis or those in which the gland has been punctured 
 by hypodermic needles for the injection of various 
 substances. Cases that have been treated with x-ray 
 or with electricity seem to be especially vascular and 
 it is often difficult to stop the haemorrhage after 
 
PLATE XV 
 
 t 
 
 ?%v\-W^l£<^ 
 
 >^v 
 
 M 
 
 A' V^S 
 
 THE SAME AS PLATE XIV, WITH THE MUSCLES RETRACTED AND NOT SEV- 
 
PLATE XVI 
 
 
 THE SUPERIOR THYROID VESSELS HAVE BEEN LIGATED DOUBLE AND CUT, 
 THE RIGHT LOBE HAS BEEN ENTIRELY FREED AND DISPLACED FORWARD, THE 
 INFERIOR THYROID VESSELS ARE ISOLATED AND HELD ON POINT OF KOCHER 
 DIRECTOR (N) AND CAUGHT BY TWO PAIRS OF FORCEPS (m) AND (m'). 
 
THYROIDECTOMY 145 
 
 luxating the gland. There may simply be diffuse 
 general oozing without any haemorrhage from vessels 
 of considerable size. Usually tamponing with gauze 
 into the cavity out of which the gland has been lifted 
 will suffice to stop this bleeding. It is well to apply 
 this gauze tampon immediately upon lifting forward 
 the gland and to leave it in place during the time 
 required for completing the remaining steps of the 
 operation. Occasionally it may become necessary 
 to pass a few catgut sutures over some of the oozing 
 surfaces. In this case it is important to bear in mind 
 the proximity of the anatomical structures shown 
 in Plates 3, 4 and 5. It is possible to injure the in- 
 ternal . jugular vein during these manipulations es- 
 pecially in cases in which there are strong adhesions 
 due to parathyroid infection some time previous 
 to operation. 
 
 In order to make these dangers more apparent we 
 have represented in Plates 16 and 17 the carotid 
 artery, the jugular vein and the pneumogastric 
 nerves as they would appear were a clear dissection 
 made. In the operation upon the living patient, these 
 structures never appear so clearly as here represented 
 although they can be readily distinguished, the artery 
 especially by its pulsation and the vein by its increase 
 and decrease in size during inspiration and expiration. 
 
 Under the actual conditions a gauze tampon is 
 packed between these vessels and the gland which 
 has been lifted forward -and pushed over to the op- 
 posite side but as this would cover up the portion 
 it is desirable to show, it has been left out of the 
 drawing. Upon lifting up the lobe of the gland and 
 pushing it over to the opposite side it is possible to 
 
146 THYROID GLAND 
 
 locate the inferior thyroid vessels as shown in Plate 
 16. A Kocher director is placed under one or both 
 of these vessels, as in Plate 16, and haemostatic forceps 
 are applied to their side as shown at (m) and (m'). 
 Usually the inferior thyroid artery and vein are 
 farther apart than shown in Plate 16, and must be 
 lig ated separately, and most commonly bifurcation 
 takes place at a point to the outside of the portion 
 grasped by the haemostatic forceps so that several 
 forceps are required and several ligatures have to be 
 employed. 
 
 Plate 17 shows the same steps of the operation il- 
 lustrated in Plate 16 without section of muscles. It 
 is often very difficult to expose the inferior thyroid 
 vessels under these conditions because all of these 
 muscles have their lower attachment to the sternum 
 and their upper attachments are very much farther 
 apart than the lower ones, consequently one en- 
 counters most difficulty during manipulations which 
 must be made in the lower portion of the field of 
 operation. 
 
 In comparing the relation of the inferior thyroid 
 vessels in Plate 17 with those represented in Plate 5, 
 it becomes apparent that the point of the forceps 
 marked (m) is dangerously near the point where the 
 recurrent laryngeal nerve crosses the inferior thyroid 
 artery. As mentioned before in the discussion of 
 Plates 3 and 5 it was pointed out that the recurrent 
 laryngeal nerve is a very fine thread-like structure 
 which can easily be located in a dissection whose 
 object it is to expose this nerve either in the living 
 body or in the cadaver, and many surgeons insist 
 upon making this demonstration in every case dur- 
 
PLATE XVII 
 
 THE SAME AS PLATE XVI, WITH THE MUSCLES NOT CUT BUT HELD OUT OF 
 THE WAY BY RETRACTORS (2) AND (3). 
 
PLATE XVIII 
 
 SHOWS THE EIGHT LOBE ENTIRELY FREE, WITH ITS POSTERIOR CAPSULE 
 (P.) AND A PORTION OF THE GLAND IN THE FORM OF A THIN LAYER OF THE 
 POSTERIOR PORTION OF THE LOWER END OF THE LOBE LEFT IN PLACE. 
 
THYROIDECTOMY 147 
 
 ing the operation and before ligating the inferior 
 thyroid artery or its branches in order that no harm 
 may come to the recurrent laryngeal nerve during 
 the operation.- It is most important for every sur- 
 geon who performs thyroidectomy to expose this 
 nerve repeatedly either in the cadaver or in the 
 living body in order to be quite positive as to its 
 location, but once having become familiar thus, it 
 seems far better to plan the operation so that this 
 tedious dissection may be avoided, provided the 
 operation can be performed with the same safety to 
 the patients. Fortunately this nerve is so located 
 that it can always be avoided if the entire lower half 
 of the posterior capsule of the thyroid gland is left 
 undisturbed in its attachment to the anterior sur- 
 face of the trachea. The same plan accomplishes 
 the protection of the lower parathyroid gland which 
 is still more intimately attached to the posterior 
 surface of the thyroid gland than is the case with the 
 recurrent laryngeal nerve. 
 
 In Plate 18 this step of the operation has been illus- 
 trated. The letter (r) represents the posterior capsule 
 together with a layer of the posterior portion of the 
 thyroid gland which has also been left in place be- 
 cause the parathyroid gland some times is situated 
 between some of the posterior lobules of the thyroid 
 gland and by leaving this layer one is perfectly 
 certain to leave the parathyroids undisturbed. 
 
 The forceps (g) and (g r ) are attached to the in- 
 ferior thyroid vein which enters the thyroid gland 
 from its posterior surface, the gland being inverted 
 by being folded forward over the opposite lobe, its 
 attachment to the isthmus forming the hinge upon 
 
148 THYROID GLAND 
 
 which the lobe is swung. The exposed portion of the 
 inferior thyroid artery and vein is somewhat longer 
 than is usually encountered, but it was difficult to 
 represent it more nearly in its exact form. Frequently 
 one encounters an artery of considerable size enter- 
 ing the gland at a point a little below the point in 
 the posterior capsule marked (r) . This is the middle 
 thyroid artery which is usually not recognized until 
 it has been severed. It must then be caught with 
 haemostatic forceps and ligated. It is well to apply 
 these forceps very carefully because by grasping too 
 much tissue in the bite of the forceps it is possible to 
 include the recurrent laryngeal nerve causing a pa- 
 ralysis of the vocal cord. The bleeding from the cut 
 surface of the gland usually is very slight. By pick- 
 ing up a few small vessels and then making light 
 pressure with a gauze pad the bleeding ceases within 
 a few minutes while the remaining steps of the op- 
 eration are carried out. The dark space between the 
 retractors (3) and (4) and the edge of the capsule 
 (r) contains the carotid artery the internal jugular 
 vein and the pneumogastric nerve, but these cannot 
 be recognized separately except upon close inspection. 
 
 Plate 19 represents the conditions that have just 
 been described in connection with Plate 18 with the 
 exception that the muscles have been retracted in- 
 stead of being severed. 
 
 In Plate 20 the inferior thyroid vein has been severed 
 and the inferior thyroid artery has been grasped 
 between two haemostats (h) and (h") and is ready 
 to be severed. The distance between these two 
 vessels, the former being held by forceps (h) 
 and (h') is more nearly as it is usually found 
 
PLATE XIX 
 
 
 1 
 
 ) 
 
 A 1 
 
 ~i 
 
 
 / i^ 
 
 »s 
 
 
 3 
 
 l 4. .<£' 
 
 
 
 
 / 
 
 ./,'_. /v 
 
 '<5\ ; 
 
 'i/dMZ-y5_ll 
 
 MM 
 
 THE SAME AS PLATE XVIII, WITH THE MUSCLES KETEACTED BUT NOT 
 SEVERED. 
 
PLATE XX 
 
 THE SAME AS PLATE XVIII, WITH BOTH THE INFERIOR THYROID ARTERY 
 AND VEIN CAUGHT IN SEPARATE HAEMOSTATIC FORCEPS. 
 
THYROIDECTOMY 149 
 
 than that shown in Plates 18 and 19. In the 
 other details this illustration will not require 
 any further discussion, while Plate 20 is a simple 
 repetition with the muscles retracted instead of 
 severed. The inferior thyroid artery is then severed 
 between the forceps (h) and (h") and ligatures are 
 applied to all of the vessels held by forceps (h) (h") and 
 (g) (g") . In this manner all of the vessels supplying the 
 enlarged lobe of the thyroid gland have been dis- 
 posed of with the least possible amount of trauma 
 to the gland and with almost no loss of blood. The 
 important structures behind the gland, the recurrent 
 laryngeal nerve and the parathyroid gland have re- 
 mained entirely undisturbed and the operation can 
 be completed by simply removing this lobe at its 
 junction with the isthmus. The point of section 
 depends upon whether only one lobe is to be re- 
 moved or whether a portion or the entire isthmus 
 is to be removed or whether it seems advisable to 
 add to this the removal of a portion of the other 
 lateral lobe. 
 
 If the section is to be made through any portion of 
 the isthmus a pair of forceps (k) Plate 22, is applied 
 and the portion beyond these forceps is removed by 
 cutting away this part and either ligating the re- 
 maining stump with catgut or suturing over this 
 surface with a few fine catgut stitches. In exophthal- 
 mic goitre it is usually well to lift up the lower end 
 of the gland by forceps (k) and then leaving the 
 lower end of the posterior capsule together with a 
 thin layer of gland tissue on the other side and 
 ligating the inferior thyroid vessels or some of their 
 branches as this was done on the other side as illus- 
 
150 THYROID GLAND 
 
 trated in Plate 21. In this manner only one upper 
 thyroid vein and one upper thyroid artery possibly 
 in connection with one middle thyroid artery re- 
 mains. 
 
 In making a dissection of the isthmus it is im- 
 portant to exercise care not to injure the trachea 
 which is exposed at this point. In one instance I had 
 the misfortune of making a small incision into the 
 trachea at this point of the operation. The opening 
 was immediately closed with three fine catgut sutures 
 and a small drain of gauze was placed against this 
 surface. The patient recovered without any unfavor- 
 able symptoms but it is plain that the blunder should 
 not occur. In advanced cases or in patients who 
 have very hard nodules pressing upon the trachea 
 one or more of the cartilages may have become 
 softened as a result of pressure and when the isthmus 
 is removed there is no support for the mucous lining 
 of the trachea and the latter is drawn into the lumen 
 of this tube by each act of inspiration giving rise to a 
 valve-like obstruction. The patient will immediately 
 become asphyxiated. If a general anaesthetic has 
 been employed this may be blamed for the condition 
 of asphyxia until it is too late. For this reason it is 
 well to bear the possibility of this accident constantly 
 in mind. The difficulty can be discovered at once 
 upon inspecting the surface of the trachea because 
 of the depression upon inspiration. 
 
 The remedy consists in the introduction of an 
 intubation tube sufficiently long to reach to a point 
 below the softened tracheal cartilage. For this 
 reason a set of intubation tubes and a reliable gag 
 should always be kept in readiness during goitre 
 
PLATE XXI 
 
 y?// fiA^\\\V\\f\\ A^kVi 
 
 THE SAME AS PLATE XX, WITH THE MUSCLES NOT SEVERED BUT RE- 
 TRACTED. 
 
PLATE XXII 
 
 A, 
 
 ^jW l 
 
 THE RIGHT LOBE OF THE THYROID GLAND ENTIRELY DISSECTED OUT, BOTH 
 SUPERIOR AND INFERIOR THYROID VESSELS HAVE BEEN SEVERED. THE POS- 
 TERIOR PORTION OF THE CAPSULE IS IN PLACE AND THE ISTHMUS IS BEING 
 COMPRESSED WITH LONG-JAWED FORCEPS (iv). 
 
THYROIDECTOMY 151 
 
 operations. If the obstructions cannot be relieved 
 by intubation, tracheotomy should be performed. 
 The depressed portion of the tracheal wall should be 
 drawn forward and a longitudinal incision should 
 be made and a tracheotomy tube should be inserted. 
 If a tracheotomy tube is not available it is usually 
 not difficult to improvise some plan to keep the 
 wound in the trachea open. The patient should be 
 protected against the inspiration of cold air by plac- 
 ing four thicknesses of aseptic gauze over a frame 
 five c. m. or more above the wound. If the air in the 
 room is very dry it is well to drop a few drops of 
 water upon this screen sufficiently often to supply 
 some moisture to the air inhaled. In these cases it is 
 well to have the lower portion of the wound widely 
 open in order to avoid serious infection which might 
 otherwise give rise to septic mediastinitis. 
 
 Plate 23 represents the same stage of the operation 
 as Plate 22 with the muscles not severed. 
 
 Plates 24 and 25 represent the completed operation 
 with the exception of closing the wound. The entire 
 right lobe together with the entire isthmus has been 
 removed. Only the posterior capsule (r) together 
 with a thin layer of the posterior portion of the right 
 lobe remains, just enough to protect the recurrent 
 laryngeal nerve and the parathyroid gland. The 
 internal jugular vein and the common carotid artery 
 together with the superior and inferior thyroid ves- 
 sels are shown in a diagramatic manner. The stump 
 of the thyroid gland has been sutured with a few 
 fine catgut sutures as shown at the end of the 
 forceps (o). 
 
152 THYROID GLAND 
 
 The left lobe of the gland remains in its normal 
 condition and position. The superior thyroid artery 
 and vein are represented as entering the upper end 
 of this lobe, the muscles having been held back by 
 the retractors (3) and (3"). In case it is desired to 
 reduce the amount of blood supply for the remaining 
 lobe this can readily be accomplished by ligating the 
 superior thyroid vessels at this point. 
 
 In Plate 25, precisely the same conditions exist 
 with the exception that the muscles covering the an- 
 terior surface of the thyroid gland have simply been 
 drawn out of the way by sharp retractors (2) and 
 (2") below and (3) and (3") above. Here also the super- 
 ior and inferior thyroid vessels and the carotid artery 
 and deep jugular vein are represented with the fascia 
 entirely removed which is quite unnecessary. The 
 capsule (r) which has been dissected off the posterior 
 surface of the lobe which has been removed appears 
 thicker and more substantial than in the actual 
 operation, except in its lower half where quite a 
 layer of thyroid tissue is left for the protection of 
 the underlying structures. 
 
 If the operation has been performed with sufficient 
 care, the surface is usually quite free from blood. 
 If any small surface remains from which there is 
 general oozing, this can be controlled by the intro- 
 duction of a few fine catgut stitches tied just tightly 
 enough to stop the oozing but not with sufficient 
 force to cause pressure necrosis. It is, of course, im- 
 portant not to injure the parathyroid glands or the 
 recurrent laryngeal nerve in introducing these su- 
 tures but both can very readily be avoided with 
 proper care. 
 
PLATE XXIII 
 
 t lA I LnLJA 
 
 THE SAME AS PLATE XXII, WITH THE MUSCLES XOT SEVEEED BUT RE- 
 TRACTED. 
 
PLATE XXIV 
 
 THE RIGHT LOBE OF THE THYROID GLAND HAS BEEN REMOVED AND THE 
 PEDICLE SUTURED. 
 
THYROIDECTOMY 153 
 
 In order to prevent absorption of blood or thyroid 
 secretion from the wound surfaces some provision 
 must be made for drainage. It is best to drain 
 through a separate opening as shown in Plate 26, in 
 order that the line of suture may not be irritated 
 by the introduction of drainage along any portion of 
 its course. The drainage may be accomplished by a 
 simple glass drainage tube or by a rubber tube or by 
 the use of gauze surrounded with rubber tissue, the 
 cigarette drain, or a simple gauze drain may be 
 employed. 
 
 In our cases a combined drain composed of a 
 layer of gauze loosely packed into the wound left 
 after the removal of the lobe as shown at (s) , Plate 
 26, with the additional introduction of a glass drain 
 have been most satisfactory. Both the tube and the 
 gauze, the latter surrounding the former, should 
 be brought out at (p), Plate 28. It is best to place the 
 gauze in such a manner that it can be withdrawn 
 easily and without disturbing the tissues after first 
 withdrawing the glass tube. The latter should be 
 withdrawn on the second or third day after the 
 operation, and the gauze a day or two later. It is 
 important not to withdraw the gauze carelessly 
 because this may give rise to quite troublesome 
 haemorrhage which may clot underneath the skin 
 flap and which may ultimately cause quite a delay 
 in wound healing. 
 
 Plate 27 represents all of the muscles on the an- 
 terior surface of the neck again in position. It is 
 best to unite these muscles with a fine continuous 
 catgut suture. 
 
154 THYROID GLAND 
 
 Plate 28 represents the muscles on the left side of 
 the patient's neck already united, those on the right 
 side are still held apart in the grasp of forceps (b) and 
 (b'). The gauze drain (s) is in place and both this 
 and the glass drain are represented as issuing through 
 a small incision (p) about two c. m. below the trans- 
 verse portion of the horseshoe incision. Plate 29 rep- 
 resents all of the muscles sutured, the symmetry of 
 the neck having been quite as thoroughly restored 
 as in Plate 28. It is important to give attention to 
 these steps represented in Plates 27, 28 and 29, be- 
 cause this will prevent the very troublesome de- 
 formities which one is sure to encounter if this pre- 
 caution is not taken. 
 
 The only step remaining in order to complete the 
 operation is the closure of the principle incision as 
 shown in Plate 30. If only the skin suture is employed 
 there is usually a considerable amount of spreading 
 of the scar because of the traction on part of the 
 platysma myoides muscle. On the other hand if 
 the wound is closed by the sub-cuticular suture 
 alone, a rather unsightly thickening is likely to 
 occur at the line of suture. In order to avoid both 
 of these sources of annoyance it is advisable to place 
 about six interrupted sub-cuticular sutures of fine 
 catgut along the line of incision at regular intervals 
 uniting the platysma myoides and the sub-cutaneous 
 connective tissue. This will remove all tension from 
 the skin proper and will leave an almost invisible 
 line of suture provided silk or horsehair is used and 
 the edges are carefully and evenly united and the 
 sutures drawn just sufficiently tight to secure accurate 
 coaption but not to cause any pressure necrosis. 
 
PLATE XXV 
 
 THE SAME AS PLATE XXIV, WITH THE MUSCLES RETRACTED BUT NOT 
 SEVERED. 
 
THYROIDECTOMY 155 
 
 These sutures can be cut on the fourth or fifth day 
 which will prevent the occurrence of even the slightest 
 suture marks. 
 
 The operation which has just been described may 
 be employed with equal satisfaction in the removal 
 of portions of the thyroid gland for whatever con- 
 dition may demand this procedure. The operation 
 is, of course, more serious in proportion with the 
 severity of the pathological condition present in the 
 patient under consideration. Generally speaking, 
 in patients suffering from exophthalmic goitre this 
 condition makes the operation more serious than in 
 simple goitre and it may be well at this point to 
 insist upon the fact that although all of the steps 
 of the operation are relatively simple, still the opera- 
 tion itself must be looked upon as one of the serious 
 major surgical procedures which should not be un- 
 dertaken by inexperienced surgeons, because in- 
 many, possibly in most of these patients, there is 
 but a relatively narrow margin even with much ex- 
 perience and excellent skill and splendid surgical 
 judgment. It seems proper to direct attention to this 
 fact at this point because the low mortality of men 
 with great skill and remarkable judgment might 
 otherwise cause those not so well equipped to suffer 
 severe disappointment and the loss of many patients. 
 
 Ligation of Thyroid Vessels. Kocher has point- 
 ed out the fact that in many cases the patient 
 is too weak to bear the radical operation of thy- 
 roidectomy in cases of exophthalmic goitre. In all 
 of these cases an attempt must be made to build up 
 the patient's strength by rest, diet and the use of 
 appropriate remedies, but there are some cases 
 
156 THYROID GLAND 
 
 which seem to become worse constantly, notwith- 
 standing this treatment. In some instances the 
 patient's condition may be so bad that even the 
 slightest operation would result fatally, but there is 
 another class which will bear a very slight operation 
 but cannot bear the shock of thyroidectomy. In 
 this class of cases Kocher recommends the ligation 
 of one or more vessels as a preliminary operation. 
 This will reduce the production and absorption of 
 thyroid poison to a sufficient extent that the patient's 
 general condition may improve sufficiently to make 
 it safe to perform a more serious operation after a 
 few weeks of recuperation. 
 
 Not enough experience has been accumulated 
 to determine positively whether this plan should be 
 generally adopted. Kocher seems confident that it 
 is indicated in certain cases and his enormous ex- 
 perience and wonderful surgical judgment must 
 always carry more weight in this subject than that 
 of any other surgeon with the single exception 
 of Charles H. Mayo, consequently we must, for the 
 present, accept this view, although its correctness 
 has been questioned by many surgeons, no less an 
 authority than Landstrom among them. These sur- 
 geons have pointed out the fact that the mortality 
 after simple ligation has been greater than after ex- 
 cision of one lobe, but as the former operation is em- 
 ployed only in cases that are in an almost hopeless con- 
 dition while the latter operation is practiced in the less 
 serious cases no comparison can, of course, be made- 
 because the two operations are performed on patients 
 whose prognosis would be entirely different were 
 they operated for any other condition. Those upon 
 
PLATE XXVI 
 
 
 
 >vr 
 
 SHOWS THE OPERATION COMPLETED TO THE POINT OF CLOSING THE 
 WOUND. (S) GAUZE TAMPON; (p) SEPARATE OPENING FOR GLASS DRAIN AND 
 GAUZE. 
 
THYROIDECTOMY 157 
 
 whom the former operation is practiced would have 
 but a very slight chance of recovery after almost any 
 operation, while those subjected to the latter opera- 
 tion would be almost certain to recover from any 
 operation which would not in itself be dangerous. 
 
 Having accepted the theory that ligation in itself 
 is a less severe procedure than removal of one lobe, 
 we must choose between the various operations 
 which have been recommended, namely: The liga- 
 tion of as many arteries and veins as it seems safe 
 to ligate in any given case as recommended by 
 Kocher; the ligation of as many veins as seems safe, 
 as recommended by Tuholske; and the ligation of 
 both upper poles of the thyroid gland including 
 arteries, veins, and lymph channels by passing 
 double ligatures around the entire upper pole on 
 both sides, including the gland together with both 
 superior arteries and veins and the capsule as recom- 
 mended by Werelins and Jacobson. 
 
 Of these methods the one recommended by Kocher 
 has been employed most frequently. If it seems as 
 though the ligation of the superior thyroid vessels' 
 on one side is as much as the patient can safely en- 
 dure at the first sitting, then the skin is cocainized 
 along the anterior border of the sterno-cleido -mastoid 
 muscle from the point (a) or (b), Plates 2 and 30, 
 downward for a distance of five c. m. A puncture is 
 then made with a fine sharp scalpel through the skin 
 at the point (a) or (b) according to the side on which 
 there is the greatest amount of enlargement, then a 
 blunt-pointed hypodermic needle with a lateral 
 opening attached to a syringe containing the anaes- 
 thetizing solution is passed into the deep tissues 
 
158 THYROID GLAND 
 
 along the anterior border of the sterno-mastoid 
 muscle and a sufficient amount of fluid is injected to 
 thoroughly anaesthetize the tissue to be manipulated 
 later. After waiting for five minutes the skin is in- 
 cised, the muscles covering the anterior surface of 
 the lobe are retracted outward and the superior 
 •thyroid artery and vein are exposed, isolated and 
 elevated with a Kocher director either singly as 
 shown in Plate 22, or together. They are then caught 
 with two pair of haemostatic forceps and ligated as 
 shown at (e) and (e') and (e") and (e"'), Plate 13. 
 It is not necessary to expose the entire gland as shown 
 in these figures to accomplish this which can easily 
 be 4one through the incision described above. If 
 the patient is in a satisfactory condition after this 
 has been done on one side the same thing may be 
 done on the opposite side immediately. This is 
 usually the better plan because as has been shown 
 all of the arteries and veins of the thyroid gland are 
 so thoroughly anastomosed that the ligation of only 
 one of the four principle arteries and veins has but 
 little influence upon the production and absorption 
 of thyroid toxins while the ligation of both superior 
 thyroid arteries and veins seems ' to have a very 
 marked effect. Were it possible at the same time 
 to ligate also the inferior thyroid artery and vein on 
 one side the results would be still better, but the 
 amount of trauma inflicted by the ligation of one in- 
 ferior artery and vein is much greater than that re- 
 quired in the ligation of both sides above, hence, 
 most patients who are sufficiently strong to bear 
 the ligation of three sets of vessels are quite strong 
 
PLATE XXVII 
 
 ft 
 
 
 CHiCflOQ 
 
 THE MUSCLE IN FRONT OF THE THYROID GLAND HAS BEEN SUTURED. 
 
PLATE XXVIII 
 
 THE SAME AS PLATE XXVI, WITH THE ADDITION OF SUTURING THE MUS- 
 CLES WHICH HAD BEEN SEVERED TRANSVERSELY. 
 
THYROIDECTOMY 159 
 
 enough to bear the excision of one thyroid lobe at 
 the same time. 
 
 In case there is a sufficient amount of enlarge- 
 ment present to make it desirable to excise one 
 lobe later, it is probably better to make the incision 
 shown in Plates 22 and 30, and to turn up the flap as 
 shown in 'Plate 31, because the incision can be made 
 in a few moments entirely painless under local 
 anaesthesia. The ligation of the anterior jugular vein 
 as shown in Plates 31 and 32, will dispose of a greatly 
 enlarged vessel. The muscles anterior to the thyroid 
 gland can be separated easily and the ligation of 
 the superior thyroid vessels can be secured in a 
 shorter time than through two separate incisions. 
 At the same time a double suture may be passed 
 around a number of the superficial branches of the 
 inferior thyroid vessels on the side on which the gland 
 is enlarged. The flap can be brought down into place 
 after all this has been accomplished and held in 
 proper position by the insertion of from four to 
 eight fine catgut sutures which grasp the platysma 
 and the sub-cutaneous connective tissue. 
 
 This operation requires somewhat less skill than 
 the one first described. In case the gland is not 
 sufficiently enlarged on either side, however, to in- 
 dicate its removal it is not necessary to make this 
 long incision. On the other hand if it is desirable to 
 remove an enlarged lobe, the patient will usually 
 be in condition to have this secondary operation 
 made in from one to two weeks, when the flap can 
 be turned up again and the operation for excision 
 of the thyroid gland which has already been fully 
 described, may be performed. 
 
160 THYROID* GLAND 
 
 Ligation of Thyroid Veins. It has been sug- 
 gested by Tuholske that the ligation of the thyroid 
 veins would reduce the introduction of thyroid 
 poison into the general circulation to such an extent 
 that the hyperthyroidism of exophthalmic goitre 
 would be abolished while there would be no danger 
 of myxoedema because the gland itself would not 
 be removed. This theory seems to be borne out by 
 the clinical observations as set forth in this most 
 interesting article and it is possible that the opera- 
 tion suggested will receive a recognized position 
 after it has been tested for a sufficient period of time. 
 At this time it seems of sufficient importance to de- 
 mand our consideration. 
 
 Operation. An incision is made as indicated in 
 Plates 2 and 30, the flap of skin and platysma is re- 
 flected as shown in Plate 32, and the sternohyoid, 
 sternothyroid and omohyoid muscles are retracted as 
 shown in Plates 31 and 32. The anterior jugular vein 
 and its branches areligated, then the two superior thy- 
 roid veins are isolated, the Kocher director is. in- 
 serted underneath each vein and two haemostatic 
 forceps are applied as shown in (e) and (e'), Plate 14, 
 the veins are severed and ligated as shown in Plates 
 31 and 32. It is a relatively easy matter to ligate the 
 superior thyroid veins because they are quite super- 
 ficial and easily-isolated. The inferior thyroid veins 
 on the other hand cannot be isolated so easily be- 
 cause they enter the gland from behind and it is 
 consequently necessary to lift the lower border of 
 the gland forward in order to expose these veins. 
 In discussing the excision of the lateral 'lobe of the 
 thyroid gland it was shown that by first ligating the 
 
PLATE XXIX 
 
 CHICAGO 
 
 THE SAME AS PLATE XXVII, WITH THE ADDITION OF SUTURING ALL MUS- 
 CLES WHICH HAD BEEN SEVERED TRANSVERSELY. 
 
PLATE XXX 
 
 SHOWS THE EXTERNAL WOUND COMPLETELY CLOSED, WITH DRAINAGE 
 TUBE AND GAUZE ISSUING FROM THE SEPARATE INCISION BELOW AT (p). 
 
THYROIDECTOMY 161 
 
 superior thyroid vessels and dislocating the lobe for- 
 ward it is not very difficult to ligate the inferior 
 thyroid vessels, although there is great danger of in- 
 juring the recurrent laryngeal nerve and the para- 
 thyroid gland on the side involved. 
 
 It is much more difficult to isolate the inferior 
 thyroid vein when the superior thyroid artery has 
 not been severed and this difficulty increases with 
 the size of the lobe, but as this operation is indicated 
 only in cases in which the excision of the lobe need not 
 be considered because of its enlargement one will, 
 of course, not be called upon to ligate the inferior 
 thyroid veins in any case in which there is a consider- 
 able enlargement of either lobe, but only in cases 
 in which the symptoms of exophthalmic goitre exist 
 without much enlargement of the thyroid gland. 
 
 In this class of cases it is possible to draw forward 
 the lower border of the gland sufficiently to isolate 
 the inferior thyroid vein as shown in Plates 31 and 32, 
 and to elevate it as shown at (n) with a Kocher 
 director. Then two forceps are applied as shown at 
 (m) and (m / ), the vessel is cut and ligated as shown at 
 (m") and (m" ') . The vein is located to the inner 
 side of the artery and is not in as close relation to the 
 recurrent laryngeal nerve as the latter, hence, the 
 operation is easier and safer than the ligation of the 
 inferior thyroid artery. In ligating the inferior 
 thyroid artery it is always necessary to expose the 
 recurrent laryngeal nerve because it is only by doing 
 this that one can be certain that the latter is not in- 
 jured during some part of the manipulation. In 
 ligating the inferior thyroid vein, on the other hand, 
 it is necessary only to expose the structure carefully 
 
162 THYROID GLAND 
 
 on the Kocher director as shown in Plates 31 and 32, 
 in order to avoid injuring either the recurrent laryn- 
 geal nerve or the parathyroid gland. In ligating the 
 inferior thyroid artery it is also important to ligate 
 near the entrance of this vessel into the gland in 
 order not to ligate the branch which sometimes sup- 
 plies the parathyroid gland. It is not necessary to 
 take a corresponding precaution in ligating the in- 
 ferior thyroid vein. 
 
 What has just been said would indicate that this 
 operation requires much surgical skill and anatomic 
 familiarity aside from that absolutely required in 
 performing thyroidectomy, but if the results will 
 justify the operation it will not be difficult to acquire 
 these. 
 
 The closure of the wound should be the same as 
 described in connection with Plate 30. It is not 
 necessary, however, to make so extensive a flap 
 in order to perform this operation." The superior 
 thyroid veins can be ligated through two incisions 
 parallel with the anterior border of the sterno- 
 cleido-mastoid muscle five c. m. long, extending 
 downwards from (a) and (b), Plates 2 and 20, and 
 the inferior thyroid and the anterior jugular veins 
 can be ligated through a transverse incision five cm. 
 long occupying the portion of the incision represented 
 in Plates 2 and 20, passing across the middle of the 
 neck. The deformity following the closure of these 
 three incisions or the horseshoe incision is very 
 slight in these cases if the platysma and sub-cutan- 
 eous connective tissue are sutured separately as 
 described in connection with the previous operation. 
 
PLATE XXXI 
 
 SHOWS THE ENTIRE ANTERIOR SURFACE OF THE THYROID GLAND EXPOSED, 
 WITH THE SUPERIOR THYROID VEINS CUT AND LIGATED AND THE INFERIOR 
 ONES CAUGHT IN HAEMOSTATIC FORCEPS AND CUT ON THE LEFT SIDE AND 
 ISOLATED WITH KOCHER DIRECTOR ON THE RIGHT SIDE. 
 
PLATE XXXII 
 
 THE SAME AS PLATE XXXI, WITH THE MUSCLES NOT CUT BUT SIMPLY 
 RETRACTED. 
 
CHAPTER IX. 
 
 OTHER OPERATIONS ON THE 
 THYROID GLAND. 
 
 Ligation of the Superior Poles. Ligation of 
 both superior poles of the thyroid gland has been 
 developed and practiced by J. H. Jacobson of To- 
 ledo, Ohio, at the suggestion of M. Stamm, of Fre- 
 mont, Ohio, for the cure of exophthalmic goitre. 
 So far eight cases have been operated by this method. 
 The underlying theory for this operation is based 
 upon the fact that by ligating both upper poles of 
 the thyroid gland in patients suffering from exoph- 
 thalmic goitre, the gland is not only deprived of its 
 most important blood supply, but the lymph channels 
 through which the greatest portion of the thyroid 
 secretion is supposed to reach the general circulation 
 are included in the ligature and permanently in- 
 terrupted. The results in all of the cases, with one 
 exception, in which the operation was performed in 
 a patient who was moribund at the time of operation 
 have been most satisfactory. Of course, the number 
 of patients is not sufficiently large, and the time ex- 
 pired since the operation is as yet too short to make 
 a final judgment as to its value possible, but there 
 seems to be enough in its favor to demand our care- 
 ful consideration. 
 
 Stamm- Jacobson Operation. One upper pole of 
 the gland is located by palpation and exposed by an 
 
164 THYROID GlvAND 
 
 incision from two to four c. m. in length through 
 the skin, superficial fascia, and platysma exposing 
 first the anterior border of the sterho-cleido-mastoid 
 muscle directly overlying the pole. The authors 
 make a transverse incision but as this leaves a more 
 unsightly scar on the neck than an incision parallel 
 with the anterior border of the sterno-mastoid muscle, 
 the latter incision would be preferable in this as well 
 as in the two operations just described. 
 
 The inner border of the sterno-mastoid is then 
 loosened, raised and retracted exposing the fibres 
 of the sternothyroid muscle which extend in the 
 opposite direction. These fibres are retracted for 
 about one inch exposing the deep fascia covering 
 the thyroid gland. This fascia is next divided and 
 the capsule of the gland brought into view. The 
 muscles are well retracted by blunt hooks. A strong 
 double ligature is then passed around the pole of 
 the gland outside of the capsule by means of a 
 ligature carrier, or a large pedicle or aneurism needle. 
 The authors advise the use of heavy silk or linen 
 ligatures because of the slowness with which these 
 are absorbed. The two ligatures are separated one 
 to one and one-half c. m. from each other and tied 
 very firmly. Immediately after the ligation the 
 tissues between and in the vicinity of these ligatures 
 becomes very severely blanched and undoubtedly 
 the tissue between the two ligatures will become 
 absorbed, permanently disposing of the arteries, 
 veins and lymph channels in both upper poles of the 
 thyroid gland. 
 
 Plate 33 represents the appearance of each pole 
 with the double ligature in place. In the actual oper- 
 
PLATE XXXIII 
 
 SHOWS THE LIGATION Of BOTH SUPERIOR POLES OF THYROID GLAND. 
 
OTHER OPERATIONS ON THE THYROID GLAND 165 
 
 ation the structures would, of course, not be exposed 
 as thoroughly, as the operation is performed 
 through a small incision, ' the extensive exposure 
 shown in this figure not being necessary. If one 
 does not injure the deep jugular vein or the carotid 
 artery externally no harm is likely to be done by 
 the passage of the ligature. In some instances it 
 is difficult to pass the ligature because of the ad- 
 hesions between the upper pole of the gland and 
 the surrounding structures, especially on the outer 
 side, but by a slight amount of blunt dissection this 
 difficulty can readily be overcome. 
 
 This operation promises much but only careful 
 observation of a large number of cases can deter- 
 mine its actual value. 
 
 Enucleation of Thyroid Tumors. Occasionally 
 the surgeon encounters a circumscribed tumor in 
 one of the lobes of the thyroid gland which may 
 suggest its removal without excising the lobe in 
 which this is found. 
 
 .Usually the lobe contains a number of these en- 
 larged lobules or cysts, and one can confidently ex- 
 pect that the removal of the large cyst will be fol- 
 lowed by the development of others. 
 
 It is consequently wise to make an enucleation 
 only in cases in which there is actually a solitary 
 cyst or a solitary fibroma. The operation is usually 
 safe and simple and readily carried out. 
 
 Operation. An incision is made over the most 
 prominent portion of the gland directly over the 
 cyst parallel with the natural lines of the neck. The 
 muscles are separated and held apart with retractors. 
 The vessels on the surface of the gland are caught 
 
166 THYROID GLAND 
 
 with two pairs of forceps, cut and ligated doubly. 
 Then the incision is carried down to the cyst through 
 the substance of the gland. The cyst wall can be 
 recognized by the abundance of connective tissue 
 fibres it contains. 
 
 It is then enucleated either with the finger or by 
 means of a blunt dissector. The cavity is tamponed 
 with a hot gauze pad. If there are any vessels that 
 continue to bleed these are caught with haemostatic 
 forceps and ligated or a few fine catgut sutures are 
 applied. Occasionally, though rarely, the haemorr- 
 hage is so severe that the superior or inferior thy- 
 roid vessels have to be ligated and sometimes thy- 
 roidectomy must be made. 
 
 The cavity is then tamponed with gauze and a 
 glass drain is inserted and the wound is closed. In 
 this and in the previous operations the glass drain 
 introduced by Kocher is most satisfactory. 
 
 Malignant Growths of the Thyroid Gland. Car- 
 cinoma of the thyroid is far more common than 
 sarcoma, but as both conditions are hopeless so far 
 as treatment is concerned, when advanced far enough 
 to be diagnosed, it might be proper to consider 
 these conditions together. 
 
 In a number of cases in which a thyroidectomy 
 has been performed for the relief of simple goitre 
 in which a postoperative microscopic examination 
 has demonstrated the presence of carcinoma, the 
 patient has remained free from recurrence because 
 of the fact that the growth had not as yet ad- 
 vanced beyond the limits of the gland at the time 
 it was removed. 
 
OTHER OPERATIONS ON THE THYROID GLAND 167 
 
 In a structure with such complete anastomosis of 
 arteries and veins and as vascular as this structure 
 no other outcome could be expected. Unless some 
 reliable plan for making a diagnosis is introduced 
 which will demonstrate the presence of malignancy 
 in the enlarged gland before it can be recognized by 
 the unaided senses, we are not likely to be able to 
 make a favorable prognosis in cases of carcinoma or 
 sarcoma of the thyroid gland. At present it seems 
 possible that some cytolitic method may be devel- 
 oped which will make it possible to recognize the 
 presence of carcinoma during its earliest stages, but 
 as yet this has not been perfected. 
 
 In carcinoma the gland is enlarged, somewhat 
 nodulated, usually very sessile and there is a distinct 
 •tendency toward infiltration of surrounding tissues. 
 Fig. 20 represents a patient suffering from carcinoma 
 of the right breast and carcinoma of the thyroid 
 gland. The picture shows how the nipple is retracted, 
 and in the neck one can see how the skin is becoming 
 involved by the invasion from below causing the 
 latter to become adherent, indurated and retracted 
 in places. 
 
 Later on there is usually marked obstruction to 
 the venous circulation so that the veins stand out 
 to a marked extent in the vicinity of the gland as 
 shown in Figs. 21 and 22. 
 
 This condition can occasionally be mistaken for a 
 sub-acute inflammation of the gland which is called 
 strumitis when it occurs in a gland which had pre- 
 viously been enlarged, or thyroiditis if it occurs in 
 a gland previously normal. In rare cases this con- 
 dition may be due to tuberculosis of the gland. 
 
168 
 
 THYROID GLAND 
 
 This can be determined by the use of the tuberculin 
 test. In four cases I have encountered an infection 
 in a carcinomatous thyroid gland, consequently it 
 is not safe to give a favorable prognosis because of 
 the undoubted presence of an infection, because the 
 proximity of the trachea and larynx makes an in- 
 fection very possible in carcinoma. This complica- 
 tion is very likely to cause an obstruction of the 
 
 Fig. 20. Carcinoma of thyroid gland and of right breast. 
 
 larynx threatening the patient's life by suffocation. 
 In this complication intubation or tracheotomy may 
 be indicated but it is usually best simply to give a 
 sufficient amount of anodynes to relieve the patient's 
 suffering. 
 
 The growth may increase rapidly in size or it may 
 remain almost stationary for weeks or months, or in 
 rare instances even for years. When operated upon, 
 however, there seems to be a rapid increase in size. 
 It seems wise to remove the entire lobe and the isth- 
 
OTHER OPERATIONS ON THE THYROID GLAND 169 
 
 mus of every goitre in patients forty years of age or 
 older in whom one suspects the possibility of the 
 occurrence of malignancy, because in this way it will 
 undoubtedly be possible to remove a number of 
 incipient carcinomata permanently. The operation 
 is safe and the patient will be relieved of pressure 
 and of a repulsive deformity, and may be saved the 
 development of an incurable carcinoma. 
 
 It is not always possible to make a differential 
 diagnosis between carcinoma and sarcoma of the 
 thyroid gland but what has been said concerning the 
 hopelessness of the former may properly be repeated 
 concerning the latter. In my experience sarcoma 
 has grown more rapidly than carcinoma. The skin 
 has remained free from the underlying tumor and 
 the surface of the growth has presented lobes rather 
 than nodules. Figs. 23 and 24 represent a typical 
 advanced case. 
 
 In one case of rapidly advancing carcinoma of the 
 thyroid gland in a woman fifty-eight years of age, 
 who came under my care two years ago, the patient's 
 condition was so severe from pressure upon the 
 trachea that she was placed in the hospital where 
 an intubation or a tracheotomy could be made at 
 any moment. In the meantime twenty-minute ex- 
 posures were made with the x-ray daily with a 
 moderately hard tube at a distance of twelve inches. 
 Within a week the patient could breathe without 
 gasping, in a month she could lie down and there 
 was a slight reduction in the size of the growth and 
 then it became stationary, and somewhat softer. It has 
 remained in this condition for eighteen months with- 
 out treatment. None of the other cases have re- 
 
170 . THYROID GLAND 
 
 sponded in this manner. In sarcoma it may be ad- 
 visable to employ the x-ray and possibly also Coley's 
 serum, but all advanced cases must be looked upon 
 as practically hopeless. 
 
 Transplantation of the Thyroid Gland. Experi- 
 mentally it has been shown that the thyroid 
 gland can be transplanted from its normal position 
 
 Fig. 21. Anterior view of carcinoma of thyroid gland showing 
 greatly enlarged veins. 
 
 to other portions of the body of the same animal, or 
 it may be transplanted from one animal to another 
 of the same species. Many locations were chosen by 
 various authors. Kocher transplanted a thyroid 
 gland under the skin of the neck ; Von Eiselberg into 
 the peritoneal space ; Payr into the spleen ; Serman 
 made a cavity in the tibia and transplanted the gland 
 
OTHER OPERATIONS ON THE THYROID GLAND 171 
 
 into this space. Schiff demonstrated in the year 1884 
 that it is possible to keep animals alive whose thy- 
 roid glands had been removed by transplanting the 
 thyroid gland of the same species of animal into 
 some portion of this animal, while other similar 
 animals invariably died of myxcedema after com- 
 plete thyroidectomy without transplantation. The 
 histological examination of the transplanted gland 
 has shown that a portion of the tissue is invariably 
 absorbed. It has been found that rapid transplanta- 
 tion and aseptic healing decreases the amount of 
 degeneration and that it is important not to injure 
 the tissues of the gland by violent manipulations. 
 Experiments have been made by injecting crushed 
 thyroid substance sub-cutaneously or interstitially 
 with the idea of supplying thyroid tissue to the 
 patient without the necessity of subjecting her to an 
 operation which in itself would subject the patient 
 to a considerable strain. 
 
 Should we attempt to discuss the subject of trans- 
 plantation of the thyroid gland in all of its phases 
 too much space would have to be consumed and there 
 would not be much practical advantage gained by 
 this as these experimentations and clinical studies 
 have not as yet reached a point where it would be 
 proper to draw positive conclusions upon which one 
 could reasonably base therapeutic practice. Salzer 
 has recently reviewed this subject most carefully 
 and has made a large number of most interesting 
 animal experiments based chiefly upon the observa- 
 tions and experiments of von Eise]berg, Enderlen, 
 Christens, Payr, Sultan and others, and it has seemed 
 to me that for the present it will be wise to accept 
 
172 
 
 THYROID GLAND 
 
 his view of this subject because he has reviewed the 
 subject in a most logical manner and supports his 
 views by definite postmortem findings in a sufficient 
 number of animal experiments to make his theories 
 plausible. 
 
 Salzer finds that in transplanting the thyroid gland 
 into animals that have been completely deprived 
 
 
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 1 
 
 
 
 
 | 
 
 
 
 
 V b f ■ 
 
 
 
 ! 
 
 
 
 
 L iLiJ 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 ^- I 
 
 
 \ — 
 
 
 H^i 
 
 i 
 
 i m 
 
 \ 
 
 
 . > 
 
 
 
 
 Fig. 22. Shows a lateral view of the same case. (Fig. 21.) 
 
 of this structure, the transplanted gland becomes an 
 active part of its new host or of its old host in any 
 location more quickly than it does if the animal has 
 been deprived of only a portion of its thyroid gland 
 or if its thyroid gland has not been disturbed. More- 
 over, the amount of degenerative changes under the 
 former condition is much less than under the latter. 
 In other words, the tissues of the animal seem to 
 
OTHER OPERATIONS ON THE THYROID GLAND 173 
 
 require the active thyroid gland as a part of the 
 organism and when this has been removed from its 
 normal location there seems to be an inherent 
 tendency to provide for its participation in the 
 physiological activity of the tissues of the body at 
 the earliest possible moment. He also finds that 
 under this condition the gland which has been trans- 
 planted to the abdominal wall actually takes up its 
 physiological function, that the production of colloid 
 substance is sufficient and that the vascularization 
 of the gland equals that in its normal location. He 
 favors the abdominal wall for the location because 
 his experiments have demonstrated this to be satis- 
 factory and because it is a simple surgical procedure 
 which is perfectly safe and can, of course, be re- 
 peated in case it becomes apparent that the amount, 
 of thyroid tissue transplanted at first is not suffi- 
 cient to supply the physiological needs of the patient 
 which would become apparent by the recurrence of 
 symptoms of myxoedema. 
 
 It seems likely that this method will be applicable 
 in cases of myxoedema and especially in cretinism. 
 The method employed in animal experimentation 
 could be applied to these cases. 
 
 Technic of Transplantation of Thyroid Gland. 
 The patient into whose body the gland is to be trans- 
 planted and the one from whom one lobe of the 
 thyroid gland is to be removed are both anaesthetized 
 simultaneously. An* incision is then made splitting 
 one of the recti muscles of the abdomen longitudin- 
 ally through its middle for a distance of ten to 
 twelve c. m. according to the size of the gland to be 
 transplanted. All of the bleeding vessels are then 
 
174 
 
 THYROID GLAND 
 
 caught in haemostatic forceps. A space is formed by 
 the separation of the rectus abdominis muscle from 
 the transversalis fascia sufficiently large to con- 
 veniently hold the gland to be transplanted, care 
 being taken not to injure the deep epigastric vein 
 which lies between these structures and is especially 
 liable to injury because of the thinness of its walls. 
 A pad of gauze wrung out of warm normal salt solu- 
 tion is now packed into this space in order to control 
 
 Fig. 23. Shows anterior view of sarcoma of thyroid gland. (By- 
 courtesy of Prof. Carl Beck.) 
 
 the oozing from the small vessels by its pressure. 
 The salt solution should not be warmer than 105° F. 
 in order not to impair these surfaces. Interrupted 
 silkworm gut sutures are now applied but not tied, 
 then the outer wound is covered with gauze and the 
 wound is left until the gland has been removed. In 
 removing the gland the technic described in the 
 chapter on thyroidectomy should be followed, great 
 care being taken to handle the organ with the great- 
 est degree of gentleness. It is at once placed in its 
 
OTHER OPERATIONS ON THE THYROID GLAND 175 
 
 new cavity as soon as it has been removed without 
 coming in contact with any fluid, antiseptic or other- 
 wise. While an assistant completes the operation on 
 the second patient, the surgeon adjusts the gland 
 to the space between the rectus abdominis muscle 
 and transversalis fascia of the new host and fastens it 
 in this place at a few points with fine catgut sutures 
 tied loosely in order to prevent pressure necrosis. 
 Then the abdominal wall is closed with catgut sutures 
 and the silkworm gut sutures are tied over all. 
 
 Selection of Material. Of ' course the same care 
 must be taken in selecting material that one would 
 employ in the transfusion of blood from one individual 
 to another. It seems wise to choose a healthy in- 
 dividual and possibly to make serum tests for tuber- 
 culosis and syphilis and possibly for carcinoma. It 
 seems that a simple hypertrophy would provide the 
 best material and whether a cystic goitre or an ex- 
 ophthalmic goitre could properly be employed, future 
 experimentation must determine. 
 
 That this operation can be performed successfully 
 on human patients has been demonstrated by von 
 Eiselberg and by Kocher. It has been suggested 
 that this form of treatment should be employed in 
 place of giving thyroid glands or thyroid extract in 
 patients suffering from myxoedema from any cause 
 and in cases of cretinism. The material for trans- 
 plantation is no longer scarce since the operation of 
 thyroidectomy has become so common. It is con- 
 sequently to be expected that the next few years will 
 demonstrate what can be expected from this method. 
 At the present time the internal use of preparations 
 made from thyroid glands has resulted in remarkable 
 
176 THYROID GLAND 
 
 improvement in the growth and development of 
 cretins, but these results have been satisfactory 
 rather from an experimental point of view than from 
 the standpoint of improving these patients as hu- 
 man beings, because in most instances they have 
 simply been changed from small deformed repulsive 
 but harmless creatures to larger, less deformed, less 
 repulsive, troublesome imbeciles. It is to be hoped 
 
 Fig. 24. Shows lateral view of sarcoma of thyroid gland. 
 
 that better results may be obtained by transplanting 
 thyroid glands. 
 
 Mr. Lynn Thomas, of Cardiff, has transplanted 
 tissue from an enlarged thyroid gland removed from 
 otherwise normal patients into cavities formed in 
 the tibias of four cretins. In all of these patients 
 thyroid extract had previously been given with 
 benefit but as soon as this was interrupted the 
 patients became worse. Since the transplantation of 
 thyroid gland substance these patients have not be- 
 come worse notwithstanding the fact that the ad- 
 
OTHER OPERATIONS ON THE THYROID GLAND 17/ 
 
 ministration of thyroid extract was interrupted 
 permanently. 
 
 It does not seem quite clear why one should un- 
 dertake so tedious an operation as Thomas has de- 
 scribed, when experiments in animals have given 
 equally satisfactory results when the thyroid gland 
 was transplanted between the posterior surface of 
 the rectus abdominis muscle and the transversalis 
 fascia. 
 
CHAPTER X. 
 
 PROGNOSIS IN EXOPHTHALMIC GOITRE. 
 
 There can be no doubt but what the prognosis 
 in Graves' disease has improved enormously during 
 the past few years and that this improvement is due 
 very largely to the recognition by Moebius of the 
 fact that the disease is due to the circulation in the 
 blood of toxic material secreted by the thyroid 
 gland under certain conditions. Founded upon this 
 theory the improvement in prognosis . is due to 
 recognition of the fact that the cause of this intro- 
 duction of toxic material into the circulation can 
 be stopped by the removal of the diseased gland. 
 That this can be done safely in over 95 per cent, of 
 all cases has been thoroughly demonstrated. 
 
 It seems likely that the prognosis in this disease 
 will be still further improved in the future, primarily 
 because the diagnosis will usually be made much 
 earlier while it will still be possible to obtain a rela- 
 tive cure of the patient before great harm has been 
 done, especially to the heart muscle. Moreover, it 
 is to be expected that some neutralizing antitoxin 
 will be introduced which will make the thyroid 
 poison harmless even in advanced cases, a quality 
 which is claimed at the present time for the serum 
 of Beebe in early cases and also for the substance de- 
 
PROGNOSIS IN EXOPHTHALMIC GOITRE 179 
 
 rived by Moebius from thyroidectomized goats to 
 which has been given the name of antithyroidin. 
 
 In a recent report on the treatment of 426 cases 
 by his serum, Beebe expresses his satisfaction with 
 first introduction of his method. He is carefully ob- 
 serving these cases and if they remain permanently 
 well for several years the method will undoubtedly 
 receive general adoption. If, on the other hand, these 
 cases ultimately come to operation, the latter form 
 of treatment will surely be applied earlier in these 
 cases. 
 
 There is undoubtedly a marked difference in the 
 gravity of the prognosis between cases which begin 
 slowly and progress in the same gradual manner and 
 those which come on acutely and progress rapidly. 
 The latter are far more grave. But even these cases 
 are not so absolutely hopeless at present as they 
 were some years ago since Kocher has pointed out 
 a way of reducing the absorption by preliminary 
 ligation of veins and by checking the secretion of 
 more toxin by simultaneously ligating the accom- 
 panying arteries, and later removing one or more 
 lobes of the gland if necessary. This is referred to 
 at this point only because of its relation to prog- 
 nosis and has been fully discussed in the chapters on 
 operative treatment. Most clinicians seem to find 
 that the prognosis is less hopeful in men than in 
 women. Whether this depends upon the fact that 
 men place greater strain upon the heart than do 
 women before they come under observation, or 
 upon the fact that in men the heart has so fre- 
 quently suffered from the effects of alcohol or to- 
 
180 THYROID GLAND 
 
 bacco or both, or upon some other condition it 
 seems difficult to determine. 
 
 My own experience bears out the general impres- 
 sion that the disease is more serious in men than in 
 women. In a general way also the prognosis becomes 
 more grave with the increase in the age of the pa- 
 tient although many patients quite advanced in 
 years have recovered, some of these with and some 
 others without surgical treatment. 
 
 Again it must be borne in mind that very chronic 
 cases which have shown little or no change for 
 months or years may flare up suddenly and take 
 upon themselves quite as violent a character as other 
 cases that started very acutely and developed into 
 a violent condition very rapidly. On the other hand 
 one may occasionally encounter one of these very 
 acute violent cases which will later take upon itself 
 a very mild chronic condition. 
 
 If there are a number of conditions which greatly 
 depress the patient, such as severe diarrhoea, violent 
 sweats, nausea, or extreme weakness, the condition 
 should be looked upon as grave. When serious heart 
 symptoms are accompanied by great emaciation one 
 should always give a guarded prognosis. Severe in- 
 tercurrent diseases and especially severe mental or 
 emotional strain make the prognosis more grave. 
 
 In reviewing the actual statistics of various au- 
 thors one is impressed most forcibly with two ele- 
 ments. First, that the immediate results with all au- 
 thors have improved enormously with each individual 
 observer's experience, and second that no one with 
 the exception of Kocher has even a considerable 
 number of cases that have been carefully observed 
 
PROGNOSIS IN EXOPHTHALMIC GOITRE 181 
 
 for a number of years after recovery. This applies as 
 well to cases that have been treated with hygiene, 
 diet, and internal medication as it does to those cases 
 which have been treated by surgical operation. 
 
 I have introduced a history blank for use in these 
 cases which when carefully filled contains all im- 
 portant facts systematically arranged so that there 
 is uniformity in all of these histories. It seems as 
 though it would be well worth while to collect sta- 
 tistics for a period of ten years of all of these cases 
 that are under treatment by careful clinical observers. 
 This would then serve as a basis for reasonable con- 
 clusions. It is likely that some other clinicians can 
 suggest a much more complete scheme for making 
 such observations but in the meantime I will offer 
 the following form: 
 
182 THYROID GLAND 
 
 HISTORY BLANK FOR EXOPHTHALMIC GOITRE No. 
 
 Date of admission Date of operation 
 
 Date of discharge Age Sex 
 
 Nativity Occupation 
 
 Name Address 
 
 Name of friend Address of friend 
 
 Name of family Dr Address of Family Dr 
 
 Diagnosis clinical 
 
 Diagnosis pathological 
 
 Family history 
 
 Previous history 
 
 Personal history 
 
 Date of first symptoms of goitre 
 
 Date of first symptom of exophthalmic goitre 
 
 Exciting cause of exophthalmic goitre 
 
 Influenced by adolescence? Pregnancy? 
 
 Puerperium? Infection? 
 
 Strain? Nervous? Mental? 
 
 Emotional? Onset Acute? Sub-acute? 
 
 Gradual? Continuous? 
 
 Intercurrent diseases 
 
 Symptoms and physical findings, goitre? 
 
 Lobes involved Degree? 
 
 Exophthalmos? Stellwag? VonGraefe? 
 
 Moebius? Pupils? 
 
 Ophthalmoscopic findings.." 
 
 Heart 
 
 Tachycardia? Character of pulse? 
 
 General strength? Respiration? Nutrition? 
 
 Tremor? Muscle spasm? 
 
 Chorea? Mental symptoms? 
 
 Sweating? Pigmentation? Hypersemia? 
 
 Anasarca? Ascites? 
 
 Blood H»m.? R. B. C W. B. C : 
 
 Polymorph. Leuc Lymph 
 
 Trans Eos 
 
 Urine Sp. gr Alb 
 
 Sugar? Casts? 
 
 Larnyx. Before Oper After Oper 
 
 Course of disease 
 
 Course after operation 
 
 Condition when discharged 
 
 Condition one year later 
 
 Condition two years later 
 
 Condition three years later 
 
 Condition four years later 
 
 Condition five years later 
 
PROGNOSIS IN EXOPHTHALMIC GOITRE 
 
 183 
 
 GOITRE 
 
 Before Oper. 
 
 After Oper. 
 
 Remarks 
 
 How long present 
 
 Exophthalmos 
 
 Tachycardia 
 
 Tremor..... 
 
 Muscular weakness 
 
 Nervous excitability 
 
 Mental deficiency 
 
 Vertigo 
 
 Graefe's sign 
 
 Stellwag's sign 
 
 Moebius' sign 
 
 Bryson's sign 
 
 Intermittent Conditions. 
 
 Vomiting 
 
 Diarrhoea 
 
 Mental depression 
 
 Exacerbation upon 
 
 Psychic excitation 
 
 Physical fatigue 
 
 Mental fatigue 
 
 Use of Thyroid extract... 
 
 Use of Iodine 
 
 Emaciation 
 
 Anaemia 
 
 Myxoedema 
 
 Oedema eyelids 
 
 Oedema extremities 
 
 Oedema circumscribed... 
 Visible pulsation goitre.. 
 
 Pigmentation skin 
 
 Erythema. 
 
 Blushing 
 
 Urticaria 
 
 Enlarged lymph nodes .. 
 
184 THYROID GLAND 
 
 From what has been said it is plain that it would 
 not be profitable at this point to give much space to 
 the actual statistics relating to the prognosis of ex- 
 ophthalmic goitre, because the older ones are in no 
 way indicative of the results one may expect from 
 treatment today and the newer statistics have no 
 value as regards the most important question of 
 what becomes of these patients a considerable num- 
 ber of years after the treatment has ceased in pa- 
 tients that have been treated by various methods. 
 
 For statistics regarding the prognosis of cases 
 treated by internal methods I will quote Forch- 
 heimer who has personally treated 56 cases described 
 in another chapter of this book, consisting in the 
 administration of five grains of hydrobromate of 
 quinine four times daily to which one grain of ergo- 
 tine is added to each dose if the quinine alone does 
 not give some relief in forty-eight hours. This method 
 has also been employed by J. M. Jackson and L. M. 
 Mead in the outpatient department of the Massa- 
 chusetts General Hospital in eighty-five cases with 
 the remarkable result of 76. per cent, cures, 13 per 
 cent, benefited and 11 per cent, failures. There can 
 be no doubt but that operative treatment of the 13 
 per cent, that were benefited but not cured and the 
 11 per cent, that were failures would result in a cure 
 of at least 90 per cent, of these cases so that first 
 treating all of these cases medicinally until it can 
 be determined which will be cured by this method 
 and then treating those that do not respond satis- 
 factorily surgically, the entire mortality will probably 
 sink below three per cent, in cases not complicated 
 with other diseases. This would, of course, presup- 
 
PROGNOSIS IN EXOPHTHALMIC GOITRE 185 
 
 pose an early diagnosis in all cases and an early 
 transfer to surgical treatment of all cases not bene- 
 fited by internal treatment. Any intercurrent dis- 
 ease may, of course, bring about a recurrence in 
 cases which have apparently been well for a shorter 
 or longer period precisely as this can be brought 
 about by severe fright, unusual physical exertion, or 
 mental or emotional strain. Moreover, there can be 
 no doubt but that patients who have suffered from 
 this disease and have actually recovered have less 
 resistance in case of any subsequent sickness than 
 others who have not previously suffered in this way 
 even though there may be no recurrence of exoph- 
 thalmic goitre during the period the patient suffers 
 from the later disease. 
 
 Before leaving the discussion of prognosis of ex- 
 ophthalmic goitre following internal treatment it 
 may be well to point out the fact that the cases in 
 which cures have been recorded have usually not 
 been kept under observation for a sufficient number 
 of years to make the statistics absolutely satisfactory, 
 although in this result they are no more imperfect 
 than are the statistics following surgical operations. 
 In either case it seems of the greatest importance to 
 assist these patients in planning their lives so that 
 all strain, physical as well as mental and emotional 
 be eliminated to the greatest possible extent. This 
 element will undoubtedly do much to improve the 
 prognosis in these cases. This is of greater import- 
 ance in cases in which non-surgical treatment has 
 been employed because in cases having undergone 
 surgical treatment the amount of thyroid tissue has 
 been reduced to so marked an extent that the flood- 
 
186 THYROID GLAND 
 
 ing of the circulation with an abnormal amount of 
 thyroid secretion from the remnant of the gland 
 is less easily accomplished than from the entire 
 gland in cases not operated. 
 
 The prognosis in cases treated with serum is still 
 more uncertain than in cases in which either medical 
 or surgical treatment has been employed. In 42 
 cases in which Beebe and Rogers used the cytolitic 
 serum they reported 18 cases cured, 14 improved, 
 6 unimproved and 4 dead, which would represent 
 43 per cent, cured, 33.3 per cent, improved, 14 per 
 cent, unimproved and 10 per cent. dead. Moreover, 
 it seems to have been shown from the histories of 
 these cases that the treatment promises success only 
 in early cases in w T hich the thyroid poison has not 
 been carried through the circulation for a long 
 period of time. 
 
 Regarding the prognosis of cases treated with 
 Moebius serum, I have not been able to find definite 
 statistics although many authors claim to have seen 
 beneficial immediate results from the use of this 
 remedy. In only one instance have I found harmful 
 effects attributed to the use of this remedy, but on 
 the other hand it has been impossible to utilize the 
 reports either singly or collectively for statistics. 
 This is the more to be regretted because it seems that 
 we must expect ultimately to secure relief for pa- 
 tients suffering from exophthalmic goitre from this 
 direction. It seems as though it must be possible 
 to find some antibody that will neutralize the thyroid 
 poison until the hyperactive gland portions have 
 finished their abnormal activity. So far Beebe's 
 serum seems to represent the nearest approach to 
 
PROGNOSIS IN EXOPHTHALMIC GOITRE 187 
 
 this end, but not near enough to be depended upon. 
 Many other conditions undoubtedly have a marked 
 bearing upon the prognosis in patients suffering from 
 exophthalmic goitre. A man who is able to earn a 
 livelihood for himself and his family only by hard 
 labor and who feels the responsibility of the support 
 of those who are dependent upon him has a much 
 less hopeful prognosis than a man who has no re- 
 sponsibilities and is not compelled to exert himself 
 either physically or mentally. 
 
 In the same way women with great domestic or 
 social responsibilities have a grave prognosis. Those 
 who are active in the social world cannot obtain rest 
 if they remain at home and if they seek rest at re- 
 sorts or sanitoria their habits of life usually prevent 
 them from obtaining the necessary rest and con- 
 sequently they usually return home in a worse con- 
 dition than was present when they left. Again, it 
 seems that patients amenable to treatment with sug- 
 gestion give a better prognosis in a general way than 
 others not so constituted. Moebius suggests that this 
 accounts for the fact that so many relatively inactive 
 remedies have received so much praise in the treat- 
 ment of this disease. So long as the remedy does no 
 harm and the physician and patient believe in its 
 usefulness the latter receives the benefit of mental 
 and physical rest and his condition is improved as a 
 result of this rest. 
 
 So far as the prognosis of cases of exophthalmic 
 goitre treated surgically is concerned one can pre- 
 dict with certainty that none of the existing statistics 
 will have any value even after a few decades because 
 of a number of conditions already referred to. I will 
 
188 THYROID GLAND 
 
 consequently give only the statistics of a few very 
 widely separated authors who are at the same time 
 the best authorities on the subject. I refer to C. H. 
 Mayo, of America; Kocher, of Switzerland and 
 Landstrom, of Sweden, although a score of others, 
 like Halstead, Shephard, Curtis, Mikulicz, Rehn and 
 others, have published lists of cases which are both 
 interesting and instructive. 
 
 Kocher 's statistics show a mortality of 3.5 per 
 cent, in cases operated for the relief of exophthalmic 
 goitre. This includes both early and late cases al- 
 though if grouped separately the cases operated 
 during the past few years would give a much smaller 
 mortality. He states also that there is not a single 
 case in which the patient has not been much bene- 
 fited. In 83 per cent, of cases a cure is reported. 73 per 
 cent, of cases with primary disease were cured and 
 92 per cent, of cases with the disease, combined with 
 ordinary goitre were cured. 100 per cent, of cases 
 with vascular goitres were cured. 
 
 The statistics of C. H. Mayo vary so little from 
 those given above that it seems scarcely necessary 
 to repeat them. Suffice it to say that the mortality 
 is less than 3 per cent, in an experience based on 
 more than 1,000 thyroidectomies for the relief of 
 exophthalmic goitre. Landstrom's statistics based on 
 54 cases show very similar immediate results. He 
 has subjected the histories of his cases to a most 
 critical study from every point of view which makes 
 his observations especially interesting and valuable, 
 although the relatively small material makes his 
 conclusions lacking somewhat in clinical support 
 compared to the above authors. 
 
PROGNOSIS IN EXOPHTHALMIC GOITRE 189 
 
 Landstrom has shown from a most careful study 
 of his cases that there is little postoperative improve- 
 ment from actual injury to the heart as a result of 
 the thyroid poisoning even in cases that seem to 
 have recovered as a result of thyroidectomy. Al- 
 though the tachycardia may subside there seems to 
 be but little reduction in the size of the heart if 
 dilatation has occurred as a result of the disease, so 
 that we can speak only of a relative cure. Although a 
 man may work after he has obtained such a relative 
 cure as a result of thyroidectomy, still the prognosis 
 cannot be good in such a case as compared with 
 recovery from many other diseases in which the 
 tissues have not been exposed to this toxic sub- 
 stance. No doubt a long period of rest following 
 thyroidectomy will enable the tissues to recuperate 
 to a marked extent although such defects as cardiac 
 dilatation may not be overcome by the natural 
 tendency of the tissues to recover under favorable 
 conditions when the cause of their pathological 
 changes has disappeared. 
 
 All symptoms which are due to the direct irrita- 
 tion of the thyroid toxin are certain to improve after 
 thyroidectomy has eliminated the possibility of 
 further production of this toxin, but it is quite 
 different with the symptoms that depend upon actual 
 degenerative processes like cardiac dilatation due 
 to myocarditis. The same is true of marked exoph- 
 thalmos. Although the muscles involved in the 
 production of the exophthalmos may recover to a 
 great extent in some cases, in others they will remain 
 in a weakened condition and consequently the symp- 
 toms may remain although no fresh poison is in- 
 troduced into the circulation. 
 
190 THYROID GLAND 
 
 It is an easy matter to determine the fact of a 
 permanent impairment of the heart muscles and the 
 cylinder-formed muscle of Landstrom which de- 
 termines the exophthalmos, but it is much less easy 
 to determine the permanent effect of exophthalmic 
 goitre, which has persisted for a considerable period 
 of time, upon the other tissues of the body. It is 
 however, clear that the effect' is not confined to any 
 muscle or groups of muscles but that all tissues of 
 the body suffer. The form of history proposed above 
 will serve to give us data for reliable conclusions, 
 provided a careful record is made in each case ac- 
 cording to this form, and some provision is made for 
 annual reports from patients after recovery. 
 
 In the meantime we know enough to be entitled 
 to the opinion that the hyperthyroidism must be 
 'stopped early in order to prevent these permanent de- 
 fects. If this can be accomplished with rest, hygiene, 
 diet, and therapy, well and good, if not, then the case 
 should be treated surgically. At this point it is well 
 again to insist upon the fact that whatever form of 
 treatment may be employed, all that can be expected 
 primarily of this treatment is to stop the progress of 
 the poisoning. 
 
 The repair of the harm that has already been 
 done to the tissues must be accomplished by the 
 after treatment which will have to consist of rest 
 tonics, diet and general hygiene. This is quite as im- 
 portant after surgical as after internal treatment. 
 In either case this after-treatment must be continued 
 for many months and this will largely determine the 
 ultimate prognosis. 
 
CHAPTER XL 
 
 HEREDITY IN GOITRE. 
 
 Heredity. The fact is well known that in innu- 
 merable cases one or both parents and a number of 
 the children and again in turn their children have 
 suffered from goitre. This has been observed as far 
 back as the disease itself. Whether this indicates 
 that the offspring have inherited the disease or a 
 tendency for its development, or simply that the 
 same conditions and habits have caused the same 
 disease in the offspring that similar conditions 
 brought about in the parent is much more difficult 
 to determine. It is true that in communities in the 
 United States in which large numbers of Swiss im- 
 migrants have established their homes, the number 
 of goitres in the children born and reared in America 
 is very small compared with the number in the par- 
 ents. But this again is not a sufficient test because 
 these children may have inherited a tendency to the 
 development of goitre which under favorable con- 
 ditions would have developed this disease quite to 
 the extent it developed in the parents, but under 
 the unfavorable conditions in which the child was 
 placed in America for the development of this dis- 
 ease the simple tendency inherited from the parent 
 did not suffice to produce the disease. It is rare to 
 encounter a goitre in a patient in whom one cannot 
 
192 
 
 Thyroid gland 
 
 find the disease in some ancestor or near blood rela- 
 tive by carefully investigating the family history. 
 
 As regards heredity in exophthalmic goitre there 
 seems to be more opposition than to the theory of 
 heredity in simple goitre. 
 
 The most satisfactory case I have encountered in 
 
 Fig. 25. 
 turret head. 
 
 Infant of 5 months shows distinct exophthalmos and 
 
 the literature is one described by Schmauch, in a 
 woman thirty-five years of age, mother of four 
 children, the last one born eight weeks prematurely. 
 At the time the different children were born the 
 mother was twenty-six, twenty-eight, thirty and 
 thirty-two years old. The goitre first appeared dur 
 
HEREDITY IN GOITRE 193 
 
 ing the second half of the first pregnancy and in- 
 creased during each succeeding pregnancy. Distinct 
 symptoms of exophthalmic goitre developed during 
 her fourth pregnancy. She had marked exophthal- 
 mos, was cyanotic, had oedema over the entire body, 
 was extremely weak, had a pulse of 145 beats per 
 minute, and the neck measured 40 c. m. Three days 
 after labor she was subjected to treatment with 
 Moebius' anti-thyroidin, thirty drops twice daily, 
 every second day. The dose was later increased to 
 fifty drops twice daily, every second day, and then 
 again reduced to twenty drops. 
 
 She improved steadily, increased in weight from 
 114 to 138 pounds. The pulse was reduced so that 
 it varied from 90 to 110 beats per minute, while the 
 average count had been about 35 beats higher during 
 the severe attack, and her general condition was 
 greatly improved. 
 
 The youngest child, a boy, born during the height 
 of her attack, weighed scarcely four pounds at birth. 
 Fig. 25 represents him at the age of five months. 
 His head is irregular in shape, his abdomen is large, 
 his eyes are protruding and there is distinct irregu- 
 larity in the growth of the forehead. The occuput 
 and forehead were bulging out, the parietal bones 
 were sunken, giving the child's head the form of 
 a saddle head and turret head at this age, a con- 
 dition which has persisted to the present time to 
 quite a marked extent as shown in Figs. 27 and 28. 
 Five weeks after labor his eyes started to bulge out 
 and the head as a whole seemed to grow rapidly, 
 especially the forehead. A few days later the temporal 
 
194 THYROID GLAND 
 
 bone began to protrude, then one side of the occiput, 
 then the other side, then the left frontal bone in the 
 region of the protuberance seemed to elevate. 
 
 Fig. 26. Front view at age of 5 months of infant shown in 
 Fig. 25. 
 
 These peculiarities are all shown in Figs. 25 and 
 26. At the age of 11 months the child weighed 19j 
 pounds, at the age of 27 months his height is 80 c. m., 
 he weighs 35 pounds and his appearance is shown 
 in Figs. 27 and 28, which still shows plainly the 
 
HEREDITY IN GOITRE 
 
 195 
 
 presence of exophthalmos. The conditions observed 
 in this child seem to show that exophthalmic goitre 
 is sometimes transmitted from mother to child. It 
 would lead too far should we go into discussion more 
 extensively at this point but for those who are 
 
 Fig 27. Front view at age of 27 months; the exophthalmos shows 
 distinctly. 
 
 especially interested in this feature, a study of the 
 essay by Schmauch, will furnish exceedingly inter- 
 esting and profitable reading. In most instances in 
 which authors mention the condition of children 
 born of exophthalmic mothers there has been no 
 
196 
 
 THYROID GLAND 
 
 transmission of this condition from the mother to 
 the child. 
 
 Congenital Goitre. . A large number of cases has 
 been reported of infants born with goitres varying 
 
 Fig. 28. At age of 27 months greatly improved in every respect 
 but exophthalmos is still present. 
 
 in size. These usually decrease in size rapidly after 
 birth or the infants die in convulsions or exhaustion. 
 Oswald has found that young calves have no iodin 
 in their thyroids, but that after nursing and before 
 taking other food iodin is found, hence, he reasons 
 
HEREDITY IN GOITRE 197 
 
 that the milk must contain iodin unless this comes 
 from the blood of the young animal bringing this 
 substance from other tissues in the body. It is pos- 
 sible that mother's milk supplies the iodin in infants 
 with congenital goitre. 
 
 In an infant in which the neck had a circumference 
 of 8 c. m. more than the head, due to congenital 
 goitre, which became slightly worse during the first 
 two weeks of life, I have seen the goitre decrease 
 perceptibly from day to day by the administration of 
 5 grs. of thyroid extract three times daily to the 
 mother and \ gr. twice daily to the infant. In four 
 weeks the little patient was in excellent health and 
 when two months old nothing of the former disease 
 could be detected. 
 
PART II. 
 
 THE PARATHYROID GLANDULES 
 
 CHAPTER XII. 
 
 INTRODUCTION— HISTORICAL— FUNCTION. 
 
 Tucked away behind the more prominent thyroid 
 gland the parathyroid glandules for a long time es- 
 caped the eye of the anatomist, and even for a long 
 time after they were finally discovered they were 
 given no particular consideration. Finally a French 
 investigator noted that a rabbit deprived of these 
 tiny bodies died in tetany. Gradually the import- 
 ance of this observation, through the extensive con- 
 firmation of animal investigation, dawned upon the 
 surgeon and the practitioner of medicine. 
 
 The anatomist, the histologist, and the embryolo- 
 gist had proven these bodies to possess a structure 
 different from that of any other tissue. The ex- 
 perimental investigator had shown their remark- 
 able physiologic importance in a wide range of 
 animals, and demonstrated that they were an inde- 
 pendent vital organ. It remained for the clinician 
 to take these results and apply them at the bed side 
 and in the operating room. There was the whole 
 range of tetanies to be considered, some of especial 
 
200 PARATHYROID GLANDS 
 
 interest to the internist and others to the neurologist ; 
 some of importance to the gynaecologist and ob- 
 stetrician. To the surgeon there was at once the 
 question of the importance of these bodies in opera- 
 tions involving the thyroid gland. All diseases that 
 manifested tetanic symptoms came at once into 
 consideration in the light of this new discovery. 
 
 Many of these diseases for which a hypoparathy- 
 roid etiology was first suggested have lacked in post 
 mortem morphologic findings, but a group of tetanies 
 has remained that may, by their study from the 
 standpoint of a parathyroid etiology, be brought 
 into a closer relation. 
 
 To the surgeon the relation of tetany to parathy- 
 roid destruction has been so definitely proven that 
 ultimately an exact acquaintance with these struc- 
 tures must be a part of all intimate surgical knowl- 
 edge. Such knowledge has been delayed, save with 
 the leaders of surgery, owing to the natural skepti- 
 cism that would for a long time be maintained to- 
 wards the striking phenomenon of the removal of 
 such small bodies giving rise to so severe and often 
 fatal tetany. But at the present time the truth is 
 coming to be generally recognized, and the parathy- 
 roid glands are being given the place of real import- 
 ance that they deserve. 
 
 The assembling of all that is known about the 
 parathyroids is not an easy task, for it must be sought 
 from many sources. So far there has been little 
 regard paid to these glands by the writers of text 
 books, but this disregard is not due to lack of work 
 on these bodies. Considerably more than three 
 hundred, titles may be collected of important articles 
 
INTRODUCTION HISTORICAL FUNCTION 
 
 201 
 
 dealing with these glands from laboratory workers 
 in Sweden, Germany, France, Italy and America. 
 
 HISTORICAL. 
 
 It was in the year 1880 that Ivar Sandstrom dis- 
 covered the parathyroid glands. He found these 
 bodies constant in fifty autopsies in man, and he 
 further studied them in the dog, cat, rabbit, ox and 
 horse. This work of Sandstrom' s is so thorough and 
 complete from both an anatomic and a histologic 
 standpoint that he deserves all credit for the discov- 
 ery. It will only add to the thoroughness of Sand- 
 stroem's work to cite a number of investigators be- 
 fore him who had noted these glandules but passed 
 them by as being probably accessory thyroids or 
 small lymph nodes. 
 
 Remak is cited by Sandstrom as having described 
 these bodies. Virchow, in 1863, also noted them, 
 as he described small rounded bodies, about the size 
 of a pea, which he found in the loose connective 
 tissue on the posterior surface of the lateral thyroid 
 lobes, but he thought these bodies were lymph nodes 
 or detached portions of thyroid tissue. 
 
 Baber, in 1876, described what we now know are 
 the parathyroid' glands of the dog, and the same 
 author, independently of Sandstrom, published in 
 1881 a description of what he termed "undeveloped 
 portions of the thyroid gland" which were undoubt- 
 edly parathyroids, but he failed to recognize their 
 constant occurrence or significance. 
 
 Among other investigators who failed to recognize 
 the significance of these bodies, although undoubtedly 
 
202 PARATHYROID GLANDS 
 
 observing them, may be mentioned Kaydi, and 
 Maselung, whose observations were published two 
 years and one year respectively before Sandstrom 's 
 paper appeared. Immediately after Sandstrom, 
 Woelfler described under the name "Glandulae Para- 
 thyreoideae" (the same term that had been used by 
 Sandstrom), similar bodies which he considered as 
 an embryonal developmental stage of thyroid tissue 
 set free from the gland at an early time. 
 
 From this time on, the parathyroid glandules, as we 
 will now term them, received more or less spasmodic 
 attention. Rogowitz, in 1888, described what he 
 called "restes embryonnaires" in the thyroid glands of 
 animals. He considered them as parts of the thyroid 
 in process of development. Christian!, in 1893, ex- 
 amined the parathyroids of rodents, finding only one 
 glandule on each side. This author also considered 
 these organs as portions of embryonic thyroid tissue. 
 Liezenska, described these glands in the dog, and 
 considered the tissue a sort of reserve material that 
 could furnish fresh thyroid follicles when necessary. 
 
 Huerthle, at about this time, described, in a 
 study of thyroid secretion, an "interfollikulaeres Epi- 
 thel," which differed in its structure from thyroid 
 and secreted no colloid substance. He considered 
 this tissue as undeveloped thyroid. 
 
 It was not until 1895 that Kohn placed the ana- 
 tomy and histology, as well as the genesis of these 
 glandules, on a definite basis and established the 
 fact that they were independent structures morphol- 
 ogically and functionally distinct from the thyroid 
 gland. He also made clear the fact that in the rabbit 
 there were two pairs of these glandules. The defi- 
 
INTRODUCTION HISTORICAL FUNCTION 203 
 
 nite establishment of the number and situation of 
 these glands in the dog, cat and rabbit by Kohn was 
 of great importance to the development of the physi- 
 ologic importance of these structures. 
 
 Next to the name of Sandstrom that of Gley is 
 most intimately associated with the development of 
 our knowledge of the parathyroid glands. In a 
 series of fifteen papers appearing for the most part 
 as short communications in the Comptes Rendus de 
 la Societe de Biologie from 1891 to 1897, Gley es- 
 tablished for the first time by animal experimenta- 
 tion the important physiological function of the 
 parathyroid glandules and showed that post operative 
 tetany after thyroid operation was due wholly to re- 
 moval of the parathyroids, and was in no way connect- 
 ed with the thyroid as had previously been supposed. 
 
 These organs, then, that for a long time had ap- 
 peared so comparatively unimportant from an ana- 
 tomic standpoint, and which presented so peculiar a 
 histologic picture as to make the idea possible that 
 they were rudimentary rather than functional or- 
 gans, were, by the work of this investigator shown 
 to possess, when regarded from an experimental 
 side, an importance in the vital economy equal to 
 that of any other functioning organ. And it is from 
 the time of Gley that the question of this important 
 •function of these tiny glands has aroused the interest 
 of the medical and surgical world, and the literature 
 has multiplied in the effort to solve the complicated 
 problems that the parathyroid glandules have pre- 
 sented to us. 
 
 Among the earlier investigators who took up and 
 added to the work of Gley in establishing the fact 
 
204 PARATHYROID GLANDS 
 
 that the loss of all the parathyroid glands results in 
 death in tetany there are certain names of historical 
 interest which may be mentioned here, though their 
 work will be taken up in more detail in considering 
 the physiology of these glands. 
 
 This list includes Verstraten and Vanderlinden in 
 Belgium, Vassale and Generali in Italy, Edmunds 
 and D. A. Welsh in England, Kohn, Pineles and 
 Erdheim in Austria, Moussu and Alquier in France, 
 and MacCallum in America. 
 
 The animals used for these experiments include the 
 dog, cat, rabbit, rat and monkey, all of which ani- 
 mals respond to the complete removal of the para- 
 thyroids by severe tetanic symptoms ending usually in 
 death. In the herbivora it seemed impossible to show 
 at first this parathyroid tetany after operation, and it 
 was thought the differences in these animals was due 
 to their vegetable diet, but even in such animals as 
 the sheep and goat, tetany, it was found, could be 
 produced provided all parathyroid tissue was re- 
 moved, the difficulty being to' find the parathyroid 
 tissue which apparently has a wide distribution in 
 these animals. 
 
 The natural result of this experimental work in 
 animals was a flow of ideas towards its application to 
 certain conditions of importance from a clinical 
 standpoint in the practice of surgery and internal 
 medicine. 
 
 The pathologist, it might be mentioned in passing, 
 found little to repay him for a morphologic study of 
 these glands, although certain facts of interest and 
 some observations of negative as well as positive 
 importance have been brought out by the studies of 
 
INTRODUCTION HISTORICAL FUNCTION 205 
 
 Peterson, Benjamins, MacCallum, Getzowa, Erdheim 
 and others as will be duly chronicled. 
 
 To the internist the question of a hypoparathy : 
 roid etiology in the various tetanies became of in- 
 terest; such as the so-called idiopathic tetany of 
 workers in certain lines, children's tetany, the tetany 
 of pregnancy and lactation, and gastric tetany. Epi- 
 lepsy, exophthalmic goitre, paralysis agitans and 
 other conditions attended with tremor have had their 
 turn as diseases for which a hypoparathyroid etiol- 
 ogy was tentatively advanced. Osteomalacia and 
 rickets interest us as being possibly associated in 
 some way with changes in the parathyroid secretion. 
 Moreover there yet remains a variety of chronic nu- 
 tritional disturbances, associated with marked dimin- 
 ished resistance to bacterial infection, to be carefully 
 considered as bound up in some manner with lack 
 of parathyroid substance. 
 
 It is to the surgeon, however, that these glands 
 have appealed most strongly on account of the ques- 
 tion of post-operative tetany in connection with 
 thyroid surgery. Such tetany was not unknown to 
 the earlier surgeons. Billroth, Reverdin and Miku- 
 licz had a high per cent of tetanies following complete 
 thyroidectomies in the early eighties and before. 
 But based on the knowledge that it was the parathy- 
 roid and not the thyroid removal that was responsible 
 for this tetany, the technic of modern thyroid opera- 
 tions, has practically obviated such untoward results. 
 
 Today perhaps the greatest interest centers around 
 the question of parathyroid therapy, i. e., the matter 
 of making good a loss of parathyroid tissue or con- 
 trolling tetany after parathyroidectomy by the feed- 
 
206 PARATHYROID GLANDS 
 
 ing of parathyroids or the use of gland extracts, or 
 by the transplantation of parathyroid glands, or by 
 the use of calcium salts as recommended by Parhon 
 and Urechie in 1907, and, independently, by MacCal- 
 lum and Voegtlin in 1908. 
 
 In detailing the main facts regarding the parathy- 
 roid glands in this brief outline it may be mentioned 
 that they have not been brought forward without 
 considerable conflicting opinion, both as to the func- 
 tion, the importance, and the independence of these 
 bodies. 
 
 A critical examination of the literature, however, 
 masses the weight of evidence not only physiologi- 
 cally and experimentally, but anatomically as well, 
 in favor of the view that the parathyroid glandules 
 are in no way associated with the thyroid sav£ for 
 the relationship of anatomical propinquity and that 
 functional relationship (which may in certain in- 
 stances be more intimate than we suppose) which 
 must exist in normal man and animals between all 
 important glands which have to do with internal 
 secretion. In a careful survey of the literature we 
 have failed to find any convincing proof that the 
 parathyroids, either in structure or function, have 
 even served vicariously for the thyroid gland or are 
 in any way to be considered rudimentary thyroids. 
 They are to be considered independent vital organs, 
 as necessary to the existence of an individual as the 
 liver, the suprarenal glands, or any other organ whose 
 function is indispensable in the maintenance of 
 life. 
 
 As to the part played by the parathyroids in the 
 body, we can only say that their complete removal, 
 
INTRODUCTION — HISTORICAL — FUNCTION 207 
 
 as has been practiced so many times in a wide variety 
 of animals, leads to death with severe symptoms of 
 tetany which is in no way associated with or depend- 
 ent on the thyroid gland as was once thought. We 
 also know that by their gradual complete destruc- 
 tion, severe nutritional disturbances may be brought 
 about ending in death in apathy, with no symptoms 
 of tetany. When destruction is nearly, but not quite 
 complete, transitory symptoms of tetany may appear 
 for a time and then subside ; the theory being that 
 some small islet of parathyroid tissue left behind has 
 undergone compensating hypertrophy sufficient to 
 maintain the life of the animal. Thus it seems that 
 we are wonderfully safeguarded by a rich abundance 
 of over supply and that even though at a goitre oper- 
 ation three of the four glandules were accidentally 
 removed there would be no untoward symptoms if 
 the remaining glandule was fairly normal. In rab- 
 bits it is stated that seven-eighths of the parathyroid 
 substance must be removed in order to produce the 
 characteristic toxemia, and we know that fatal 
 tetanic symptoms never develop in dogs that possess 
 a single parathyroid gland. 
 
 While the exact mechanism by means of which 
 the symptoms of tetany are brought about following 
 the loss of the parathyroid glands is still open to 
 investigation, it may be stated that there are two 
 main hypotheses; first, the idea that a metabolic 
 toxin (which under normal conditions is neutralized 
 by the parathyroid secretion) gives rise to the symp- 
 toms; and second, that the symptoms are due to a 
 diminution of calcium in the tissues (which has been 
 shown to follow parathyroid removal), the with- 
 drawal of which leaves the nerve cells in a state of 
 
208 PARATHYROID GLANDS 
 
 hyperexcitability which expresses itself in tetany. 
 While there is some question as to the fact that such 
 a condition as exists in the second hypothesis is 
 present following the removal of the parathyroid 
 glands, nevertheless the administration of a soluble 
 calcium salt will promptly check the symptoms of 
 tetany. It is a mooted question at present as to 
 whether this calcium deficiency is always present 
 after parathyroidectomy. 
 
 That a poison is circulating in the blood, following 
 parathyroid removal, seems to be shown by the fact 
 that symptoms may be controlled for a time by 
 bleeding and transfusing an animal with normal 
 blood. Moreover, as PfeirTer and Mayer have demon- 
 strated, while the serum of a parathyroidectomized 
 animal will not produce symptoms of tetany in 
 a normal animal, it does bring on these symptoms 
 in an animal that has suffered partial removal of 
 the parathyroid glands. 
 
 In concluding this chapter it may be noted that 
 there has been more or less lack of unity in the 
 nomenclature of these organs. Sandstroem first 
 designated the bodies "Glandulas Parathyreoideas," 
 Gley used the term "Glandules Thyroidiennes;" Hof- 
 meister, "Nebenschilddruesen;" Zielinska, "Acces- 
 sorische Schilddruesen;" von Jacoby and Blumreich, 
 "Nebendruesen;" von Tourneux and Verdun, "Glan- 
 dules Thymiques." Kohn originated the term "Epi- 
 thelkoerperchen," which is still used more or less 
 extensively by German writers, and Verebely ex- 
 tends this to "Branchiale Epithelkoerperchen." By 
 most writers these organs are today generally des- 
 ignated the "Parathyroid Glands," or "Glandules." 
 
CHAPTER XIII. 
 
 ANATOMY. 
 
 Normally there are present in man four parathy- 
 roid glandules, situated on the posterior surface of 
 the lateral lobes of the thyroid, two on either side, 
 one above and behind the other, and separated from 
 the thyroid by connective tissue. While the position 
 of these glandules may vary, the variation is within 
 certain definite limits, so that the position is fairly 
 constant. The superior (external) glandules are 
 more constant in position than the inferior (internal) 
 glandules. They (the superior) are usually found, 
 one on each side, on the posterior wall of the oesoph- 
 agus, at the posterior edge of the lateral thyroid 
 lobes, about opposite the cricoid cartilage midway 
 between the upper and lower poles of the thyroid. 
 The height may vary, the superior glandules have 
 been found as high as the inferior cornu of the thy- 
 roid cartilage.. They are usually wholly outside the 
 thyroid, but they may be found within the capsule 
 of this organ. The inferior thyroid artery and re- 
 current laryngeal pass up in front and internally to 
 the glandules, and the superior bodies can usually 
 be found at the entrance of the end branches of the 
 inferior thyroid artery. 
 
210 PARATHYROID GLANDS 
 
 The inferior (internal) parathyroids are anterior 
 to the upper bodies, lie always in front of the inferior 
 thyroid artery, and are usually about opposite the 
 lower pole of the thyroid, though they may be found 
 as low as the fourteenth tracheal ring. They may 
 be either postero-lateral or antero-lateral to the 
 thyroid or may be at some distance from the thyroid 
 (usually below it) imbedded in fat and areolar tissue. 
 The fact that the inferior glandules are found less 
 constantly than the superior is due to their incon- 
 stant position, and the difficulty in distinguishing 
 them from small lymph nodules, pieces of thymus 
 tissue, fat, and accessory thyroid nodules that may 
 be found in this locality. 
 
 The parathyroids are rarely perfectly symmetrical 
 in arrangement. The two on one side may be in 
 normal position, while one or both of the glandules on 
 the other side may be considerably above or below 
 or laterally removed from their normal position. 
 
 When the neck organs are removed as at autopsy 
 and observed from the posterior (oesophageal) side, 
 the superior parathyroids are seen in the loose fatty 
 tissue along the posterior edge of the thyroid lobes. 
 By careful dissection the superior parathyroids can 
 be exposed lying on the posterior wall of the thyroid 
 near the oesophagus at the place where the artery 
 divides. The inferior parathyroids lie near the pos- 
 terior edge of the thyroid in the loose tissue that fills 
 the space below the rounded lower pole of the thy- 
 roid, ventral to the inferior thyroid artery and the 
 recurrent laryngeal nerve. 
 
 Size. — The average size of the parathyroid glands 
 is six to seven millimeters long, by three to four 
 
PLATE XXXIV 
 
 P. T. PARATHYROID GLANDULES IN NORMAL SITUATION ON POSTERIOR 
 SURFACE OF THYROID GLAND. 
 
ANATOMY 211 
 
 millimeters wide, by one and a half to five milli- 
 meters thick. Their most constant dimension is their 
 thickness. Sandstroem found one gland measuring fif- 
 teen millimeters in longest diameter. Berkeley gives 
 the average measurement as 6x4x2 m. m. MacCal- 
 lum's figures are about the same, six to eight milli- 
 meters long by three millimeters wide by one to two 
 millimeters thick. Berkeley gives the maximum 
 total weight of four glands out of 125 autopsies as 
 .3763 grams. 
 
 Shape. — The parathyroid glandules usually appear 
 as somewhat flattened, oval or spherical disk-like 
 bodies. They may have a flattened pyriform out- 
 line. Sometimes they are bean or kidney shaped, 
 resembling a small lymph node, but are usually more 
 flattened. At times they may be nearly square or 
 rectangular. The bodies have been compared with 
 a hemp seed or a grain of maize. 
 
 Color. — In color the parathyroids vary from pale 
 grayish white, to dark reddish brown. They prac- 
 tically always show a shade of yellow, due to their 
 fat content which is apt to be more pronounced in 
 older individuals. Their color is never exactly the 
 same as the adjacent thyroid tissue or lymph nodules. 
 They are less transparent than the lymph nodes, less 
 elastic than thyroid tissue, and not so flabby as small 
 fat tabs which may be found in this region. The sur- 
 face of the glandules is smooth and shining, and a 
 delicate venous tracery is to be seen under their 
 capsule. 
 
212 PARATHYROID GLANDS 
 
 VARIATIONS IN THE NUMBER OF PARATHYROID 
 GLANDS IN MAN. 
 
 While there are normally four parathyroid glands 
 in man their small size, variation in situation, and 
 their similarity to lymph nodules, accessory thy- 
 roids and other small bodies occurring in the neck 
 region, make their identification difficult, and the 
 average number found in any given series of exam- 
 inations is less than four to each individual. The 
 average number found, however, constantly increases 
 with the experience of the searcher, so that while 
 there may actually be less than four glands in cer- 
 tain cases, the difficulties attendant on their deter- ' 
 mination make the diminution in this number a 
 matter of not finding all the glands in many instances 
 rather than of the glands not being present. 
 
 Accessory parathyroids may at times be found. 
 Erdheim found eight accessory glandules in one case 
 and four in another; both were cases of thyroid 
 aplasia. Schaper found six parathyroids in one case. 
 Zuckerkandl reports a case in which there were 
 eight glandules. Getzowa found displaced masses 
 of parathyroid cells in seven cases, three of them in 
 the thyroid. Thompson and Harris have found five 
 glands in several instances; once the extra gland 
 was imbedded deeply in the thyroid. Accessory 
 parathyroids have been noted imbedded in remnants 
 of the thymus, especially in children. Kursteiner 
 
 The author, in a number of instances, where the most careful search of fresh ma- 
 terial yielded only three parathyroids, has found a fourth glandule by putting the 
 neck organs in Pick's solution and subsequently developing the tissue in 80% alco- 
 hol. Often, however, even this method fails to disclose a missing glandule as a 
 gland is easily lost in the material dissected away, or the neck organs are removed 
 without taking tissue far enough below the thyroid, so that a glandule well below 
 the thyroid, which is a not infrequent situation, is left behind. Hardening the 
 neck organs in 10% formalin solution especially if there is much oedema and con- 
 gestion of the tissue, also aids in finding glandules that might be overlooked in 
 fresh material 
 
ANATOMY 213 
 
 calls attention to the frequency with which remnants 
 of the thymus are found in the loose tissue below the 
 lower pole of the thyroid frequently enclosing a 
 parathyroid fragment. 
 
 Sandstroem in fifty autopsies found never more 
 than two parathyroids on each side; five times he 
 was only able to find one on each side and twice he 
 found only a single gland on both sides, but he him- 
 self says that his search was incomplete. 
 
 Von Verebely in 138 cases found four glandules 
 108 times. He states, however, that in the last 100 
 of these cases he found four glandules in ninety, which 
 is significant of the increased number found with 
 increased experience in their search. 
 
 Forsyth, who groups his findings unilaterally, ob- 
 served in sixty cases one gland on a side in less than 
 half his cases, two on a side in one-fourth, several 
 times three, in two instances four and five, and once 
 six parathyroids on a single side. 
 
 Welsh, who made a most exhaustive anatomical 
 and histological study of these glands, found in nearly 
 all cases in man two on a side, and he states that 
 when fewer are found, either the glands have es- 
 caped observation or else there is a more or less inti- 
 mate connection between two of the glands so that 
 they appear as one mass. 
 
 Schreiber, in twenty-five cases, found usually two on 
 a side, in four cases only one on a side was found, in 
 two cases there was one on the right and three on the 
 left side. He did not find more than four in any case. 
 
 Benjamins found the internal parathyroids so 
 rarely that he questioned if their presence was not 
 due to an abnormality of development. 
 
214 PARATHYROID GLANDS 
 
 Peterson, who studied 100 cases, does not give his 
 exact findings, but says that his results confirmed 
 the findings of earlier authors. He did not fail to 
 find the parathyroids in any case. The external 
 
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 Fig. 62. Normal parathyroid glandule, low magnification. A 
 portion of the thyroid gland is shown at the top of the section. 
 
 glandules he found most constantly present. In 
 some cases he found three glandules on one side and 
 one on the other. 
 
 MacCallum, in sixty -four cases, found four parathy- 
 roids thirty-six times, three ten times, two fifteen 
 
ANATOMY 215 
 
 times, and three times only one glandule. MacCal- 
 lum says: "The number found is directly propor- 
 tional to the patience and persistence with which 
 they are searched for." He calls attention, more- 
 over, to the especial difficulty in recognizing these 
 glands in the obese and in atrophic conditions. 
 
 Rogers and Ferguson examined forty-six adults 
 and eight infants for parathyroid glandules. In 
 twelve cases no parathyroids were found ; in twenty, 
 two were found; in four, three: in three, there were 
 four glandules. The findings in these cases are much 
 below the average although the investigation seemed 
 to be attended with much care. 
 
 Berkeley tabulates the details of forty autopsies 
 in which his average finding was about two and a 
 half glands per case. In one instance he found six 
 glandules. This author emphasizes the necessity 
 of experience in searching for these glands. In his 
 first twenty-five autopsies no glands at all could be 
 found in about four cases. In his second twenty- 
 five he failed only once or twice to find glandules. 
 In the last fifty cases he never failed. 
 
 Thompson found four glandules in thirty-three 
 out of forty cases. Three of these cases presented 
 also accessory glandules (five instead of four in each 
 instance.) In four of the forty cases only three 
 glandules were found; in one instance one of the 
 superior glandules was missing, in the other cases 
 it was one of the inferior glandules that was not 
 found. In two cases, only the two superior para- 
 thyroids were found; the inferior glandules were 
 missing. In one case no parathyroids were found. 
 In nearly all the cases where the author did not 
 
216 PARATHYROID GLANDS 
 
 find four parathyroids there was some pathologic 
 condition present that made the search difficult. 
 Two cases were subsequent to carcinoma operations ; 
 one showed extensive tuberculous cervical lymph- 
 noditis, and in others the neck organs were cedema- 
 tous and congested. 
 
 Thompson and Harris found four parathyroids in 
 ninety per cent of all cases, where careful search was 
 made for the same. 
 
 THE PARATHYROID GLANDULES *IN CHILDREN. 
 
 Thompson has found that the situation, general 
 appearance, and microscopic structure of the para- 
 thyroid glandules of the infant does not differ essen- 
 tially from that of the adult. The glandules are 
 much smaller in the infant than in the adult. They 
 average about two to five millimeters in diameter 
 normally in the infant, while in the adult they aver- 
 age about eight millimeters in longest diameter. 
 They are more difficult to find in the infant than in 
 the adult, not only on account of their small size, 
 but owing to their resemblance to certain lenticular 
 bits of tissue which extend upward along the pos- 
 terior border of the thyroid on both sides of the 
 oesophagus. This tissue is continuous with the in- 
 terscapular gland of Hatai, and at a later period of 
 infant life is not to be distinguished microscopically 
 from fat. In marantic infants, in whom there is no 
 fat, this tissue persists, and the tiny nodules are ex- 
 tremely difficult to distinguish in size, color, and sit- 
 uation from the parathyroids. By preserving the 
 neck organs entire in Pick's solution the author was 
 
ANATOMY 217 
 
 able to get a color differentiation that distinguished 
 this tissue from the glandules. Another source of 
 difficulty is in distinguishing the parathyroids, es- 
 pecially the lower, from remnants of the thymus gland 
 which are much more frequently found in the infant 
 than in the adult. ■ This in many instances can only 
 be done microscopically. Several times Thompson 
 . found what microscopically appeared to be parathy- 
 roids, to be, microscopically, parathyroid incorpor- 
 ated in a remnant of thymus. This finding is ex- 
 plained by the close embryological relationship of 
 the two structures, and Verebely has noted the same 
 thing in the adult. The number of glandules found 
 were, owing to these difficulties, less than in the 
 adult. In twelve cases of marasmus the author 
 found four glandules in six cases ; three were found in 
 five cases; in one case only two were found. In 
 twelve routine cases in infants four glandules were 
 found in eight; three were found in one case; two 
 were found in two cases, and only one glandule in 
 one instance. 
 
 BLOOD SUPPLY. 
 
 The parathyroid glands are supplied by the para- 
 thyroid artery which is a branch of the inferior thy- 
 roid artery. Vascular connections are also found 
 between the capsule of the thyroid and the para- 
 thyroid glands. Evans states that complete injec- 
 tions have shown only a scant blood supply to the 
 capsule, consisting only of a few minute capillaries. 
 These capsular vessels have been brought out with 
 considerable distinctness by Thompson and Leighton 
 after ligation of the parathyroid artery in dogs. 
 
218 PARATHYROID GLANDS 
 
 While Welsh, Halsted and Evans, Ginsburg, and 
 Geis, describe the parathyroid artery as a branch of 
 the inferior thyroid, Pool has described the para- 
 thyroid artery as springing from the superior thy- 
 roid artery. It is possible that the superior thyroid 
 artery may give off a parathyroid branch in the rare 
 cases in which the bodies lie above and behind the 
 upper pole of the thyroid gland. The parathyroid 
 artery, according to Ginsburg, is about a centimeter 
 long. Evans finds variations in length from four 
 or five millimeters to two or three centimeters. 
 Evans also describes a prominent anastomosing chan- 
 nel between the inferior and superior thyroid vessels 
 running along the posterior margin of the lateral 
 thyroid lobe in eight out of twenty cases. In these 
 the superior parathyroid artery is a short branch 
 from this channel. The parathyroid artery enters 
 the gland at the hilum, and gives off branches which 
 spread toward the periphery from which numerous 
 capillaries arise. 
 
 Ginsburg calls attention to the existence of a sec- 
 ondary blood supply to the parathyroid glands by 
 anastomotic channels from the opposite side, so that 
 even though a ligature be applied to the superior 
 and inferior thyroid arteries outside the capsule, the 
 parathyroid glands may receive a blood supply from 
 the opposite side. 
 
 The veins of the parathyroid glands are derived 
 from the inferior thyroid vein either directly or by 
 the intermediary of the veins which cover the surface 
 of the thyroid glands. 
 
 Halsted has called attention to the danger of 
 sacrificing the parathyroid glands in the control of 
 
ANATOMY 219 
 
 haemorrhage during goitre operations. He recom- 
 mends therefore that the thyroid vessels be divided 
 as far from the gland as possible so as not to cut off 
 the blood supply to the parathyroids. This opera- 
 tion of "ultra ligation" is done by drawing forward 
 the superior pole of the thyroid gland and putting 
 
 ■■**-%> 
 
 
 
 Fig. 63. Ligation of the parathyroid artery in the dog, showing 
 that no change takes place in the glandule following such procedure. 
 A moderate exudation of leucocytes is seen between the ligature and 
 the parathyroid. 
 
 the superior thyroid vessels on the stretch. From 
 above downwards and from before backwards the 
 vessels are then divided at their point of entrance 
 into the gland as far peripherally as possible. 
 Thompson, Leighton and Swarts have shown that 
 
220 PARATHYROID GLANDS 
 
 in the dog the parathyroids possess sufficient collat- 
 eral blood supply so that the ligation of their main 
 vessel is of no importance. Dogs in which the para- 
 thyroid artery to one glandule was ligated and the other 
 three glandules were excised showed no symptoms 
 following the operation. If at a second operation, 
 however, the ligated glandule was excised the dog 
 died in tetany. This showed that the ligated glan- 
 dule was functionally sufficient to maintain the life 
 of the animal. Microscopic examination of ligated 
 glandules at intervals of twenty-four hours to several 
 months showed them to be morphologically intact. 
 
 PARATHYROID GLANDULES IN MAMMALS AND 
 BIRDS. 
 
 On account of the experimental work that has 
 been done on the parathyroid glands their anatomy 
 has been worked out with much care in a wide va- 
 riety of animals. While in general the situation and 
 number of these glands is the same in animals as 
 in man, there are certain variations that may be 
 briefly reviewed. 
 
 Cat. — In the cat the thyroid consists of two separ- 
 ate lobes not connected by an isthmus. The para- 
 thyroids are four in number, two on each side, the 
 external usually free but sometimes imbedded in 
 the substance of the thyroid lobe near the internal 
 surface. The internal gland is smaller than the ex- 
 ternal and is imbedded in the thyroid lobe. Kohn 
 was the first to accurately describe these glandules 
 in the cat. According to Harvier and Morel, accessory 
 parathyroids are frequently found in the thymus 
 of this animal. 
 
ANATOMY 
 
 221 
 
 D g # — The glandules in the dog have a similar 
 situation to those described in the cat, but are sub- 
 ject to more variation. The external glandule is 
 situated superficially near the upper pole of the 
 thyroid. It is usually in close connection with the 
 capsule of the thyroid. 
 
 The internal parathyroid is ordinarily under the 
 capsule of the thyroid, but superficially situated in 
 the upper half of the internal aspect of the thyroid. 
 It is identified with more difficulty than the external 
 gland owing to its smaller size, greater variation in 
 position and deeper situation than the former. 
 
 Gley noted fourteen variations in the situation 
 of the glandules in thirty-three dogs, and Alquier 
 found the classic situation of the bodies only nine 
 times in fifteen dogs. MacCallum calls attention to 
 the fact that accessory parathyroids may occur 
 deeply imbedded in the thyroid. Thompson and 
 Leighton noted the frequent appearance of accessory 
 parathyroid glandules in this animal; eight glands 
 were found in one animal. Moussu speaks of supple- 
 mentary parathyroid tissue about the trachea and 
 in connection with the branches of the thyroid ar- 
 tery. Pianca has noted these aberrant glandules 
 in this animal. Alquier has also found accessory 
 parathyroids in the dog, but these always in connec- 
 tion with the thyroid gland. 
 
 The size of the parathyroids also varies greatly in 
 the dog. They may be so small as to be scarcely 
 visible to the naked eye, or they may be found as 
 large as five millimeters in diameter. 
 
 The irregularity of the glandules in this animal, 
 and the frequent finding of accessory parathyroids 
 
222 PARATHYROID GLANDS 
 
 should be borne in mind in considering the results 
 of experimental work in the dog. 
 
 Monkey. — In the monkey the thyroid lobes may 
 or may not be connected by an isthmus. The para- 
 thyroids are four in number, two on each side, an 
 outer larger, and a smaller inner body. According 
 to Vincent and Jolly both glandules are frequently 
 imbedded in the substance of the thyroid so that 
 simple parathyroidectomy is extremely difficult in 
 these animals. 
 
 Guinea Pig. — Comparatively little attention has 
 been paid to the parathyroids of the guinea pig. 
 Vincent and Jolly state that the number and position 
 of these bodies is extremely variable in this animal. 
 As a general rule two of the glandules are more or 
 less deeply imbedded in the thyroid, while the other 
 two are distinct from the thyroid substance and 
 separated from it by a variable interval. The above 
 mentioned authors have found as many as six glan- 
 dules in one animal. 
 
 Rabbit.— The superior parathyroids are imbedded 
 in the thyroid lobes. The inferior parathyroids are 
 distinct from the thyroid lobes, and sometimes con- 
 siderably removed from them. The inferior bodies 
 are considerably larger than the superior in this 
 animal. 
 
 Rat. — This animal possesses only two parathy- 
 roid glands. They are situated within the thyroid 
 lobes near the upper pole. 
 
 Horse. — Litty found in the horse a parathyroid 
 gland on each side, embedded in the thyroid lobe, 
 yellowish red, round or oval, measuring about one 
 centimeter in diameter. Estes has described in the 
 
ANATOMY 
 
 223 
 
 horse both an external and an internal parathyroid. 
 The former is found easily and is from pea to hazel 
 nut size. It has a peculiar lobulated appearance. 
 It is most often found near the superior pole of the 
 thyroid, usually in the peri-thyroid areolar tissue. 
 Its position varies with the variations of the thyro- 
 laryngeal artery. The internal parathyroid was 
 found by Estes only by making histologic sections of 
 the thyroid gland after hardening the same. Even 
 by this method the internal gland was found in only 
 about half the cases and its distribution was very 
 irreeular. It could be easily confused in gross with 
 small adenomatous growths, which are not uncom- 
 mon in the thyroid of the horse. 
 
 Sheep and Goat. — MacCallum, Thomson and 
 Murphy have found a very irregular distribution of 
 the parathyroid tissue in these animals. Four para- 
 thyroids were found quite regularly in the thymus 
 and thyroid but this does not include all the parathy- 
 roid tissue in these animals. Two glands are to be 
 found imbedded or partly imbedded in the thymus, 
 one on each side, at the level of the thyroid cartilage 
 and just in front of the carotid artery and vagus 
 nerve, and may easily be distinguished with the 
 naked eye. These glands measure from about three 
 to five millimeters in diameter. The remaining 
 parathyroids are imbedded in the thyroid lobes. 
 They cannot be easily seen in the living animal. 
 When the thyroid is removed and hardened, however, 
 they stand out plainly from the surrounding thyroid 
 tissue with which they come into very intimate re- 
 lation through lack of capsule. 
 
224 PARATHYROID GLANDS 
 
 Ox. — In the ox the external parathyroids lie, one 
 on each side, just under cover of the free dorsal bor- 
 ders of the lateral lobes of the thyroid opposite about 
 the lower level of the isthmus. They occupy the 
 stratum of fat which separates the thyroid lobe 
 ventrally from the pharynx and oesophagus dorsally. 
 They may be blended with islets of thymus tissue. 
 The internal parathyroids are incorporated within 
 the thyroid gland. 
 
 Forsyth has made a very complete study of the 
 parathyroid glands in mammals and birds. He ex- 
 amined forty-two species of the former and thirty- 
 five of the latter. This detailed search has led the 
 author to conclude that the parathyroids vary widely 
 in number in different species and even in different 
 members of the same species. "An instance of this 
 is afforded by three specimens of the Green Monkey 
 in which the parathyroids numbered one, one, and 
 eight respectively. Further, the existence of para- 
 thyroid tissue in the thyroid, not isolated by connec- 
 tive tissue, has been found to be of much commoner 
 occurrence than was supposed. Even in the same 
 species the parathyroids were found subject to con- 
 siderable variations in number and in position. 
 "Further, parathyroid tissue is commonly present 
 in the thyroid, and intermediate types are readily 
 found both in the thyroid and in accessory glands, 
 with the result that the identity of some bodies has 
 often presented difficulty." 
 
 "Isolated glands possessing a parathyroid structure 
 were found in most, but not in all, the members of 
 the series. When present their total number was 
 two, three, or four; but these numbers were exceeded 
 
ANATOMY 225 
 
 in certain specimens. A two-spotted paradoxure 
 {Naudinia binotata) and a fossa (Crypto pro eta ferox) 
 each had six; a Green Monkey (Cercopithecus calli- 
 trichus) eight, and a collared Fruit Bat (Cynonyc- 
 teris collar is), ten." 
 
 ' 'The parathyroids can scarcely be said to possess 
 any definite anatomical relations in these animals, 
 so widely do their positions vary. The commonest 
 site of occurrence was on the convex lateral surface of 
 the thyroid ; but they were also found on the tracheal 
 surface, or sunk in the thyroid either deeply or just 
 beneath the capsule or in the immediate neighbor- 
 hood of the thyroid, either dorsal anterior, posterior 
 or external to it, or some distance remote, either 
 isolated or in association with accessory thyroids or 
 lymphatic glands. They present no naked-eye fea- 
 ture by which their identity can be established; and 
 over and over again in this series they have been 
 found unexpectedly on microscopical section. Fre- 
 quently glands too small for macroscopic identifica- 
 tion have been found attached to the capsule of the 
 thyroid." 
 
 Birds. — The thyroid and parathyroids of birds, 
 as examined by Forsyth, agree generally with those 
 structures in mammals, but they also present certain 
 points of contrast." As with mammals, so with 
 birds, it has sometimes been difficult to decide 
 whether a particular gland was to be regarded as a 
 thyroid or parathyroid. Each of these in its typical 
 appearance is of course readily identified, but the 
 two structures are so often intermixed that it is 
 not always easy to settle which name to give to the 
 whole. A few examples will illustrate this diffi- 
 
226 PARATHYROID GLANDS 
 
 culty. The anatomical thyroid of the Californian 
 Quail was found to be wholly parathyroid in nature. 
 In the Barn Owl only the cortex of the thyroid 
 possessed thyroidal structure ; the deeper parts were 
 typically parathyroidal. In the Gray Parrot, the 
 Oyster-Catcher, and other birds the anatomical 
 parathyroid was directly continuous with the thy- 
 roid, no connective-tissue septum being interposed 
 so that the whole formed a single gland." 
 
 In the majority of cases the number of parathyroids 
 in birds was found to be limited to one on each 
 side, lying in contact with the thyroid at or near the 
 posterior pole. "In a few specimens the parathy- 
 roid is bilobed, while occasionally two separate para- 
 thyroids occur. When this last condition holds it 
 is frequently found that the glands are some little 
 distance remote from the thyroid. Most parathy- 
 roids are oval or spherical in shape, and their color 
 is white or yellow without any translucency." 
 
 Among the papers that have appeared on the com- 
 parative anatomy of the parathyroids may be men- 
 tioned that of Pepere, who includes in his very com- 
 plete anatomical study of the parathyroid glands, 
 a description of these bodies in a number of animals 
 as well as a study of variations in man from the foetus 
 to old age. 
 
 T^ie nerve supply of the parathyroid glandules 
 has been studied by Sacerdoti, who states that they 
 are furnished by nerves of the thyroid. According 
 to Anderson the nerves terminate within the in- 
 terior of the epithelium of the glandule. 
 
CHAPTER XIV. 
 
 EMBRYOLOGY AND HISTOLOGY. 
 
 When one studies the development of the para- 
 thyroids, and observes their changing relations to 
 thyroid and thymus in its course, anomalies in the 
 ultimate situation of these bodies are readily ac- 
 counted for. 
 
 The thyroid gland arises from a median body at 
 the root of the tongue, and two lateral bodies which 
 begin as small buds from each side of the posterior 
 wall of the fourth branchial cleft. 
 
 The thymus gland arises from two epithelial 
 evaginations of the third branchial cleft which grow 
 downward and meet to form the two lobes of this 
 body. 
 
 The parathyroids arise as two separate pairs; one 
 from the fourth branchial cleft, the other from the 
 third branchial cleft. The former pair come to lie 
 on the dorsal surface of the lateral portion of the 
 thyroid and form the superior bodies. The other 
 pair pass further backwards and come to rest behind 
 the lower border of the thyroid, forming the inferior 
 bodies. The name "inner" and "outer" bodies was 
 given these glandules by Kohn because of the fact 
 
228 PARATHYROID GLANDS 
 
 that in certain animals the parathyroids derived 
 from the fourth branchial cleft were found within 
 the thyroid lobe while those derived from the third 
 groove were situated outside the thyroid. 
 
 Steida, as early as 1881, discovered in a pig em- 
 bryo, in addition to the thymus, thyroid, and caro- 
 tid gland, four other epithelial anlage, which 
 Schreiber later described as the parathyroids. Among 
 other earlier workers on the embryology of these 
 bodies may be mentioned Prenant, who described 
 an origin for these organs in the sheep from the 
 fourth branchial cleft together with the lateral thy- 
 roid bodies. Tourneux and Verdun also described 
 the parathyroids as arising from the dorsal part of 
 the fourth branchial cleft in human embryos. Simon 
 observed the bodies in rabbit embryos, and Gros- 
 chuff in the mole. Soulie and Verdun differentiated 
 in the rabbit the inner parathyroids (arising from 
 the fourth branchial cleft) and the outer parathy- 
 roids (arising from the third branchial cleft). Ben- 
 jamins, who included with his own work a discussion 
 of previous articles, definitely stated that in man the 
 bodies have independent anlage in both the third 
 and fourth branchial clefts. 
 
 For a more complete abstract of the origin of 
 these bodies in various species we are indebted to 
 Maurer, who first described the parathyroids in 
 amphibians : 
 
 Anura. — In tadpoles the parathyroids arise at 
 the time when the outer gills form. They arise as 
 compact epithelial buds on the ventral end of the 
 third and fourth branchial clefts; the spaces also 
 form a similar bud which, according to the observa- 
 
EMBRYOLOGY AND HISTOLOGY 229 
 
 tions of Maurer, goes to form the carotid gland. 
 The last branchial cleft forms no parathyroid. 
 
 At first these glands are histologically composed 
 of epithelial cell masses, which stand in relation with 
 the epithelium of the gill cleft by means of an epi- 
 thelial pedicle. This pedicle disappears and the 
 small structure grows by increase of its cells to form 
 an egg-shaped body which may be recognized by 
 spiral, interwoven cell cords. A lumen is never found 
 in these organs. Their construction is peculiar, dif- 
 fering from the thymus, the thyroid and the post- 
 branchial body. These organs persist throughout 
 life and are found even in very old animals, (frogs, 
 toads, tree-toads). 
 
 Urodeles. — In triton the parathyroids are formed 
 during the metamorphosis stage. They come from 
 the epithelium of the closing third and fourth branch- 
 ial clefts. At the same time the carotid gland arises 
 in the neighborhood of the second cleft. The bodies 
 lie here on the lateral convexity of the aortic arches, 
 or are between these. Sometimes two such bodies 
 are found between the third and fourth arches so 
 that three are formed on one side. In other cases 
 there is only one such structure on one side, so that 
 individual variation is not uncommonly met with. 
 
 Reptilia. — In the lizard the parathyroids also 
 arise from the third and fourth clefts. In serpents 
 one body has been found in the second cleft. They 
 arise at the same time as the thymus, during the 
 closure of the branchial clefts. In the lizard the 
 bodies arise from the third cleft on the ventral end 
 of the thymus and are in connection with this through 
 an epithelial cord. The ventral pocket of this cleft 
 
230 PARATHYROID GLANDS 
 
 suffers a complete atrophy. The parathyroid of 
 the fourth cleft is formed from the wall of this cleft 
 which throws out a lateral projection from the oesoph- 
 agus. The middle portion of this projection thick- 
 ens and forms the anlage of the parathyroid. The 
 body is loosened from the oesophagus and for a time 
 is in connection with the post -branchial body. 
 
 At first this organ consists of epithelial cells which 
 form the boundary of a lumen, but with increase 
 of epithelial cells this lumen disappears, and at the 
 same time connective tissue elements enter, so that 
 the body possesses a complex of epithelial cells 
 which are separated from one another by delicate 
 interstitial connective tissue. In this condition the 
 parathyroid of the lizard remains throughout life. 
 It never contains a lumen and colloid substance is 
 never secreted, so that the structure cannot be con- 
 founded with that of the thyroid. 
 
 Aves. — In birds the parathyroid glands are pres- 
 ent in varying number. They are formed by the 
 third and fourth .gill cleft and lie ventrally to the 
 thymus. According to Verdun, in the chick and the 
 duck, a third body is formed in connection with the 
 post -branchial body which is possibly a derivative of 
 the fifth branchial cleft. Verdun further concludes 
 that the first two are often in connection with the 
 thyroid and that the derivative of the fourth cleft 
 is frequently attached to the post-branchial body. 
 
 In mammalia, as we have already noted, these 
 structures arise from the third and fourth branchial 
 clefts and differ in their relation to thymus and thy- 
 roid from the parathyroids of the lower vertebrates. 
 
EMBRYOLOGY AND HISTOLOGY 231 
 
 At first the parathyroids of the third cleft are in 
 direct relationship with the thymus; the two being 
 separated from the oesophagus at the same time. 
 It is only later that the parathyroid of the third 
 cleft separates itself from the thymus, and indeed, 
 we see that at times a parathyroid becomes imbedded 
 in the thymus lobe. 
 
 The relations of the parathyroids of the fourth 
 cleft are even more complicated. The primary con- 
 nection here is thymus, parathyroid and post -bran- 
 chial bodies, and through this latter connection 
 the parathyroids acquire a connection with the thy- 
 roid lobe. 
 
 HISTOLOGY. 
 
 Kohn was the first to establish the independence 
 of the parathyroid glands by his ground breaking 
 histologic and genetic study of these organs. He 
 clearly made evident the distinct independence of 
 parathyroid from thyroid. Previous authors al- 
 though they had carefully recorded the histologic 
 structure of these glands regarded them as embry- 
 onic thyroid. 
 
 The histology of the parathyroid glandules has 
 been described in detail by various authors, includ- 
 ing Sandstroem, Kohn, Welsh, Erdheim, Peterson, 
 Verebely and Getzowa, and save for minor differ- 
 ences, the descriptions are fairly uniform. All 
 authors describe two main types of cells which may 
 be grouped as follows : 
 
 Type 1. — Comparatively small cells (somewhat 
 larger than those of the thyroid) with relatively 
 large nuclei which stain deeply. The cell cytoplasm 
 
232 PARATHYROID GLANDS 
 
 is colored with difficulty, but the cell border is dis- 
 tinct. These cells constitute the greater part of 
 the gland tissue and are always present in every 
 glandule, but may vary in size, shape, and intensity 
 of cytoplasmic stain, and in size and shape of the 
 nucleus. These cells will be referred to as the "prin- 
 cipal" cells. 
 
 Fig. 64. Normal parathyroid glandule, ordinary type of cell 
 arrangement. A — Groups of "functional" cells. 
 
 Type 2. — Comparatively large cells with small 
 deeply staining, nucleus and considerable deeply 
 staining, eosinophilic, granular cytoplasm. These 
 cells have a distinct cell boundary. They are not 
 found in every glandule, though they are present in 
 almost all cases. They are never so numerous as 
 
EMBRYOLOGY AND HISTOLOGY 266 
 
 the "principal" cells. These cells will be referred to 
 as the "functional" cells. 
 
 The number and arrangement of these cells is 
 subject to wide variation. They may occur in masses 
 forming small islets scattered throughout the gland 
 tissue, or may occur irregularly scattered among the 
 principal cells, either singly or in groups of three 
 or four, without any definite arrangement. Some- 
 times they form definite acini or occur in continuous 
 anastomosing columns. 
 
 The principal cells are also subject to a great va- 
 riety of arrangement, giving different pictures in 
 different glandules. The cells may form a uniform 
 mass continuous in every direction, being broken 
 only at infrequent intervals by delicate strands of 
 connective tissue carrying small blood vessels. The 
 cells in this instance appear irregularly polyhedral, 
 and the cell walls are everywhere in direct contact 
 with each other. 
 
 The glandules may show connective tissue, with 
 blood vessels, between the masses, thus breaking 
 them into anastomosing columns, or cell trabecule. 
 Here the cell cytoplasm stains more deeply and the 
 cells are apparently rounder than in the former ar- 
 rangement. There may be seen further subdivision 
 of the cell masses by fibrillar stroma or capillary 
 reticulum, or denser fibrous stroma with- blood ves- 
 sels, so that small islets of epithelial cells appear 
 within the stroma somewhat akin to the arrange- 
 ment in carcinoma. 
 
 In parts of the glandules the principal cells may 
 form definite acini, so that the structure resembles 
 
234 PARATHYROID GLANDS 
 
 secreting gland, the center of which usually contains 
 colloid. 
 
 The glandules present, then, in general, a together- 
 hanging cell mass composed for the most part of 
 small cells with indistinct cytoplasm and deeply 
 staining nucleus, interrupted irregularly by small is- 
 lets, or groups of two or three, larger eosinophilic 
 cells, which may or may not have a characteristic 
 arrangement. These cell masses are divided irregu- 
 larly by blood vessels into lobular or reticular cell 
 strings, or may be separated into distinct lobules by 
 connective tissue septa. Both the cells and the con- 
 nective tissue may contain considerable fat, which 
 is believed by most authors to arise in the organ it- 
 self without outside influence. 
 
 Sandstroem, who described the glands with con- 
 siderable accuracy, grouped them histologically into 
 three main types: 1. A continuous mass of epi- 
 thelial cells penetrated by a considerable capillary 
 network. 2. A continuous cellular reticulum, the 
 meshes of which are occupied by blood vessels and 
 connective tissue. 3. An arrangement of cells into 
 numerous small follicles, in some of which are drops 
 of a colloid-like substance. 
 
 Welsh confirmed and added to the work of Sand- 
 stroem. He described four types: "1. The cells 
 form a uniform mass, their protoplasm taking little 
 if any stain, and there being but slight degree of 
 vascularity. 2. The cell masses show a tendency 
 to break up into anastomosing columns, between 
 which are capillaries borne in a fine connective tissue 
 stroma ; the protoplasm stains somewhat more deeply 
 than before. 3. The cells form branching: columns 
 
EMBRYOLOGY AND HISTOLOGY 235 
 
 between which lies a fine or dense stroma, bearing 
 blood vessels. These cells are large and faintly 
 staining. 4. The cells are arranged in a single layer 
 around a central lumen to form definite acini. These 
 cells are large, with cytoplasm staining variously 
 and the lumen is usually occupied by a small globular 
 mass of colloidal substance." Welsh specially notes 
 that commonly several "types" coexist in one gland. 
 
 Welsh also added a description of what he terms 
 "oxyphile" cells. These he mentions as occurring 
 in a very large proportion of cases, though not in 
 all, and never attaining the same abundance as the 
 above mentioned cells, ("principal" cells). They 
 have a relatively large amount of cytoplasm, which 
 is usually full of fine oxyphile granules, and he recog- 
 nized what he considered differences between the 
 nuclei of the two varieties of cells ; those of the oxy- 
 phile being smaller, more nearly circular, and with 
 their chromatin more dense. According to their 
 grouping he makes four types of these cells also. 
 They occur as: 1. — Uniform masses forming islets 
 scattered irregularly through the gland; 2. — Ana- 
 stomosing columns; 3. — Cells either singly or in 
 groups of twos and threes; 4. — Cells forming defi- 
 nite acini, the lumina of which are occupied by colloid 
 material — -a very exceptional type. 
 
 Ebner, Chantemesse and Marie, Benjamins, Kohn 
 and Kollman were among the earlier contributors to 
 the histology of these glands. Their findings in 
 general agree with what has been related. 
 
 Peterson, who carefully studied the glands in one 
 hundred autopsies, noted that the structure of the 
 parathyroids varied from a compact cell mass, to a 
 
236 PARATHYROID GLANDS 
 
 gland composed of independent islets of cells separ- 
 ated by connective tissue in considerable amount. 
 He separates the cells of the parathyroid distinctly 
 into two main types. The first type is distinguished 
 by its strong affinity for the eosin, and when a con- 
 siderable number of these cells are massed together 
 the picture is similar to that of the adrenal gland. 
 The cells of the second cell type are less characteristic 
 than the first. The cell bodies may run into one anoth- 
 er without sharp differentiation and are much smaller 
 than those of the first type. The cytoplasm may be 
 so diminished that one sees only a complex of strongly 
 colored nuclei. Between these extreme forms are 
 all possible variations. Peterson also notices that 
 rarely there may be observed cylindric cells with 
 basal nuclei which group themselves in tubular 
 gland-like form. The appearance of a third cell 
 type, noted by this author (large voluminous cells) 
 may represent a degenerative change rather than 
 normal histology. 
 
 Peterson's work shows that the parathyroid gland 
 is a secreting organ which presents certain (func- 
 tioning) cells which set free a secretion product. 
 The parathyroids possess no duct ; the carrying away 
 of the secretion is by the blood stream, with which 
 the cells are directly continuous by means of capil- 
 laries as in the adrenal. A proof of the entrance of 
 this secretion into the blood is offered by Peterson 
 in the regularity with which the red blood corpus- 
 cles show an increased affinity for eosin (similar to 
 the cytoplasm of the functioning cells) in congested 
 organs where secretion is increased. 
 
PLATE XXXV 
 
 P. T. PARATHYROID GLANDULES. THE RIGHT SUPERIOR GLANDULE IS 
 DOUBLE. THE LEET SUPERIOR GLANDULE IS SITUATED ABNORMALLY LOW. 
 
EMBRYOLOGY AND HISTOLOGY 237 
 
 Koenigstein, who studied in serial section 200 
 glands, described a passing over in successive series 
 of the different types of parathyroid cells. The 
 large, polygonal, eosinophilic, sharply bounded type 
 may be transformed into another distinct type, 
 smaller, shrunken and having but little affinity for 
 the eosin. He considers the difference in picture 
 due to different stages in the function of cells of the 
 same original type, which after filling with their 
 secretion present different forms. 
 
 Von Verebely in reviewing these various cell types 
 suggests that it is best to consider that the parathy- 
 roid is made up of a single cell type which changes 
 its form and appearance under different conditions 
 of secretion and rest. This is in line with the views 
 previously expressed by Koenigstein and later em- 
 phasized by Forsyth and by Thompson. 
 
 Getzowa describes four types of cells which are 
 designated: 1. — Wasserhelle cells; 2. — Rosarote cells; 
 3. — Oxyphile cells; 4. — Syncytium-like cells. 
 
 Forsyth lays special emphasis on the histologic 
 variations of activity and rest. The so-called oxy- 
 phile cells are those distended with granular secre- 
 tion, and the so-called principal cells represent the 
 exhausted stage; intermediate forms are common. 
 This author states that the granular secretion of the 
 cells is extruded into the surrounding lymphatic spaces. 
 
 So far we have called attention to the parenchyma 
 rather than to the framework of the parathyroid, 
 although we have spoken of the considerable varia- 
 tion in the amount and distribution of the latter. 
 A most careful study of the framework of the para- 
 thyroid glands by digestion methods has been made 
 
238 
 
 PARATHYROID GLANDS 
 
 by Flint. In the dog and monkey this author states : 
 "In thin digested sections the framework appears as 
 irregular septa which do not form a continuous net- 
 work throughout the organ, but are broken up into 
 smaller processes which support the irregular coiled 
 columns of cells of which the organ is composed. 
 These septa carry the arteries, capillaries, veins, and 
 nerves. They are in some places built up of fasciculi 
 
 Fig. 65. Normal infant parathyroid (a) in connection with (6) 
 remnant of thymus gland. (Magnified 575 times). 
 
 of reticulum fibrils, in others, of a thinner, looser 
 formation of anastomosing and branching fibrils. 
 When thick stained, digested sections from fifty 
 microns up are studied, these broken septa are ob- 
 viously continuous in the third dimension with other 
 processes that turn off and occupy various planes 
 according to the branching of the anastomosing cell 
 columns. In sections stained by the ordinary meth- 
 
EMBRYOLOGY AND HISTOLOGY 239 
 
 ods, and thin sections varying from three to six 
 microns in thickness, stained by Mallory's connective 
 tissue stain, numerous cells with oval nuclei are 
 found imbedded in the fibrils. These are the con- 
 nective tissue corpuscles, and do not differ in this 
 position from those found in other parts of the body." 
 
 HISTOLOGY OF THE INFANT PARATHYROID. 
 
 Microscopically, certain differences between in- 
 fant and adult parathyroid may be noted. The 
 most noticeable difference seems to be that there is 
 only a single type of cell in the infant glandule. The 
 differentiation into "principal" and "functional" 
 cells, as described for adult parathyroids, cannot be 
 made. 
 
 In the infant Thompson has found that, micro- 
 scopically, the parathyroid glandules present a fairly 
 uniform picture. They consist of closely set cell 
 masses arranged in groups or in strands, which are 
 separated by a rather delicate connective tissue 
 stroma bearing blood vessels. The relation between 
 parenchyma and stroma is more uniform, and there 
 is less tendency to form varying types of arrange- 
 ment than in the adult. The cell masses consist 
 of cells a little larger than those of the thyroid, 
 which vary in size and shape and intensity of nuclear 
 and cytoplasmic staining, but which conform to a 
 single type, the so-called principal cells of the adult 
 glandule. The cytoplasm of these cells may be in- 
 distinct or lacking, but the cell membrane is usually 
 distinct. Along the capsule and septa these cells 
 frequently assume a radial arrangement, the so- 
 
240 PARATHYROID GLANDS 
 
 called "palisade" formation. As previously noted, 
 the functional cells of the adult do not appear in the 
 infant gland. 
 
 Erdheim notes that the structure of the parathy- 
 roids in infants is more solid than in adults, but after 
 the twentieth year the parenchyma undergoes a 
 breaking up by the penetration of connective tissue 
 trabecular. He finds the functional cells first at 
 the tenth year of life. After the fifth year fat cells 
 appear in the connective tissue of the gland. This 
 fat increases with age till it includes quite generally 
 the whole gland. 
 
 Forsyth says that during the first few months of 
 life the parathyroid glands show no activity, and that 
 this inactivity may persist for some years, although 
 in one case colloid secretion was found as early as 
 the third month. 
 
 HISTOLOGY IN ANIMALS. 
 
 In general the histology of the parathyroid glands 
 in animals bears a close resemblance to the picture 
 seen in man. Forsyth, to whose extensive work we 
 have already referred, finds that these glandules are 
 usually made up of solid masses of polygonal cells 
 whose cytoplasm may be pale and clear or filled 
 with oxyphile granules, or intermediate between 
 these extremes. Often the cells may arrange them- 
 selves around a lumen which is filled with a drop of 
 colloid. In birds this author found that the glands 
 possessed a similar structure, with less attempt at 
 follicular formation. The cytoplasm of the cells 
 showed the same variations in activity and rest as 
 
EMBRYOLOGY AND HISTOLOGY 241 
 
 has been described in mammalian parathyroids. 
 On the whole, the parathyroids in birds are more 
 often inactive than those in mammals. 
 
 Alquier has carefully described the structure of 
 these glands in the dog, and divides them into three 
 types. The first type (Type ordinaire) : the cells 
 are large and possess a clear finely granular pro- 
 toplasm with a large nucleus. These cells are ar- 
 ranged in anastamosing cords within a mesh-like 
 network in varying dimensions. The second type 
 (Type compact) : consists of polyhedral cells disposed 
 without order. The cells are voluminous and clear. 
 The third type (Type reticule ) : the cells are smaller 
 and the intercellular spaces are not clearly defined. 
 
 In the sheep and goat the parathyroids are practi- 
 cally not to be distinguished from one another his- 
 tologically, according to MacCallum. The glands 
 are very compact and very vascular. The cells are 
 apparently all of one type and are closely arranged 
 in anastomosing strands and cords so that the in- 
 tervening capillaries come into direct contact with 
 all the cells. The cell nuclei are large and round 
 and the cytoplasm very abundant with a somewhat 
 granular structure. The perfectly clear cells and 
 the eosinophile cells seen in the human parathyroid 
 are not to be found here. 
 
 SECRETION OF THE PARATHYROID GLAND. 
 
 Various substances have been noted in the para- 
 thyroid gland appearing either as degeneration prod- 
 ucts or as gland secretion. Among these may be 
 mentioned colloid, fat droplets and granules, gly- 
 
242 PARATHYROID GLANDS 
 
 cogen, hyaline, and pigment. These substances will 
 be specifically dealt with in the chapter on patho- 
 logic histology. 
 
 It was stated by Gley that the parathyroids (of 
 the dog and rabbit) contained considerably more 
 iodine than did the thyroid. Chenu and Morel, on the 
 contrary, found only a very small amount of iodine 
 in these glandules. The work of these latter authors 
 is sustained by Estes and Cecil who state that if 
 iodine is present at all in the parathyroid it is in 
 such minute quantities as to be of no functional 
 significance. Nagel and Ross found that ablation 
 of a parathyroid did not modify the iodine content 
 of the remaining glandules. 
 
 Fiori, who has removed portions of the parathy- 
 roid glands in animals, found that no regeneration 
 of parathyroid tissue whatever took place following 
 injury. The removed epithelial tissue was replaced 
 by connective tissue and a cicatrix resulted as is 
 the case with all highly specialized tissues. 
 
CHAPTER XV. 
 
 THE PATHOLOGIC HISTOLOGY OF THE 
 PARATHYROID GLANDS. 
 
 While the greater part of the work on the para- 
 thyroids has been along experimental lines, never- 
 theless morphological observations relating to alter- 
 ations from the described normal histology have been 
 made by a number of investigators, although per- 
 haps it might be truthfully stated that the negative 
 observations on these bodies have been of more 
 value in clearing our mind in regard to certain dis- 
 eases than any described pathological alteration. 
 
 Sandstroem mentioned that cystic degeneration, 
 and amyloid infiltration of the vessel walls and cap- 
 sule occurs in certain cases. Muller called especial 
 attention to fatty change. Konigstein studied es- 
 pecially the secretion of the glandules from a histo- 
 logical standpoint, but stated he could not bring 
 anatomical changes into correlation with clinical 
 conditions. Harnett, in a series of routine autopsies, 
 found no changes in the parathyroid glands that 
 could be differentiated from normal glands at the 
 corresponding period of life. Verebely in one hun- 
 dred and thirty-eight cases described various lesions 
 
244 PARATHYROID GLANDS 
 
 of the glandules, including two instances of tuber- 
 culosis, three cases of cyst, three of hemorrhage, and 
 one tumor. Getzowa called especial attention to 
 the colloid content, which was found present in 
 nearly all cases over ten years of age. Pepere noted 
 a number of progressive and retrogressive changes, 
 including suppuration. Guizzetti described dense 
 mononuclear cell infiltration of the parathyroid in 
 two cases of tetanus. Yanase found hemorrhage 
 thirty-three times in eighty-nine children showing 
 tetanoid conditions. Kohn described hemorrhagic 
 cysts. Peterson, who examined one hundred cases, 
 noted the frequency with which degenerative changes 
 are found in the glandules from cases over twenty 
 years old. Among these changes he found atrophy 
 of the parenchymatous cells brought about by fatty 
 changes, cloudy swelling, and cystic degeneration 
 very frequently. In twenty-five of his cases he 
 found cloudy swelling; in fifteen, colloid; in six, 
 cyst formation; in twenty-one, fatty infiltration. 
 This author was unable to correlate changes in the 
 gland with clinical conditions. Gamier described 
 slight changes in severe infectious disease. 
 
 Benjamins, in twenty cases of goitre, found no pro- 
 gressive changes in the glandules but a variety of 
 retrogressive changes. In a general study of the 
 parathyroids he found hydropic degeneration twen- 
 ty-five times, pigment, atrophy, connective tissue 
 increase, and frequent colloid. He described a 
 tumor of the parathyroid the size of a child's head. 
 
 Erdheim found glycogen and colloid frequently 
 and observed mast cells in the connective tissue of 
 certain of the glandules. He also noted the fre- 
 
THE PATHOLOGIC HISTOLOGY 
 
 245 
 
 quency of cysts. He found hemorrhage in eight 
 cases. 
 
 Thompson has called attention to the condensa- 
 tion of the cytoplasm at the edge of the cell in these 
 glands, due to various degeneration products such 
 as fat, glycogen, and colloid. This produces the 
 optical appearance of an intercellular framework 
 
 Fig. 66. Sclerotic type of parathyroid glandule showing epithelial 
 islets separated by considerable connective tissue. 
 
 which characterizes many of these glands. In. a 
 later paper by the same author, degenerative and 
 especially progressive changes were described in 
 these glandules in cases of primary infantile atrophy. 
 Forsyth, who regards the cells of the parathyroids 
 as all of a single type representing different stages 
 of activity and rest, has described excess of colloid, 
 
246 PARATHYROID GLANDS 
 
 connective tissue proliferation, both general and 
 perivascular, and also speaks of instances (in ani- 
 mals) where there is a similarity between thyroid 
 and parathyroid structures. This author also notes 
 that the cortex of the gland stains more deeply than 
 the medullary tissue, and that drops of colloid and 
 regular vesicles are met with more frequently near 
 the surface than elsewhere. The nearer the sur- 
 face, the more abundant the secretion. 
 
 MacCallum, who has worked extensively on these 
 glandules, found in certain of the glandules examined 
 following thyroid removal for exophthalmic goitre, 
 some increase in fibrous stroma and moderate atrophy 
 of the cells. In general, however, the parathyroid 
 tissue was abundant and normal in these cases. A 
 tumor of a parathyroid, and hyperplasia of the glan- 
 dules in gastric tetany has also been noted by this 
 author. 
 
 Tuberculosis of the parathyroid glands, occurring 
 as a part of general miliary tuberculosis, has been 
 described by Carnot and Delion, Benjamins, Verebely, 
 Eggers and Winternitz. 
 
 Amyloid infiltration of the parathyroids has been 
 especially well described by Schilder who found these 
 glandules involved in three cases of amyloidosis. 
 
 The attempt to establish a symptom complex for 
 diseases of the parathyroids has been due to the re- 
 sults of physiological experimentation rather than 
 to histological findings, and a great range of diseases, 
 in which tetanic symptoms are present, has been 
 advanced as due primarily to deficiency in parathy- 
 roid secretion. In many of these diseases, how- 
 ever, examination of the parathyroids has failed to 
 
THE PATHOLOGIC HISTOLOGY 247 
 
 reveal constant morphological change when symp- 
 toms were such as to suggest severe or complete loss 
 of their functioning power. 
 
 The various tetanies for which a parathyroid 
 etiology seems most probable will be discussed in 
 a later chapter. At present we will only concern 
 ourselves with such morphologic work as concerns 
 these conditions, as well as the results of a study of 
 these bodies in those diseases in which a parathyroid 
 etiology has been suggested but found lacking. 
 
 Exophthalmic Goitre. — The suggestion that ex- 
 ophthalmic goitre might be due to lesions of the para- 
 thyroid glands suggested itself very soon after tetanic 
 symptoms were noted following the removal of these 
 bodies. Moussu was probably the first to formulate 
 this theory. At about the same time papers ap- 
 peared by Gley and by Edmunds, the former sug- 
 gesting alterations in the thyroid apparatus involv- 
 ing in the first place the parathyroids, and the latter 
 partial aparathyroidia as an explanation of this 
 disease. 
 
 Edmunds has also stated that when the parathy- 
 roids are removed in the dog the thyroid gland un- 
 dergoes compensating hypertrophy with changes sim- 
 ilar to those found in exophthalmic goitre, namely 
 "enlargement of the vesicles with alteration in shape 
 from round to oblong or branched; intracellular 
 growth takes place, the secretory cells become col- 
 lumnar instead of cuboidal and the colloid contents 
 of the vesicle tend to disappear." 
 
 Humphry, on the basis of this assertion, describes 
 two cases of exophthalmic goitre in which the para- 
 thyroids (only two of which were found in each case) 
 
248 PARATHYROID GLANDS 
 
 exhibited extensive infiltration of fat. In another 
 case there was some fat, and in a fourth case (age, 
 twenty- two years), there was no fatty infiltration. 
 For comparison the author examined microscopically 
 the parathyroids in eighteen cases, not goitre, and 
 came to the conclusion that it would be premature 
 to consider this fatty change as a pathological fea- 
 ture of Graves' disease without further observation. 
 
 Haskovec, on the ground of his experimental in- 
 vestigation of exophthalmic goitre, concludes that, 
 while this disease has its origin in the thyroid gland, 
 the parathyroids should be considered as participat- 
 ing in the condition. 
 
 In general it may be stated that no characteristic 
 histological changes are found in the parathyroid 
 glands in connection with this disease. Erdheim 
 examined a case, in which exophthalmic goitre and 
 epilepsy were combined, and found no changes save 
 for the usually fatty infiltration that might be ex- 
 pected in a flfty-three-year old man. Benjamins 
 also failed to find changes in the parathyroid glands 
 in this condition. This author examined the para- 
 thyroids from twenty cases of goitre of various kinds 
 including three cases of exophthalmic goitre. 
 
 MacCallum, who has examined the parathyroids 
 from a number of cases of exophthalmic goitre, states 
 that there are no constant lesions in these organs in 
 this disease. 
 
 On the negative histological findings, then, as 
 well as on the fact that the symptoms in parathy- 
 roidectomized animals are very different from those 
 of exophthalmic goitre, and considering that para- 
 thyroid therapy is of no benefit in the disease, we 
 
THE PATHOLOGIC HISTOLOGY 249 
 
 can conclude that the parathyroids have little or 
 nothing to do with this condition. 
 
 Myxoedema. — It is to be questioned if the para- 
 thyroid glands play any role whatever in the causa- 
 tion of myxcedema, which is definitely known to be 
 due to loss of the thyroid gland. Occasionally, 
 however, certain disturbances in the muscles have 
 been observed in the course of this disease, as re- 
 ported by Lundborg, Schlesinger, Rosenberg, and 
 others, w T hich might suggest that the parathyroids 
 were also involved. 
 
 Maresch and Peucker found the parathyroids pres- 
 ent in cases of congenital absence of the thyroid. 
 Erdheim found in several cases where there was 
 absolute aplasia of the thyroid, not only the four 
 normal parathyroids but a number of accessory 
 glandules, none of which presented any pathological 
 alteration. 
 
 Forsyth has reported a case of myxoedema . of 
 four years standing in a woman aged fifty-eight, 
 which showed in addition to the typical sclerotic 
 changes in the thyroid, certain departures from the 
 normal structures of the parathyroid glands. The 
 bodies showed a marked tendency to form vesicles 
 lined by a cubical epithelium, with a profuse secre- 
 tion of colloid which filled the follicles and lay among 
 the masses of cells and distended the lymphatic 
 channels. There was also observed an abnormal in- 
 crease in the connective tissue and a thickening of 
 the arterial walls of these glandules. Such a change 
 as this is too commonly observed, however, in para- 
 thyroid glands from ordinary cases of people of this 
 age to make Forsyth's observation of any impor- 
 
250 
 
 PARATHYROID GLANDS 
 
 tance. Both fibrosis and colloid are frequently found 
 in the parathyroids. 
 
 Brissaud considers the parathyroids to be involved 
 in myxcedematous idiots, and not involved in 
 myxcedema frustes. 
 
 Epilepsy. — Owing to certain of the symptoms 
 that have been observed in animals following in- 
 complete operation on the parathyroids it was early 
 
 Fig. 67. Parathjrroicl glandule of the sclerotic type, from a case of 
 primary infantile atrophy, high power, showing (a) perivascular in- 
 crease of connective tissue, (b) crowding together of epithelial cells 
 and (c) mast cells in connective tissue. (Magnified 575 times.) 
 
 suggested (Jeandelize, Vassale, MacCallum), that 
 epilepsy might in certain instances have a relation- 
 ship to changes in the parathyroid gland. Erd- 
 heim, indeed found considerable increase of connec- 
 tive tissue of all four parathyroids in a case of epi- 
 lepsy in a twenty-three-year old male, but in another 
 case he found the glands perfectly normal. Schmorl 
 
THE PATHOLOGIC HISTOLOGY 251 
 
 found hemorrhage in the parathyroids in two cases 
 of epilepsy. 
 
 Claude and Schmiergeld examined the parathy- 
 roids, as well as the thyroid glands, in seventeen 
 cases of epilepsy, and found no changes in the former 
 that they were able to construe as pathologic for 
 this condition. 
 
 Paralysis Agitans.— As early as 1885, Horsley 
 from observations on thyroidectomized apes, de- 
 scribed certain muscular tremors and stated that 
 the causation of the constant tremor such as that 
 in paralysis agitans might find an explanation in the 
 loss of the thyroid apparatus. He did not consider 
 the parathyroids at that time, as up to then little 
 or no attention had been paid to these organs, but 
 of course, a considerable amount of parathyroid 
 tissue had been removed in his animals. Despite 
 Horsley's observation no attention was paid to these 
 organs as far as paralysis agitans was concerned 
 until 1904, when Lundborg's well known paper on 
 the relation of the parathyroids to paralysis agitans 
 appeared. The same hypothesis was advanced by 
 Berkeley independently although his paper did not 
 appear until later. 
 
 Both these papers were wholly hypothetical, 
 Lundborg having no autopsy material on which he 
 could prove- his assumptions, and Berkeley being 
 able to secure but one autopsy in this condition. 
 In this case he found two parathyroid glands, which 
 are described as less than average size, and as pre- 
 senting sclerosis and thickening of the blood vessels 
 in part, with other parts of the gland appearing 
 normal. 
 
252 PARATHYROID GLANDS 
 
 The hypothetical part of both these articles is not 
 without interest. Lundborg cited Luzzato, Dana, 
 Mobius, Frenkel, Burzio, Casteloi and SchiefTer- 
 decker, all as expressing the idea that the disease 
 is an endogenous toxemia. He emphasized the 
 tetanic symptoms that arise in animals after para- 
 thyroidectomy; and after a considerable discussion 
 which it is impossible to abstract completely, gives a 
 diagram wherein the system of thyroid and para- 
 thyroid hypo and hyper function is delineated in 
 terms of myxoedema, morbus Basedowii, paralysis 
 agitans, and paralysis myasthenia respectively. Lund- 
 borg 's paper must be read in its entirety to appre- 
 ciate the full force of his argument. He concludes 
 with the statement, however, "das es aber noch fur 
 ausserst hypotetisch gehalten werden muss, ob die 
 glandulae parathyroidae eine bestimmte Rolle in deren 
 Pathologenese spielen." 
 
 Berkeley cites in support of his theory: tetanic 
 symptoms observed in slowly dying parathyroid- 
 ectomized rabbits; the endogenous toxemia concept 
 of the disease, which seems to be borne out in a 
 measure by the fact that the author considered that 
 the administration of parathyroid gland extract was 
 of therapeutic value in a majority of his cases; 
 and the possibility that, in cases of concurrent myxoe- 
 dema and paralysis agitans the parathyroids may 
 have been diseased or atrophied through contiguity 
 with the diseased thyroid. 
 
 Alquier in a general review of this subject adds the 
 weight of his opinion to this hypothesis on the ground, 
 especially, that it seems more probable than any of 
 the previously advanced theories. 
 
THE PATHOLOGIC HISTOLOGY 253 
 
 Thompson, however, failed to find any constant 
 changes in the parathyroid glands of nine cases dy- 
 ing of this disease, which were controlled by the 
 examination of the glandules from forty autopsies 
 not paralysis agitans. In summing up these nine 
 cases of paralysis agitans it was found that the para- 
 thyroid glandules, in individuals dying with this 
 disease, presented no changes either in number, 
 size, position, or histologic structure that would 
 serve to distinguish them from the parathyroid 
 glandules in individuals dying from other diseases. 
 
 In two of the nine cases, only three glandules were 
 found (in one other case where only three glandules 
 were found the technic was faulty). Many writers 
 find three glandules more often than they find four, 
 in routine examination. In three cases five glan- 
 dules were found. The finding of the minute ac- 
 cessory parathyroids in these cases more frequently 
 than in the routine cases was undoubtedly due to 
 the extra care that was used in searching for them in 
 the paralysis agitans material. 
 
 The average size of the glandules was a little 
 smaller in the cases of paralysis agitans than the 
 general average of the routine cases. This could be 
 accounted for by the fact that all the paralysis 
 agitans cases were over seventy years of age. Rou- 
 tine cases over seventy years of age show in general 
 smaller glandules than young individuals. 
 
 There was nothing to be found microscopically in 
 the parathyroids in the paralysis agitans cases that 
 could differentiate them from other parathyroids. 
 Five of the cases can be passed over without remark ; 
 they were in every way identical with the type pic- 
 
254 PARATHYROID GLANDS 
 
 ture presented by the majority of the glandules in 
 routine parathyroid examination. Two of the cases 
 presented a moderate increase of connective tissue 
 stroma. The percentage of glandules showing a 
 considerable connective tissue stroma was higher in 
 the routine cases than in paralysis agitans. Eight 
 of the routine cases were of this type. One of the 
 paralysis agitans cases showed a great amount of 
 interlobular fatty connective tissue, so that only 
 small islets of glandular tissue were seen. Three 
 of the routine cases, however, gave even greater con- 
 nective tissue stroma, with corresponding atrophy 
 of the parenchyma. Fat was found in every glan- 
 dule examined, both in the paralysis agitans and the 
 routine cases. Some of the paralysis agitans cases 
 showed a great amount of fat. Many of the routine 
 cases showed an equal amount, and some even more. 
 The glandule that showed the most fat was from a 
 case of diabetes. 
 
 All the cases of paralysis agitans showed both 
 types of cells (principal and functional),- although 
 the ratio between the two varied greatly in different 
 cases and in different glandules from the same case, 
 as they did also in the routine cases. In one case, 
 one of the inferior glandules exhibited apparent in- 
 creased activity of the functional cells. No mitotic 
 figures were seen in the principal cells, in either the 
 paralysis agitans or the routine cases. 
 
 Erdheim also examined the parathyroids in three 
 cases of paralysis agitans and found no evidence of 
 hypoplasia. In two of the cases the glandules were 
 perfectly normal. In the third case one glandule 
 was greatly enlarged and showed marked increase 
 
PLATE XXXVI 
 
 /.*- 
 
 P. T. SUrERIOE PARATHYROIDS. THE LEFT IS ABNORMALLY HIGH. THE 
 INFERIOR GLANDULES (NOT SHOWN) ARE ON THE ANTERIOR SURFACE OF THE 
 THYROID LOBES. 
 
THE PATHOLOGIC HISTOLOGY 255 
 
 in the functional cells while the other three glan- 
 dules were normal. 
 
 In conclusion, then, it must be stated that there 
 is no morphologic ground for the assumption that 
 the parathyroid glandules are insufficient in paral- 
 ysis agitans. Whether or not there is faulty secre- 
 tion of these organs; whether they are unable to 
 cope with a poison circulating in the blood that their 
 cells or their secretion is not able to neutralize; or 
 whether the specific relation between these glan- 
 dules and some other organ is upset, must be deter- 
 mined by experimentation other than morphologic, 
 and offers a promising field for investigation. On 
 morphologic grounds there is every reason to oppose 
 the hypothesis that paralysis agitans is a chronic, 
 progressive hypoparathyroidismus . 
 
 Tetany. — Microscopic lesions have been described 
 in the parathyroids in various forms of tetany, 
 which will be dealt with in more detail in a later 
 chapter. MacCallum found hyperfunction of the 
 glandules in gastric tetany, and Konigstein also re- 
 ported a case in which similar changes were found. 
 
 Tetanus. — In tetanus Guizzetti found infiltration 
 of mononuclear cells in two cases in which the dis- 
 ease had lasted for four and seven days, respectively. 
 Two other cases were negative. Babonneix and 
 Harvier have described changes in the parathyroids 
 in three cases of tetanus, consisting especially in 
 hypersecretion of colloid. Thompson found no 
 changes in the parathyroids in five cases dying from 
 tetanus infection that could be considered specific. 
 Erdheim found the glandules normal in one case. 
 
256 PARATHYROID GLANDS 
 
 In a case of experimental tetanus the glandules 
 were found normal by Gamier. 
 
 Tetany of Children. — Erdheim (three cases) and 
 Konigstein have found hemorrhage in the para- 
 thyroids in children exhibiting tetanic symptoms. 
 Verebely, and also Thiemich, have found hemor- 
 rhages in cases where there was no tetany. The most 
 convincing work in this line has perhaps been done 
 by Yanasse who examined the parathyroids in eighty- 
 nine children showing tetanoid conditions and found 
 hemorrhage in thirty-five cases. Degeneration of 
 the parathyroids in a case of tetany in course of a 
 case of tuberculous meningitis has been described 
 by Escherich. 
 
 Eclampsia. — The greater amount of work on this 
 condition has been experimental and is given in more 
 detail in a later chapter, but several authors have 
 examined the parathyroids histologically in this 
 condition. Pepere found changes in the glandules in 
 four cases. Zanfrognini found only two glandules 
 in a case, but these were both normal. Erdheim 
 in four cases found hyperemia, circumscribed injury 
 once, hemorrhage once. Schmorl in five cases of 
 eclampsia found hemorrhage four times. He con- 
 siders that the hemorrhage was the result of the 
 convulsions. 
 
 Rachitis. — Escherich, under whom the work of 
 Yanasse previously cited was done, has suggested 
 congenital parathyroid hypoplasia as the etiological 
 factor in rachitis. This assumption is based on the 
 frequent coincidence of tetany and beginning rachitis ' 
 as well as on Erdheim 's findings in the teeth of para- 
 thyroidectomized rats. At present this hypothesis 
 
THE PATHOLOGIC HISTOLOGY 257 
 
 lacks morphological confirmation. Schmorl found no 
 changes in the parathyroids in four cases of rachitis. 
 
 Osteomalacia. — In two autopsies in this disease 
 Erdheim found hyperplasia of the parathyroids in 
 one case and normal glandules in the other case. 
 Schmorl in four cases found the glandules normal 
 three times and hyperplasia in one case of one of the 
 upper glandules. 
 
 Primary Infantile Atrophy. — In this disease Thomp- 
 son found constant changes in the parathyroids, 
 practically all of a progressive nature, which the 
 author considered the result of this condition rather 
 than an etiological factor in the same. 
 
 In the cases of infantile atrophy the changes that 
 are found in the parathyroids can be quite sharply 
 differentiated into two types, which may be desig- 
 nated as (a) degenerative, and (b) sclerotic. In the 
 first type the glandules may be diminished in size 
 or may be of normal size, and are pale in color, or, 
 as in one case that showed intense congestion, the 
 glandules were cherry red. Microscopically, no in- 
 crease of connective tissue is found, but the epithelial 
 cells show everywhere a marked degeneration. They 
 are larger and more irregular than normal, the nuclei 
 are swollen and the cell boundaries are usually 
 thickened, appearing as though the protoplasm had 
 condensed in part at the cell periphery, as happens 
 in certain forms of reticular degeneration. In places 
 there was complete loss of cell structure with crowd- 
 ing' together of the cytoplasm into a fused mass, in 
 which the nuclei were irregularly arranged. The 
 blood vessels may be greatly distended, but are 
 usually moderately injected. 
 
258 
 
 PARATHYROID GLANDS 
 
 Fig. 68. A and B. Sketch of the neck organs from cases of primary 
 infantile atrophy, showing the small size of the parathyroid glandules; 
 compare with C'and D, which are control cases of infants of the same 
 age. (pt) parathyroids, (th) remnants of thymus gland (in B replacing 
 the two lower parathyroids and surrounding the left upper); (gl) 
 represents tissue continuous with the interscapular gland. (In) 
 lymph node. 
 
THE PATHOLOGIC HISTOLOGY 259 
 
 The most common finding, however, in these cases 
 of marasmus is a marked increase in the connective 
 tissue stroma of the glandules, which corresponds 
 closely to the sclerosis (chronic fibrous parathyroid- 
 itis), described in the adult. These cases are called, 
 therefore, the sclerotic type. In these cases the 
 glandules are smaller than normal, dark brownish- 
 red in color, and firm. Microscopically the connec- 
 tive tissue stroma separating the cell masses is found 
 increased in amount in varying degree. The epith- 
 elial cells appear as irregular strands between the 
 thickened bands of connective tissue. This connec- 
 tive tissue increase is frequently noted about the 
 blood vessels. The connective tissue is loose, vas- 
 cular, and rich in nuclei, which have a spindle shape. 
 Mast cells are frequently seen in the connective tis- 
 sue. In the epithelial islets between the connective 
 tissue strands the principal cells are crowded to- 
 gether so that the typical sharp-lined epithelial 
 structure is lost. The cell membrane is usually not 
 seen, but masses consisting of closely set, irregularly 
 arranged nuclei, without definite cell boundaries, 
 are apparent. Groups of five or six cells occasion- 
 ally in the centres of these islets preserve their 
 original structure. As tetany was never observed 
 in these cases the findings are interesting as tending 
 to show that extensive changes may take place 
 in the parathyroids without exhibition of any 
 tetanic symptoms, a finding that might serve as 
 a check, perhaps, upon a too liberal interpreta- 
 tion of morphological change in cases that do 
 exhibit tetany. 
 
260 PARATHYROID GLANDS 
 
 Pellagra. — Marinesco has recently described atro- 
 phy and marked fatty change in the external para- 
 thyroids in two cases of this disease. 
 
 General Pathology. — Thompson and Harris, in 
 a study of these glandules from a morphologic stand- 
 point in two hundred and fifty routine autopsies, 
 state that they have been unable to correlate to any 
 extent clinical symptoms and morphological para- 
 thyroid alteration. They nevertheless add the fol- 
 lowing report of certain histological findings in these 
 glandules that are of interest : 
 
 Fat. — The fat content of these glandules is so 
 constant in the adult that it gives a distinct yellow 
 color to the gland and serves as a macroscopic aid 
 in differentiating parathyroids from lymph nodes, 
 accessory thyroids, or thymus, sympathetic nerve 
 ganglia, or other bits of tissue which make the 
 search for these organs more or less difficult, espe- 
 cially to one who has not had considerable experience 
 in their isolation. Microscopically one should differ- 
 entiate perhaps between the fatty content of the 
 connective tissue of the gland and the fatty content 
 of the cells of the parenchyma, although as a matter 
 of fact it is doubtful if one occurs to any marked 
 extent without the other being present. In a great 
 number of the glandules there was a replacement 
 of considerably more than half the parathyroids 
 with fatty tissue and in addition, the principal cells 
 of the gland contained fat; but such cases showed 
 nothing clinically that would serve to call attention 
 to a lack of parathyroid function. 
 
 While it may be stated that in general more fat 
 is to be found in elderly" individuals than in those of 
 
THE PATHOLOGIC HISTOLOGY 261 
 
 middle age, still one would hesitate to accept the 
 view that a regular and constant increase of fat is 
 an accompaniment of increasing age. A number 
 of glandules in individuals over sixty years of age 
 were found that were only moderately fatty, and 
 on the other hand, there were found glandules in 
 patients from twenty to thirty years of age in which 
 there was marked fatty change both in parenchyma 
 and stroma. One would not, therefore, limit the 
 diagnosis of fatty degeneration to the earlier years 
 of life, although admitting the increased difficulty 
 of making such a diagnosis in the later years. 
 
 The fat content is, as previously stated, so physio- 
 logically variable that one hesitates to attempt any 
 classification for fatty degeneration of the glandules. 
 The most marked changes in these cases, the factor 
 of age being kept in mind, have been found in the 
 following conditions: cirrhosis of the liver; chronic 
 nephritis, especially chronic parenchymatous neph- 
 ritis; chronic heart affections with the usual asso- 
 ciated lesions ; chronic tuberculosis ; diabetes. Espe- 
 cially are the glandules apt to be fatty when an acute 
 infection is superimposed on a chronic condition. 
 The most constant and marked fatty change in any 
 one series of cases was in five instances of ascending 
 infection of the genito-urinary tract with pyelo- 
 nephrosis. In all these cases, which were of various 
 ages, marked fatty change in the parathyroids was 
 found. These cases are representative only of a 
 type of rather long continued acute infection where 
 considerable chronic disease of the lungs, heart, and 
 liver was present. 
 
262 PARATHYROID GLANDS 
 
 The association of marked, fatty change in the para- 
 thyroids .with cases of infection of the gall-bladder 
 and ducts, with extreme jaundice in four cases of 
 this condition, might be noted in passing. In ma- 
 lignant diseases, carcinoma especially, of either 
 comparatively long or comparatively short duration, 
 there was no fixed condition of fatty content in the 
 parathyroids. At times these organs showed marked 
 fatty change ; at times there was no apparent increase 
 of fat. The same was true in regard to the para- 
 thyroids in cases dying from uncomplicated acute in- 
 fectious diseases of short duration such as lobar pneu- 
 monia. A case of tertiary syphilis (the only one in 
 this series), showed marked fatty degeneration of 
 the glandules. 
 
 Colloid. — It would be unfair to exclude the pres- 
 ence of colloid unless serial sections are made of all 
 glandules, although if colloid is present at all it is 
 usually more or less widely distributed in a given 
 glandule. Colloid was found in about fourteen per 
 cent of all cases. This agrees with the statement that 
 the presence of a certain amount of colloid in indi- 
 viduals over twenty years of age is not to be consid- 
 ered abnormal. The interesting point in regard to 
 colloid is the fact that its secretion not infrequently 
 leads to appearances in the parathyroid that makes 
 circumscribed areas within them exceedingly sug- 
 gestive of thyroid structure. These areas begin by 
 a dozen cells, more or less, assuming an alveolar ar- 
 rangement. In the center so formed a droplet of 
 colloid appears. Continued secretion of colloid pushes 
 back and flattens the cells so that finally a follicle, 
 similar to those seen in the thyroid gland, appears. 
 
THE PATHOLOGIC HISTOLOGY 263 
 
 If enough of these are formed in juxtaposition, thy- 
 roid-like structure results. Usually, however, these 
 colloid follicles are discrete, or the amount of colloid 
 is not sufficient to alter the general topography of 
 the glandule. 
 
 Even though a picture somewhat like thyroid 
 structure may be produced, one should remember 
 that on embryological, anatomical; and physiological 
 grounds there is no relationship between human 
 thyroid and parathyroid, save that of propinquity. 
 They are independent of each other, and there is 
 no reason for assuming that one acts for the other, 
 although it is probable that there is some inter- 
 action between the two. There is no reason to be- 
 lieve, as stated by Forsyth, that histologically in- 
 termediate stages between thyroid and parathyroid 
 are common, in the human being at least, or that 
 the difference in the glands is merely a difference in 
 the amount of secretion; neither have we reason to 
 suppose that the parathyroids exhibit a partial 
 change to thyroid structure with advancing age as 
 claimed by Rogowitz. 
 
 Vincent and Jolly find that parathyroid tissue left 
 behind after thyroid extirpation "approximates in 
 appearance to ordinary thyroid tissue," and believe 
 that the parathyroid functionally replaces thyroid. 
 Their view is directly opposed by Hagenbach, how- 
 ever, who obtained a typical cachexia thyropriva 
 when two parathyroids were left behind. 
 
 Thompson and Harris did, however, find in this 
 region appearances which they chose to consider 
 accidents of propinquity and in which there was an 
 apparent transformation of one organ into the other, 
 
264 PARATHYROID GLANDS 
 
 but which they considered should be interpreted on 
 more rational grounds than transformation of para- 
 thyroid into thyroid. 
 
 In this case (which showed at autopsy caseous 
 tuberculous pneumonia, chronic pleuritis, localized 
 peritonitis, and peri-hepatitis) there were fairly firm 
 adhesions in places between the capsule of the thy- 
 roid and surrounding tissue. The upper parathy- 
 roids were normal; left lower not found; left right 
 lower pole showed a circumscribed thickening of 
 the surrounding structures and was excised. Micro- 
 scopically, section of this showed, on the outer edge, 
 fairly typical parathyroid structure penetrated by a 
 dense connective tissue stroma. The inner part of 
 the section showed typical thyroid structure with a 
 similar increase of stroma. There was no line of 
 demarcation between the two, but one seemed to 
 run into the other so as to suggest the transformation 
 of parathyroid into thyroid tissue. It seems more 
 rational to assume, however, that a perithyroiditis 
 leading to proliferative changes in both glands joined 
 the two organs together in this peculiar manner, the 
 connective tissue ingrowth being so distributed that 
 both appear to be one and the same organ. 
 
 Degenerations. — Acute degenerative changes oc- 
 cur in the parenchymatous cells of the parathyroid 
 glandules, but a diagnosis of "cloudy swelling" or 
 "acute degeneration" is to be made only when one 
 can exclude post-mortem changes and other adventi- 
 tious factors that might arise wholly apart from in- 
 trinsic parathyroid changes. In many cases the 
 glandules are microscopically enlarged, are soft and 
 pale, or firm and tense. These changes are usually 
 
THE PATHOLOGIC HISTOLOGY 265 
 
 due to increased fluid content (oedema) and are prac- 
 tically always a part of a general oedema of the neck 
 organs. Microscopically the cells in such glandules 
 are larger than normal, the cytoplasmic granules are 
 more distinct than usual and the nuclei large and pale. 
 Frequently the usual structure of the gland is lost 
 and no good cell pictures obtained. The authors 
 have been unable to fix such appearances as being of 
 significance. 
 
 Hemorrhage. — Hemorrhage was found in these 
 cases of Thompson and Harris only three times. The 
 rarity of hemorrhage in adults has been noted by Erd- 
 heim, who found it seven times in children but only 
 in one instance in an adult. Getzowa found it only 
 once in the adult. Yanase also speaks of the in- 
 frequency of hemorrhage in these glandules in adults 
 although he has been able to demonstrate it fre- 
 quently in the first year of life, as previously noted. 
 Verebely found hemorrhage only once in the adult 
 (twice in children), in his one hundred and twenty- 
 five cases. Benjamins and Peterson only report 
 single cases, the latter in one hundred autopsies. 
 Our cases of hemorrhage were found in connection 
 with toxic glomerulo-nephritis, marked general ane- 
 mia secondary to syphilis, and acute parenchyma- 
 tous nephritis, respectively. In none of these cases 
 was' there any clinical manifestation- of tetany. 
 
 Fibrosis. — The amount of connective tissue found 
 in the parathyroids is, in general, subject to wide 
 variation. The gland may consist of a continuous 
 mass of epithelial cells penetrated by a considerable 
 capillary network, unaccompanied by connective 
 tissue, or there may be a continuous reticulum run- 
 
266 PARATHYROID GLANDS 
 
 ning throughout the gland. When the gland is 
 broken up into distinct islets by a decided connective 
 tissue stroma there is in the gland more connective 
 tissue than should be considered normal for the 
 structure. Some authors, however, choose to class- 
 ify this as a particular ' 'type' ' of gland. In any event 
 the widening of such a stroma and the decreased 
 size of the islets leads to the different degrees of 
 what may be termed "chronic interstitial parathy- 
 roid it is;" or, as Verebely, who found the condition 
 well marked in two cases, terms it, "parathyroiditis 
 chronica fibrosa." The best examples of this con- 
 dition have already been described under primary 
 infantile atrophy. 
 
 In the series of cases described by Thompson and 
 Harris every possible variation in connective tissue 
 content of these glandules was met with. 
 
 The cases exhibiting connective tissue increase in 
 the parathyroids are, in this series, almost without 
 exception in poorly nourished individuals showing 
 at autopsy chronic heart lesions with general chronic 
 passive congestion, cirrhosis of the liver, and chronic 
 tuberculosis. However, the greater number of cases 
 exhibiting the above lesions show no changes in the 
 parathyroids, so that chronic fibrous parathyroiditis 
 is not necessarily an accompaniment of these condi- 
 tions, although it may be most frequently found in 
 connection with such. 
 
 That specific infectious agents may bring about 
 this condition is suggested by the extreme sclerosis 
 found in a lower parathyroid in a case of acute 
 miliary tuberculosis. The reaction in this case can 
 be compared with the appearance sometimes seen in 
 
THE PATHOLOGIC HISTOLOGY 267 
 
 very chronic, tubercle bacilli poor, tuberculosis of 
 lymph nodes, where there is little or no caseation or 
 tubercle formation but marked connective tissue 
 hyperplasia. 
 
 In the opinion of these authors the fact that even 
 in extreme age and in a great variety of severe dis- 
 eases the parathyroids are so comparatively free 
 from lesion is more noteworthy, and a better proof 
 of their importance than would be the frequent 
 finding of lesions that would seriously impair their 
 function. In none of the cases that showed fibrosis 
 was there any clinical manifestation of tetany. 
 
CHAPTER XVI. 
 
 CYSTS AND TUMORS. 
 
 Cysts occurring in connection with the parathyroid 
 glands may be broadly classified as (1) retention 
 cysts; (2) polycystic degeneration; (3) cysts arising 
 either without, or in the neighborhood of, the para- 
 thyroids (branchial cysts). The production of cysts 
 of the former class has already been discussed under 
 colloid. These small cysts are quite common. 
 Thompson and Harris found them in about five per 
 cent of their cases. Peterson found cysts six times 
 in his one hundred cases. Cysts have also been 
 noted by Benjamins, by Pepere and by Kohn. The 
 latter author was the first to describe retention cysts. 
 They may be single, or three or four may be found in 
 a single glandule; rarely do these cysts exceed the 
 diameter of a low power field. 
 
 Polycystic degeneration has been found by several 
 authors — Schaper in the parathyroid of a sheep; 
 Erdheim in an eighty -three year old woman. Vere- 
 bely also describes a similar picture in the parathy- 
 roid, but on account of the variation in the lining 
 epithelium of the cysts prefers to class his case as 
 a branchial poly cystoma. 
 
 It would seem that colloid filled spaces are in gen- 
 eral so frequent that there is no necessity for consid- 
 
CYSTS AND TUMORS 269 
 
 ering these "retention cysts" in detail unless they 
 assume a number or size that brings them into rela- 
 tion with the condition described elsewhere, namely : 
 true cysts and thyroid-like structure. 
 
 The cysts included in class (3) are to be con- 
 sidered as developmental anomalies. Verdun has 
 contributed extensively to their embryological de- 
 velopment, and more recently Erdheim has sought a 
 classification for these branchial cysts. The latter 
 author finds two different types of cysts in relation 
 with the upper parathyroids which arise from the 
 fourth gill pouch. The more common and better 
 known cysts are, however, in relation with the lower 
 parathyroids which arise from the third gill pouch. 
 Verebely describes in detail two cysts in connection 
 with the upper glandules, one of which he terms 
 a post branchial cyst, the other a branchial cyst. 
 
 Thompson and Harris found only two cysts 
 of the parathyroid of any considerable size. The 
 first in a woman seventy -two years old with atrophic 
 thyroid (lateral lobes measured only 3x2.5 centi- 
 meters), upper parathyroids in normal position but 
 quite small (5x1 . 5x . 5 millimeters) . Left lower para- 
 thyroid not found. At the base of the right lower 
 lateral pole of the thyroid is a parathyroid gland 
 forming a flattened cap to a cyst which measures 
 two by two by two and one half centimeters in diam- 
 eter. The cyst wall is lined with a single layer of 
 flattened epithelium. The second cyst was also in 
 connection with a lower glandule and practically its 
 equivalent in size (7x4x3 millimeters). This was a 
 simple cyst. 
 
270 PARATHYROID GLANDS 
 
 TUMORS OF THE PARATHYROID GLANDS. 
 
 Tumors of the parathyroid glands have been re- 
 ported by a number of writers, and we can now find 
 in the literature a number of these growths which 
 are described in considerable detail. 
 
 The first of these was a tumor described by de 
 Santi (1900) as a rather large vascular growth, the 
 structure of which corresponded to parathyroid 
 tissue. The tumor grew with considerable rapidity, 
 but was classified as not malignant. 
 
 Most of these tumors represent reproduction of 
 parathyroid tissue, and should be designated, per- 
 haps, as examples of hypertrophy and hyperplasia 
 rather than classified as true tumors. Weichselbaum 
 and others lean toward the designation of adenoma 
 for these growths, although, as this author states, a 
 distinct boundary line between adenoma and hyper- 
 plasia cannot be sharply drawn. Most of these 
 growths have been of small size. In certain of these 
 tumors, as those of Benjamins, of Hulst, and of 
 Thompson and Harris, the proof of parathyroid 
 origin is lacking, save for the resemblance of the 
 tissue to parathyroid structure, and the latter au- 
 thors refer to their growth simply as a ' 'parathyroid- 
 like" tumor. 
 
 Verebely has noted the fact that there is a great 
 similarity between the cells of the parathyroid and 
 rapidly-growing parenchymatous thyroid nodules, 
 so that one must keep in mind the question of con- 
 genital fetal anomalies in the origin of these growths ; 
 such, for instance, as the failure of closure of the 
 central canal of Prenant. The work of Getzowa and 
 
PLATE XXXVII 
 
 P. T CYSTIC PARATHYROID GLANDULE. 
 
CYSTS AND TUMORS 271 
 
 of Langhans has thrown much new light upon these 
 epithelial forms of malignant struma and brought up 
 the question of the origin, of certain types, at least, 
 from the post -branchial bodies. 
 
 Tumors of the parathyroid glands may be grouped 
 primarily as (1) Extrathyro ideal (2) Intrathy- 
 roideal. To the first group belong the cases reported 
 by Erdheim, MacCallum, Weichselbaum, and Vere- 
 bely. 
 
 Erdheim's case occurred in an eighteen year old 
 individual in one of the inferior parathyroids. It 
 was situated below the lower pole of the thyroid and 
 entirely separated from the same; it measured two 
 and a half, by one and a half centimeters in diameter. 
 The tumor consisted of a fine, faintly vascularized 
 stroma in which were imbedded strands and irregu- 
 lar masses of epithelial cells. The cells corresponded 
 to those of the normal parathyroid and between 
 them, here and there, colloid droplets were to be 
 seen; there was no definite follicular structure. In 
 one part of the tumor a small cyst lined with a single 
 layer of epithelium and having a fatty content was 
 noted. 
 
 MacCallum reported a tumor found at autopsy in 
 a male, aged twenty-six years, who died of uremia. 
 This tumor was just below the lower pole of the thy- 
 roid, on the right side and separated from it. It 
 consisted of a long, smooth mass about two centi- 
 meters in diameter, enclosed in a delicate capsule and 
 richly supplied with blood vessels. The thyroid gland 
 in this case was normal, and two normal parathyroids 
 were found. On microscopic examination the tissue 
 comprising the tumor was found to closely resemble 
 
272 PARATHYROID GLANDS 
 
 parathyroid. The mass was made up of strands and 
 large groups of cells separated by a delicate vascular 
 stroma. No colloid was found in either the cells 
 or the alveolar spaces and the blood supply was less 
 than was normally present in the parathyroid. Mac- 
 Callum classified the tumor as an adenoma. 
 
 Goris found a tumor in a twenty-two year old male 
 consisting of three closely connected cysts which 
 contained colloid and degenerated parathyroid tissue. 
 This case should perhaps be classified under cystic 
 degeneration of the parathyroid rather than in this 
 place. 
 
 Von Verebely has described a tumor of the para- 
 thyroid, belonging to the first group. This tumor 
 was found in a forty-two year old woman in whom 
 three parathyroids were found, normal in size and 
 position. The tumor appeared as an oval, flabby, 
 concave body under the lower pole of the right thy- 
 roid, measuring two and a half, by one and three- 
 quarters, by one and a half centimeters in diameter. 
 It possessed a thin, stretched out capsule. On sec- 
 tion it was found to be made up of a soft homo- 
 geneous, vascular tissue. Microscopically the cap- 
 sule gave off delicate septa ramifying within the 
 tumor and connecting with the perivascular tissue, 
 so that a delicate framework was formed, carrying 
 capillaries, and possessing spaces filled with epithe- 
 lial cells. The epithelial cells formed rows and 
 strands, and were sometimes arranged in round or 
 irregular islets. Three extreme types of cells, which 
 shaded into each other by various gradations, were 
 described in this growth. These cells corresponded to 
 the type of principal cells of the parathyroid for the 
 
CYSTS AND TUMORS 273 
 
 most part. The cells of the second type were vacuo- 
 lated, and appeared singly or in small groups. The 
 third type corresponded to the functioning cells, and 
 varied considerably in size. No mitoses were to be 
 seen in any of the described cells. 
 
 Weichselbaum described a tumor of the parathy- 
 roid found at autopsy in a woman who died of pneu- 
 monia. In this case both of the lower parathyroids 
 and the right upper parathyroid were normal in size 
 and position. In the left upper glandule was a flat- 
 tened tumor measuring four and three-tenths by 
 three and six-tenths, by one half to one centimeter 
 in diameter. It covered a part of the posterior 
 surface qf the left thyroid as well as the posterior 
 surface of the right thyroid. It was very soft, and 
 gray-red in color. Histologically the tumor consisted 
 essentially of normal parathyroid structure, with no 
 suggestion of malignant tendency. The tumor pos- 
 sessed a delicate connective tissue capsule, strands 
 of which penetrated the mass, separating the cells 
 into groups of different size. These cells could be 
 divided into four different types — the first cor- 
 responding to the principal cells of the normal para- 
 thyroid; the second corresponding to the functional 
 cells of the normal parathyroid ; the third character- 
 ized by the grouping of the cells around a central 
 lumen ; and, finally, cell groups not definitely separ- 
 ated by a stroma in which cells and nuclei were quite 
 small. 
 
 Intrathyroideal tumors have been described by 
 Benjamins and by Hulst and, as previously stated, their 
 origin is open to question, as are the other tumors 
 whose description follows. The tumor described by 
 
274 PARATHYROID GLANDS 
 
 Benjamins was in a fifty-seven year old male; situ- 
 ated in the right thyroid lobe. This tumor developed 
 within three years to the size of a child's head, and 
 recurred after extirpation. This tumor showed a 
 connective tissue framework in which cells similar 
 to those of the parathyroid were found arranged in 
 groups ; they possessed a pale nucleus with clear • 
 protoplasm and showed a tendency toward palisade 
 arrangement ; they were a little larger than the nor- 
 mal parathyroid cells . Mitoses were rarely seen in the 
 cells. Here and there small masses of colloid were 
 found. A normal parathyroid was found in the 
 capsule of the tumor. 
 
 The tumor described by Hulst was found in a very 
 old woman, in the right lobe of the thyroid, postero- 
 medial, about the height of the isthmus of the gland. 
 It measured two and a half, by two and a half, by 
 two centimeters, and was inclosed in a calcified cap- 
 sule. Microscopically this tumor consisted of a 
 stroma rich in blood vessels and made up of cells of 
 two types; the larger were polygonal and stained 
 deeply with eosin, and their nuclei showed signs of 
 degenerative change; the smaller which appeared in 
 groups among the other cells possessed little proto- 
 plasm, and showed an eccentric nucleus which stained 
 intensively. There were various gradations between 
 these two types of cells. Mitoses were not found. 
 The author characterized the tumor as an adenoma 
 arising from parathyroid; he makes no mention, 
 however, of other parathyroid glands in this case. 
 
 Askanazy has called attention to a tumor appar- 
 ently derived from parathyroid tissue which he found 
 in a case of ostitis deformans. 
 
CYSTS AND TUMORS 
 
 275 
 
 Thompson and Harris have described a tumor 
 possessing a parathyroid-like structure which was 
 removed at operation so that no careful dissection 
 of the neck could be made. These authors state: 
 "The extreme similarity of the greater part of the 
 structure to parathyroid tissue justifies its discussion 
 in this place although certain parts of it suggest the 
 possibility of its origin from the post branchial body. 
 
 
 
 
 
 V^t ; 
 
 #%«*•» * 
 
 S «»* 1 € 
 
 •- 
 
 w+- 
 
 T \ 
 
 "* §8 o o 
 
 
 f ***V %«^ ^ • ft 
 
 * 
 
 f #• 
 
 
 
 1 m 
 
 
 
 tl 
 
 * » ■ 
 
 
 Fig. 69. Section of parathyroid tumor,, magnified 400 times. 
 (Thompson and Harris.) 
 
 We have chosen to call the growth simply a para- 
 thyroid-like tumor and regret that circumstances 
 were such that neither a careful topographical study 
 of the neck region could be made in the case, nor 
 even, owing to the way the tumor was received, could 
 the differential histological stud) 7 -, especially in re- 
 
276 PARATHYROID GLANDS 
 
 gard to glycogen content, be done that was desired. 
 
 "The specimen is a nodular encapsulated mass 
 (15x10x6 centimeters), weighing two hundred and 
 fifty grams. Some of the nodules push sharply above 
 the level; others are low, broad, and seemed fused 
 together. The larger reach a diameter of four cen- 
 timeters; the smaller measure one-half to one centi- 
 meter. The tumor is firm throughout. The cap- 
 sule is thick, fibrous, and tense, and entirely covers 
 the mass with the exception of an area, four by five 
 centimeters, which represents the severed point of 
 attachment. This capsule dips between the nodules 
 and marks their outlines. The color is brownish 
 yellow, mottled by scattered hemorrhagic areas in 
 and upon the nodules. There are no large or con- 
 gested vessels to be seen. 
 
 "On section the mass is found to consist of many 
 discrete and confluent light brownish yellow areas 
 separated more or less by fibrous trabecule. These 
 areas correspond to the superficial nodules. They 
 are firm, homogeneous, and friable ; their cut surface 
 presents a milky exudate, rich in cells. Variations 
 in the appearance of these areas depend, in the main, 
 upon the blood content. Some are pale and blood- 
 less, some show congested capillaries; others con- 
 tain bright red or dark brown areas of hemorrhage. 
 In one nodule the cut surface is marked by translu- 
 cent, silver-gray anastomosing bands of connective 
 tissue which arise from the capsule. There are a 
 few small cysts filled with a gelatinous semi-solid 
 material. 
 
 "The capsule, which on the surface is distinct both 
 in color and structure, loses its fibrous character as 
 
CYSTS AND TUMORS 277 
 
 it passes into the mass and fades into a broad brown- 
 ish yellow band. Numerous small blood vessels 
 course along the connective tissue trabecular. 
 
 "For microscopical study a segment about five 
 millimeters in thickness, cut from the median zone, 
 was carefully plotted so that in the end it was possible 
 to reconstruct the entire cut surface of the gross 
 specimen. Histologically, the specimen is an epithe- 
 lial tumor in which the cells are arranged as tubules 
 or in nests and cords resembling the structure of 
 parathyroid glandule. The connective tissue in 
 places is prominent and forms anastamosing septa 
 between the epithelial islands. In other parts it 
 is present only as a delicate basement membrane, 
 or very fine interlacing reticulum between the cords 
 and clusters of loosely lying epithelial cells. Differ- 
 ent lobules show wide variations in this proportionate 
 distribution of epithelial cells and stroma. In an 
 individual lobule this relationship is constant. The 
 epithelial cells vary in diameter from twenty to 
 twenty-five microns. The nuclei measure from four 
 to eight microns and stain deeply. The protoplasm 
 is vacuolated and stains lightly. As a rule, the cell 
 boundary is not sharply defined. For the most 
 part the cells are cuboidal or columnar and rest upon 
 a distinct but delicate basement membrane. 
 
 "The structural formation follows the type of a 
 simple gland with a small lumen, or the cells are 
 grouped into small solid nests of six or more cells. 
 From this original gland-like type, two variations 
 arise. In the* one the lumen becomes dilated, with 
 the formation of numerous small cysts, the epithelium 
 becomes flattened, and papuliferous outgrowths arise 
 
278 PARATHYROID GLANDS 
 
 from the walls. In the other variation the cells are 
 freed from their attachment to the basal membrane 
 and appear as compact or loose clusters, cords and 
 nests; the lumen disappears and all structural regu- 
 larity is lost. 
 
 "For the most part the tumor is rich in capillaries 
 upon whose delicate walls the cells are 1 attached di- 
 rectly. In a few nodules the blood supply is sur- 
 prisingly scant, entire fields being apparently free 
 from determinable vessels. The hemorrhagic areas 
 are numerous in certain lobules, the blood lying in 
 large lakes and tubules and nests. The absence of 
 large blood vessels with well developed walls is 
 striking." 
 
 DaCosta found in a female aged thirty-two years, 
 on the right side of the neck, a tumor about as large 
 as an orange. His tumor is described as follows: 
 "It passes to some extent back of the level of the 
 upper border of the thyroid cartilage above. It also 
 passed to one centimeter to the left of the median 
 line. It was smooth, regular in outline, except for 
 a bulb-like projection at its lower anterior portion; 
 and of firm consistency throughout. The growth 
 was in extremely close relation with the recurrent 
 laryngeal nerve of the right side, and great difficulty 
 was experienced in effecting a separation between 
 the nerve and the tumor mass. No parathyroids 
 were identified. The tumor was brownish yellow and 
 irregular, and presented, in front of the lower por- 
 tion, a bulb-like projection the size of a walnut, 
 which was somewhat softer and decidedly darker 
 than the remainder of the mass, but apparently a 
 portion of it." 
 
CYSTS AND TUMORS 279 
 
 The growth is described histologically as consist- 
 ing of parathyroid gland (tissue), surrounded by a 
 fibrous capsule. The epithelial-like cells were ar- 
 ranged in fairly distinct columns, or masses separated 
 by thin walls of vessels, or vascular intercellular 
 tissue. In some areas, the tissue was arranged in 
 the form of acini, lined with cuboidal or polygonal 
 cells ; although even in these instances, there was no 
 sharp demarcation between neighboring cells. The 
 protoplasm of most of the cells was granular or vesi- 
 cular, and showed weak affinity for acid stains. The 
 nuclei of these cells were small masses of material 
 that gave the staining reaction of chromatin. In a 
 number of the acini were small masses of colloid. 
 Bands of fibrous tissue, enclosing numerous areas of 
 weakly acidophile substance, or distinct masses of 
 cells, were distributed through portions of the sec- 
 tion. Many areas of hemorrhage appeared at va- 
 rious points in the section. Most of these were re- 
 cent; but at a few points there were degenerative 
 changes in the bordering gland tissue. Separated 
 from the parathyroid structure by a broad, distinct 
 band of fibrous tissue, containing many large blood 
 vessels, was a portion of attached thyroid. 
 
 De Paoli has reported two tumors of the para- 
 thyroids occurring in males aged twenty-one and 
 forty-one years, respectively. These tumors are 
 described as being composed equally of thyroid and 
 parathyroid tissue. 
 
 Pepere has reported two cases of angioma of the 
 parathyroid as well as two cases of myoma and a 
 lymphoma of these glandules. The same author also 
 described a parathyroid adenoma the size of a large 
 
280 PARATHYROID GLANDS 
 
 apple. A similar tumor, but smaller in size (1.5 
 cm. x 7 min. x 5 min.), has been described by Claude 
 and Schmiergeld. Tumors have also been described 
 by Makai, by Walther and, quite recently, by Berard 
 and Alamartine, who also give a considerable review 
 of the literature, 
 
 Metastatic involvement of the parathyroids from 
 malignant growths arising elsewhere has been re- 
 ported by Konigstein, from a bronchial carcinoma 
 which involved thyroid and three parathyroids; 
 by Pepere, two cases, from a breast carcinoma and 
 a thyroid carcinoma; and by Thompson from a 
 breast carcinoma in which there was involvement of 
 all four glandules. In none of these cases was tetany 
 observed. 
 
CHAPTER XVII. 
 
 RELATION OF THE PARATHYROID GLANDS 
 TO POSTOPERATIVE TETANY. 
 
 It is rather a peculiar coincidence that the discov- 
 ery of the parathyroid glands by Sandstroem in 
 Upsala and the first description of tetany following 
 goitre extirpation by Weiss in Vienna, should have 
 occurred in the same year. Ten years elapsed, how- 
 ever, before the relationship of these observations 
 was disclosed. It was just about this time that opera- 
 tions for goitre, which had previously been uncom- 
 mon, were, thanks to the work of Billroth and Kocher, 
 becoming more frequent. Following such opera- 
 tions it was noted that either cachexia or tetany 
 might manifest itself. 
 
 Also for many years it had been noted that certain 
 animals after thyroidectomy showed convulsive or 
 tetanic symptoms which quickly led to death, but 
 no one had considered these symptoms, either in 
 * animals or man, due to anything other than removal 
 of the thyroid gland. Schiff (1883), performed a 
 complete thyroidectomy (which of necessity included 
 the parathyroids) on 'sixty dogs, fifty-nine of which 
 died in tetany and convulsions as a result of the 
 operation. Horsley in 1892, in ignorance of the work 
 of Gley on the parathyroids which was then just 
 appearing, made the following- statement in con- 
 
282 PARATHYROID GLANDS 
 
 nection with thyroidectomized apes: "In the mon- 
 key I have found that, as a rule, the animal, after 
 complete thyroidectomy, appears perfectly well for 
 about five days. Then there is noticed a slight 
 fibrillation of the intrinsic muscles of the hands, 
 feet, and jaws following this order in successive in- 
 vasion. As a rule the fibrillation soon becomes a 
 constant tremor. The constant tremor is soon added 
 to by a series of powerful clonic spasms. This par- 
 oxysmal stage usually appears about the second or 
 third day after the tremors are first noted, and per- 
 sists about twenty days. They gradually fall in 
 force, reassume the type seen at their onset and dis- 
 appear sometimes as much as ten days before death." 
 
 Another suggestive picture of a thyroidectomized 
 ape is given by Langhans, who thus described the 
 animal: "Ich habe die Tiere vielfach gesehen, wo 
 sie hulflos auf dem Bo den sassen, zum Theil mit 
 Zwangsbewegungen, namentlich des Kopfes itnd selbst 
 des ganzen Korpers nach links, ein rechtes mitleid 
 erregendes Bild." 
 
 In herbivora, after the removal of the thyroid no 
 such accidents occurred. We now know that a con- 
 siderable amount of parathyroid tissue must be 
 present in sheep and goats outside the thyroid gland, 
 and in the rabbit two of the parathyroids are situ- 
 ated at some distance from the thyroid, so that they 
 were always left behind in removal' of this latter 
 gland. Therefore it was the lack of removal of all 
 parathyroid tissue in these animals that was the 
 reason for the lack of tetany, and not the fact that 
 animals feeding on vegetable diet were immune to 
 
POSTOPERATIVE TETANY 283 
 
 these symptoms, while animals feeding on a meat 
 diet succumbed to them. 
 
 At this point begins our second important epoch 
 in the history of the parathyroid glands, which was 
 inaugurated by the discovery of Gley, in 1891, that 
 the tetanic symptoms which appeared after removal 
 of the thyroid were not due to the loss of the thyroid 
 but were due to the loss of the parathyroid glands 
 which were removed with the thyroid. 
 
 Gley demonstrated that in the rabbit there were 
 two parathyroids separate from the thyroid and if 
 these were removed together with the thyroid, which 
 contained the other two parathyroids, the same 
 tetanic symptoms arose in the rabbit as had been 
 obtained in the dog. 
 
 Gley removed in his first experiments both the 
 thyroids and the parathyroids from sixteen rabbits. 
 Fourteen of these animals following such treatment 
 showed rapidly fatal symptoms, which began within 
 twenty-four hours after operation and led to death 
 in a few hours. Gley continued these experiments 
 and, in all, removed the parathyroids in more than 
 fifty rabbits. When the external parathyroids alone 
 or the thyroid lobes alone were removed there was 
 no tetany, but when these external bodies plus thy- 
 roid (which contained the remaining parathyroids) 
 were removed tetany and death resulted. It is to 
 be noted that the islets of parathyroid tissue that 
 are sometimes found in the thymus, were then un- 
 known, and therefore in the rabbits that survived 
 all the parathyroid tissue was probably not removed. 
 
 Gley also showed that in the dog if the thyroid 
 was removed and the parathyroids were left intact, 
 
284 PARATHYROID GLANDS 
 
 the animal did not show acute symptoms, while if 
 the parathyroids were subsequently removed the 
 usual fatal tetany resulted. Similar results were ob- 
 tained in the rabbit. When the parathyroids were 
 removed a month subsequent to the thyroid removal, 
 the animal .died with acute symptoms. 
 
 In all this work, however, Gley failed to recog- 
 nize the internal parathyroids which are within the 
 thyroid lobes, and therefore, he concluded that the 
 negative effect of removing the thyroid alone was 
 due to the vicarious action of the external parathy- 
 roids. 
 
 These researches of Gley were begun in 1891, and 
 covered a number of years. Soon after his first ar- 
 ticles appeared, a number of other investigators took 
 up this fascinating problem. 
 
 • Hofmeister confirmed the work of Gley in so far 
 as to find that severe symptoms and death followed 
 the extirpation of the parathyroid glands; he did 
 not observe the compensatory hypertrophy of the 
 organ after extirpation of the thyroid that Gley 
 had described. 
 
 Moussu in a number of experiments on the rabbit 
 and cat brought forward proof that thyroid and para- 
 thyroid .each possessed a distinct function ; the loss 
 of the thyroid was followed by chronic trophic dis- 
 turbances, such as myxcedema and marked cachexia, 
 while extirpation of all the parathyroids led to acute 
 tetanic symptoms and death. This teaching, which 
 involved a strong separation between the symptom 
 complex of thyropriva and of parathyropriva was 
 for a time a much vexed question. Moussu's ex- 
 periments, which comprised fifty-five complete para- 
 
POSTOPERATIVE TETANY 285 
 
 thyroidectomies, principally on dogs, were followed 
 by tetanic death in thirty-three cases. In the ani- 
 mals which survived, the author considered that the 
 operations were incomplete, as at autopsy one or 
 more parathyroids that had escaped ablation were 
 found in a number of instances. 
 
 Moussu gives the following description of para- 
 thyroid insufficiency in a dog where ablation was 
 not quite complete: "Appetit capricieux, elevation, 
 legere et permanente de la temperature, augmentation 
 du nombre des battements cardiaques, tacky car die, 
 dyspnee, polypnee des que les sujets sont soumis a 
 un exercice un peu actif: secousses fibrillaires ou 
 crampes musculaires momentanees, albuminuric legere 
 et inconsiante, etc.' 1 '' 
 
 Christ iani extirpated the parathyroids of the rat, 
 together with the thyroid, and observed with great 
 regularity death in tetany after the operation. 
 
 Kohn, in 1895, published a most important work 
 on the parathyroid glands in which he gave us a more 
 perfect knowledge of the anatomy of these bodies 
 than we had previously possessed, and definitely 
 established 'the independence of these organs which 
 up to this time even Gley himself despite his experi- 
 mental work had continued to regard as embryonic 
 thyroid. After the publication of Kohn's paper es- 
 tablishing the identity of the "internal" as well as 
 the "external" parathyroids, a more sure basis for 
 experimental work was offered. 
 
 As a result of this work of Kohn, Vassale and Gen- 
 erali for the first time removed all four parathyroid 
 glands without removing the thyroid. These ex- 
 periments were done on ten cats and nine dogs with 
 
286 
 
 PARATHYROID GLANDS 
 
 the following results. Of the ten cats only one sur- 
 vived (and this one developed chronic cachexia) ; the 
 other nine died as a result of the operation with con- 
 vulsive symptoms (fibrillary tremors, muscular 
 twitchings, depression, rigid and staggering gait, 
 anorexia, tachycardia, loss of weight and death). 
 The maximum time of death was ten days. The nine 
 dogs all died in less than eight days; usually on the 
 
 ' " ''Xl'S^ik 
 
 Fig. 70. Persistent islet of parathyroid tissue with granulation 
 tissue twenty-eight days after mass ligation of glandule. 
 
 third or fourth day with the respiratory and con- 
 vulsive symptoms that are now so well known. 
 
 Vassale and Generali supplemented their first ex- 
 periments by a series of two-stage operations on a 
 number of animals. They found the results were the 
 same following total parathyroidectomy if the glands 
 were removed in this way as were obtained in the 
 first experiments, save that the dog survived a little 
 longer after the final complete parathyroid removal. 
 
POSTOPERATIVE TETANY 287 
 
 Out of three dogs, two survived for twelve days after 
 the second operation, the third died on the fifth day. 
 Out of four dogs in which two parathyroids were 
 left there were no symptoms save in one instance 
 where a little transitory rigidity occurred which soon 
 cleared up. Out of two dogs in which a single para- 
 thyroid was left one presented transient symptoms, 
 the other no symptoms whatever. 
 
 Rouxeau removed the parathyroids in twenty-one 
 rabbits leaving the thyroid intact and only three of 
 these animals escaped death. The symptoms were 
 the same in general as when complete thyro-parathy- 
 roidectomy was performed. The author concluded 
 from this that in the rabbit parathyroidectomy is 
 a grave offense, while removal of the thyroid is in- 
 offensive. 
 
 Since that time these experiments have been fre- 
 quently repeated and always with analogous results. 
 Among these early workers may be mentioned De- 
 Quervain, Verstraeten and Vanderlinden, Paladino, 
 Cadeac, Guinard, Capobianco, Edmunds and Van- 
 Ecke. The details of the early work may be found 
 in the very complete monograph of Jeandelize which 
 includes as well experiments of his own. Jeandelize 
 was the first to make a sharp distinction between 
 the chronic symptoms that follow thyroid removal 
 and the acute symptoms that follow parathyroid 
 removal and to establish the independence of these 
 latter organs. 
 
 Although, with the earlier workers, the rabbit was 
 the favorite animal for experimentation, the dog, 
 owing to its larger size and its more direct connection 
 of thyroid and parathyroid has been the animal 
 
288 PARATHYROID GLANDS 
 
 most generally employed by later investigators. 
 Gley himself has used the dog in a number of his ex- 
 periments. It is well to remember, however, that 
 in many cases in this animal the glandules may be 
 so situated as to make a total parathyroidectomy 
 impossible.* Not only may there be accessory para- 
 thyroids buried in thyroid gland but aberrant para- 
 thyroids have been found at times quite a distance 
 removed from the thyroid. 
 
 Lusena was able to produce tetany in nineteen 
 dogs by parathyroidectomy, which was always rap- 
 idly fatal, (three days on the average after opera- 
 tion). Walter Edmunds on the contrary had of 
 nine dogs similarly operated on, four which survived. 
 Such apparent discrepancies can only be accounted 
 for by the lack of complete parathyroid removal 
 which is to be accomplished only by the most care- 
 ful operative procedure. 
 
 D. A. Welsh removed the four parathyroids in 
 the cat and obtained severe and fatal symptoms; 
 even with one parathyroid left in situ the experi- 
 ment was fatal for some of these animals. If two 
 parathyroids were left no serious acute symptoms 
 resulted. 
 
 Pineles operated on the ape, cat and rabbit. He 
 noted in the ape that the symptoms were of more 
 chronic character than in the other animals. His 
 operations were done for the most part in two or 
 three stages; tetanic death was obtained only after 
 
 *Gley noted 14 variations in the situation of the glandules in 33 dogs, and 
 Alquier found the classic situation of the bodies only 9 times in 15 dogs. Acces- 
 sory glandules are at any time liable to complicate the work. Vassale found one 
 on the right side of the cricoid at the first tracheal ring, five in the mediastinum, 
 three on the posterior surface of the aorta. Pianca found parathyroids on the 
 aortic trunk. MacCallum, and Thompson and Leighton have repeatedly called at- 
 tention to extra parathyroids. 
 
POSTOPERATIVE TETANY 289 
 
 removal of all parathyroid tissue, the loss of three 
 parathyroids gave rise to practically no symptoms. 
 In two apes in which all parathyroids were removed, 
 a progressive tetany developed with flaccid par- 
 alysis and contraction with final apathy, spasm 
 and death. Apes, from which the whole thyroid and 
 nearly all the parathyroid tissue was removed, 
 showed trophic disturbances, such as falling of the 
 hair, anemia, skin ulcer, and oedema of the upper 
 eyelids. Cats, from which all the parathyroids were 
 removed, died on an average in five and a half days 
 in acute tetany. If, in the cat, the entire thyroid 
 and only a part of the parathyroid was removed, 
 apathy and trophic disturbance appeared, but no 
 muscle spasm. As result of these experiments, 
 Pineles concluded that fatal tetany resulted from 
 extirpation of the parathyroid glands, while trophic 
 disturbances arose from the loss of the thyroid sub- 
 stance. 
 
 Walbaum obtained results similar to those of the 
 authors previously cited. His results will be dealt 
 with more fully in the chapter on parathyroid trans- 
 plantation, as will also the results of Biedl whose 
 work on apes, as well as on the dog and fox, is in 
 line with that previously cited. 
 
 We may mention in passing that fatal results have 
 been obtained following parathyroidectomy in birds 
 by Doyon and Jouty, and in the turtle by Doyon 
 and Kareff . 
 
 MacCallum performed either complete or partial 
 parathyroidectomy on twenty dogs. His classic 
 description of the symptoms in the parathyroidec- 
 tomized animals isasfollows: "Beginning with symp- 
 
290 PARATHYROID GLANDS 
 
 toms of unrest and anxiety with slight, twitchings of 
 the muscles here and there and fibrillary tremors of 
 the tongue, the animal rapidly passes into a state 
 in which the most violent tetanic spasms of all the 
 muscles occur. The dog is able to walk at first but 
 rather stiffly, the hind legs being especially awkward 
 and beyond his control, frequently with a sudden 
 twitch, they slip from under him and bring him 
 down upon the floor. Sometimes in walking about 
 or climbing stairs the dog suddenly falls to the floor 
 in an epileptiform convulsion, the legs are stretched 
 out rigid, the head stretched forward, all the mus- 
 cles of the neck being thrown into a tetanic con- 
 traction — breathing stops for a few moments and 
 is then gradually resumed, the legs finally relax and 
 the dog recovers and walks about again. Usually 
 however, the onset of tetany is more gradual and 
 continuously progressive and from the condition in 
 which spastic walking is possible the dog goes on 
 to that stage in which, with all the muscles rigid and 
 twitching violently, he is unable to stand at all. The 
 most violent trismus with snapping of the jaws ap- 
 pears and the tongue is often bitten; saliva pours 
 from the mouth; all the facial muscles twitch and 
 the eyes project from the fact that the upper lid 
 is much retracted. Respiration is profoundly af- 
 fected and the dogs appear to stretch out their heads, 
 panting for breath. The rate of respiration is 
 greatly increased, even up to 200 or 250 a minute. 
 With this there is no sign of cyanosis and the blood 
 is readily arterialized by shaking up in the air. Ex- 
 haustion soon supervenes and the convulsions be- 
 come less violent and the respiration less rapid, so 
 
POSTOPERATIVE TETANY 291 
 
 that if the animal does not die in the height of the 
 attack he lies relatively quiet for a time before 
 death." 
 
 Vassale and Donaggio found in the spinal cord of 
 six parathyroidectomized dogs a microscopic alter- 
 ation (after Mueller's fixation) which they con- 
 sidered a degeneration in the crossed pyramidal 
 tracts identical in situation with that following abla- 
 tion of the motor cortex, and also a similar change 
 in the posterior tracts. This apparent degeneration, 
 however, could not be demonstrated microscopically 
 with either the Marchi or the Weigert-Pal method. 
 With a nigrosin stain the axis cylinders showed 
 swelling and a granular appearance, and the myeline 
 sheath showed atrophy and did not stain well. 
 
 Russell examined the brain and cord of* seven dogs 
 which died of tetany after parathyroid removal and 
 found rather extensive chromatolysis, shrinkage and 
 distortion of the pyramidal cells and increase in the 
 number of neuroglia cells. He concluded that the 
 anatomical alterations were sufficiently well marked 
 to afford a basis for the functional changes which 
 led to tetany. 
 
 Edmunds also found changes in the brain and cord 
 of parathyroidectomized dogs. The Nissl bodies 
 were no longer defined; chromatolysis was striking. 
 Sometimes the substance took the stain deeply; in 
 some cells the chromatophilous substance was ab- 
 sent. Swelling of the nucleus and various stages of 
 destruction was observed. The changes are similar 
 to those observed after acute poisoning. 
 
 Alquier and Theunveny found that in dogs after 
 partial parathyroidectomy the menstruation periods 
 
292 PARATHYROID GLANDS 
 
 were less frequent and duration brief, and conception 
 more difficult to obtain. Study of the ovaries failed 
 to show any changes after these operations. 
 
 Manca reports the observation of changes in the 
 kidney in various animals after complete thyro- 
 parathyroidectomy. These changes are not specific 
 and appear sometimes in parenchymatous, sometimes 
 in interstitial, form. 
 
 Christens may also be cited as contributing to the 
 etiology of the parathyroid glands in the produc- 
 tion of tetany by experiments on the cat and goat. 
 
 Berkeley has removed the parathyroid glands in 
 over seventy-five rabbits, seven dogs and fourteen 
 cats. While he usually obtained lethal results, he 
 sometimes noted recovery in the animals even after 
 they had exhibited severe symptoms. He concluded 
 that in these instances a remnant of gland left be- 
 hind had time to hypertrophy. 
 
 Erdheim has contributed one of the most inter- 
 esting, important and complete articles that have 
 appeared on the subject of postoperative tetany in 
 parathyroidectomized animals. His experiments in- 
 clude partial and total operations in fifty rats. The 
 parathyroid glands were destroyed in these animals 
 by a fine cautery. . 
 
 Erdheim made careful serial microscopic sections 
 of the neck organs in all these cases exhibiting tetany 
 and demonstrated conclusively the presence of thy- 
 roid and the absence of parathyroid; thus establish- 
 ing beyond a doubt the parathyroprivic nature of 
 the tetany. 
 
 Different grades of tetanic symptoms appeared 
 following his operations. Usually symptoms were 
 
POSTOPERATIVE TETANY 298 
 
 noted in the first twenty-four to thirty-six hours, 
 consisting of tremor and spasm, continual movement 
 of the whole body musculature, shaking, tonic spasm, 
 and status epilepticus. In twenty-nine rats both 
 parathyroids were destroyed (this animal possesses 
 only two parathyroids), and, in all but two cases, 
 tetany appeared in between three and seven days. 
 In some of these animals where a third (accessory) 
 parathyroid was found in the apex of the thymus, 
 this glandule seemed to have no influence on the course 
 of the tetany. 
 
 In twelve of these cases where total parathyroid- 
 ectomy was performed the death of the animal was 
 delayed, occurring in fifty -four to one. hundred and 
 sixty-two days. In these cases the tetany showed 
 an outspoken chronic character. In addition, in 
 these twelve animals, there occurred notable trophic 
 disturbances, especially in the incisor teeth. Enamel 
 defects showed themselves as white flakes on the 
 normally yellow colored tooth. In addition the 
 teeth became brittle, and gave rise to considerable 
 pain if broken off within the alveolar process. Gan- 
 grenous stomatitis was noted in the lower jaw about 
 .the broken off roots while the teeth of the upper jaw 
 increased in length. Erdheim considered these tro- 
 phic disturbances an absolute constant symptom of 
 tetany, due to a lack of calcium deposit in the grow- 
 ing tissue. In addition cataract formation was ob- 
 served in the rat. 
 
 If in Erdheim's animals one-half a parathyroid 
 was left behind, no tetany at all, or only very mild 
 tetany, appeared. In eight cases only one parathy- 
 roid was removed, and in a third of these cases there 
 
294 PARATHYROID GLANDS 
 
 were seen only slight indications of tetany. In 
 eight rats a part of the thyroid was removed without 
 injury to the parathyroids and in these cases no sign 
 of tetany or of cachexia appeared. This work of 
 Erdheim's, in addition to proving conclusively the 
 tetany parathyropriva, is especially significant in 
 calling attention to the trophic disturbance that 
 may occur as the result of a partial loss of parathy- 
 roid tissue. 
 
 Alquier has observed the classic results following 
 parathyroidectomy in a considerable number of 
 dogs, the symptoms appearing from three to five 
 days after complete ablation of the parathyroid 
 glands. This author calls attention to the care that 
 must be used in speaking of hypertrophy of the para- 
 thyroids, as he finds great variation in size under 
 normal conditions (some authors have stated that 
 if two or three of the glands are removed the ones 
 left behind undergo hypertrophy). Alquier states 
 that he attempted to produce hypertrophy, and has 
 studied histologically glands left behind from several 
 days up to six months, after a part of the glands have 
 been removed, and he is unable to state with cer- 
 tainty that any hypertrophy takes place. 
 
 Hagenbach found that in the cat it was possible 
 to extirpate the thyroid plus the inner parathyroids 
 and leave the outer. When this was done the para- 
 thyroids left behind protected the animal from tet- 
 any. Later removal of the remaining parathyroids 
 was followed by pronounced tetany. This author 
 found that the parathyroids did not act vicariously 
 for the thyroid, as a typical cachexia thyropriva 
 developed after the first operation. Hagenbach in- 
 
POSTOPERATIVE TETANY 295 
 
 sists that functionally, as well as anatomically and 
 embryologically, the thyroid and ' parathyroid are 
 separate organs. 
 
 Frommer's experiments have confirmed the work 
 of other investigators. These will be referred to in 
 more detail later on. Segale has also published the 
 results of much experimental research on these bodies 
 and discusses these results from a metabolic stand- 
 point. This author states that tetany, although of 
 frequent development after parathyroidectomy, is 
 not a fundamental symptom. After parathyroid- 
 ectomy' such profound disturbance of metabolism 
 occurs that all efforts on the part of the organism 
 to repair it are absolutely ineffectual. He empha- 
 sizes the importance of a cachexia strumipriva due 
 to the removal of the parathyroid glands. 
 
 Pfeiffer and Mayer have also studied extensively 
 post operative tetany in a number of animals. In 
 twenty-nine dogs it was found that the full-grown 
 animal developed tetany on the average in forty- 
 three hours after removal of the parathyroid glands. 
 The longest latent period in the adult dog was sixty- 
 three hours, the shortest twenty-eight hours. In 
 four "goitre" dogs the latent period was somewhat 
 shorter, symptoms appearing as early as sixteen 
 hours after the operation. In puppies the latent 
 period was prolonged to an average of sixty-nine 
 hours, and the animal died on the average in a hun- 
 dred and ten hours after the operation. These 
 authors also operated on twenty-four rats, removing 
 the parathyroid on one side in six cases, and on both 
 sides in eighteen cases and observed chronic and 
 acute forms of tetany similar to those described by 
 
296 PARATHYROID GLANDS 
 
 Erdheim. In addition, the parathyroid glands were 
 removed from sixty-eight mice, on both sides in 
 sixty-three, on one side in five. The latter showed 
 no notable symptoms, but thirteen of the former 
 developed the typical tetanic symptom complex and 
 death. 
 
 Iselin has extirpated the parathyroid glands in 
 young rats (five to twelve weeks old). Seven of 
 these animals after excision of the parathyroids de- 
 veloped acute tetany and death within two days, 
 showing that the young rats are much more suscept- 
 ible to this injury than the full grown animals. 
 Still more susceptible are young rats born from 
 parathyroidectomized parents. These animals sur- 
 vived operation usually only four hours, and died in 
 epileptiform fulminating tetany. This work is sig- 
 nificant in regard to its bearing on children's tetany. 
 
 A second article of this same author has to do 
 with the body development of the young rats which 
 have survived partial parathyroidectomy. In some 
 of these animals a chronic form of tetany developed 
 which showed itself through apathy, trembling and 
 continued moderate paralysis. Later nutritional 
 disturbances, fracture of the teeth, the result of 
 alveolar periostitis, and fistula formation appeared. 
 Moreover, these animals acquired a roughing of the 
 fur and suffered loss in the .whole body development. 
 
 Berkeley and Beebe have obtained the following 
 results, which are too positive to need discussion 
 "The entire thyroidparathyroid apparatus has been 
 removed, a complete thyroparathyroidectomy, with 
 the result that the animals have almost invariably 
 developed symptoms of tetany in twelve to forty- 
 
POSTOPERATIVE TETANY 
 
 297 
 
 eight hours. In two cases, after what was supposed 
 to be the complete operation, there was no develop- 
 ment of symptoms and the animals were kept in 
 one instance for six weeks, and in the other for some 
 months without symptoms. Probably an accessory 
 parathyroid not removed was responsible for the 
 nondevelopment of symptoms in these cases, al- 
 though no such gland was found at the autopsy. 
 Thirty-four dogs were operated upon in this group." 
 
 
 
 i 
 
 
 
 
 
 
 
 
 
 /}> ,'.? ,?■ ' '" 
 
 
 
 
 ' %*! ; 
 
 
 
 
 ... a% >^ '- & p 
 
 
 
 ■. 
 
 
 
 
 
 * ! S? & G 
 
 ■-1 
 
 
 
 "" ^» S i_ ''5: 
 
 ...Jjg 
 
 
 iP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Fig. 71. Parathyroid glandule sixteen days after mass ligation 
 showing fusion of masses of degenerated parathyroid epithelium. 
 (Thompson and Leighton.) 
 
 A second group of sixteen animals having a com- 
 plete thyroparathyroidectomy were fed or inocu- 
 lated with thyroid proteids, in order to determine 
 whether provision of thyroid function would modify 
 the development of symptoms. Even the hypo- 
 dermic injection daily of the extract of two normal 
 dog's thyroids had no effect in retarding the develop- 
 ment of symptoms. 
 
298 PARATHYROID GLANDS 
 
 A third group of eighteen animals was submitted 
 to operation by resection of a portion of the glands 
 (thyroid and parathyroid combined) ; in one set the 
 anterior one-half, in the other set the posterior one- 
 half. In resecting the anterior one-half of the gland, 
 careful search was always made for the parathyroid 
 on the external surface of the thyroid, and care was 
 exercised to make the dividing line posterior to this 
 glandule, so that in a successful removal of the an- 
 terior one-half all the parathyroid tissue would be 
 removed .and yet an amount of thyroid tissue suffi- 
 cient to provide for the physiological need of the ani- 
 mal would remain in a normal functional condition. 
 In six out of eight cases in which four parathyroids 
 were seen at the operation and removed with the 
 anterior half, the characteristic symptoms of tetany 
 developed in the usual time. Subsequent removal 
 and section of the thyroid tissue remaining showed 
 it to be in a physiological condition. In those cases 
 in which the posterior half was removed, the divid- 
 ing line being posterior to the external parathyroid, 
 no symptoms were observed. 
 
 In a fourth group of nine animals an attempt was 
 made to destroy the parathyroids with the actual 
 cautery, with a minimal amount of injury to the thy- 
 roid. In four of these animals four parathyroids 
 were found and cauterized and in these the operation 
 was followed by the characteristic symptoms of 
 tetany. The cautery caused only a small amount of 
 injury to the thyroid. Microscopic section showed no 
 pathological condition of the latter gland and its 
 blood supply was not impaired, so that there can be 
 no doubt that it was capable of functioning in these 
 
POSTOPERATIVE TETANY 299 
 
 cases, but the symptoms of tetany came on promptly 
 and were quite as characteristic in this group as in 
 the others having a more complete operation. 
 
 Thompson, Leighton and Swarts, in connection 
 with their work on ligation of the parathyroid artery 
 referred to in the first chapter, have shown that a 
 single parathyroid glandule is sufficient to maintain 
 life in a dog, but when this is removed the animal 
 quickly dies in tetany. 
 
 These authors selected dogs in which four nor- 
 mally situated parathyroids could* be found and at 
 their first operation three parathyroids were excised 
 and one glandule (with its artery ligated), left in 
 place. Following such operation no symptoms, save 
 in a few instances slight transient tetany, occurred, 
 When the sustaining glandule was excised, however, 
 the dog died in tetany. In three dogs removal of 
 the fourth glandule did not result in tetany and 
 autopsy showed extra parathyroids in these latter 
 instances; so that not infrequently it may happen 
 that four superficial parathyroids may be excised 
 in this animal and extra glandules (usually intra- 
 thyroidal) protect the animal from death. As long 
 as a single glandule remains the animal does not ex- 
 hibit tetany. When this last glandule is removed 
 the animal dies in tetany. 
 
 EXPERIMENTS OPPOSED TO TETANY. 
 
 In consideration of the vast amount of proof that 
 has been brought forward by so many skilled investi- 
 gators in favor of postoperative tetany as a result 
 of the removal of the parathyroid glands, it seems 
 
300 PARATHYROID GLANDS 
 
 hardly necessary to quote the few articles that have 
 appeared from time to time in opposition to this 
 theory. That doubt should arise, however, is quite 
 natural from the small size of the parathyroids and 
 the seeming inconsistency that such little organs 
 could be of such vital importance. As Erdheim 
 says: "Between the small size of the parathyroid 
 glands and the severe, often- fatal result of their re- 
 moval there is such a striking contrast, that the 
 function of these bodies strikes us as something 
 marvelous, and we are apt to maintain a skeptical 
 attitude thereto." 
 
 Blumenreich and Jacoby have denied the influ- 
 ence of the parathyroids in the production of the 
 tetanic symptoms described by other authors. A 
 careful examination of their work fails to show that 
 they removed all the parathyroid tissue in their ex- 
 periments, and we know that a single parathyroid 
 left intact is sufficient to prevent the development 
 of tetany. In twelve rabbits these authors removed 
 the thyroid and two parathyroids, in five animals 
 the thyroid and one parathyroid, and in four only 
 the thyroid. They found no difference between re- 
 moval of the thyroid alone and the thyroid with 
 one or two parathyroids. 
 
 Blum has declared that in his opinion the para- 
 thyroids are nothing more than embryonic thyroid 
 possessing no particular function in the body. He 
 rests this assumption, however, on the work of Kishi 
 which has been severely attacked by Erdheim as 
 showing sovereign ignorance of the work of previous 
 investigators on the embryology and anatomy of 
 these glands Kishi seems to be absolutely unaware 
 
POSTOPERATIVE TETANY 301 
 
 of the presence of the internal parathyroids in cats 
 and dogs and his work, therefore, is practically with- 
 out value. 
 
 As a further proof of his assumption Blum offers 
 the results of his experiments on a number of dogs 
 from which the greater part of the thyroid and (pre- 
 sumably) the parathyroids were removed without 
 obtaining tetany. However, in several of these dogs 
 on which a second operation was performed for the 
 extirpation of the tissue left behind death in tetany 
 was obtained. Blum describes changes in the thy- 
 roid that have been left behind consisting in an ex- 
 traordinary cell increase which caused them to ap- 
 pear similar to parathyroid in their structure and 
 he thinks that the small thyroid rests were able to 
 perform the duty of both thyroid and parathyroid. 
 In this conclusion he has few supporters and his 
 technic may be criticised as not definitely proving 
 the removal of all parathyroid tissue. 
 
 Bayon has, incidentally in the course of other work, 
 made the observation that thyro-parathyroidectomy 
 is not fatal for the rabbit. Apparently this author 
 has not taken into consideration the extrathyroidal 
 parathyroids in the rabbit and in his experiments 
 failed to remove two parathyroid glands. 
 
 Caro thinks that the accidents observed by pre- 
 vious authors cannot be separated into those due 
 to loss of thyroid and those due to loss of parathyroid. 
 His experiments on dogs led him to conclude that 
 a very small amount of thyroid protected the animal 
 from tetany, but when these remnants were removed 
 death of the animal in tetany resulted. These thy- 
 roid remnants he describes as being entirely free from 
 
302 PARATHYROID GLANDS 
 
 parathyroid tissue. This author attacks especially 
 the work of Erdheim, but as Schirmer, who has criti- 
 cally reviewed both the results, states: "If one com- 
 pares the large amount of material of Erdheim 
 worked out with such rare industry, and such min- 
 ute exactness in its technical and histological detail, 
 with the work of Caro's which lacks weight in many 
 essential points and leaves important details to in- 
 complete footnotes, one will be convinced that the 
 attack of Caro will have little effect in weakening 
 the results of Erdheim's extensively compiled evi- 
 dence." 
 
 Vincent and Jolly have also reached results that 
 differ considerably from those of previous investi- 
 gators and are not so easy of criticism since the work 
 appears to have been carried out with much care 
 and exact knowledge of anatomy on a large number 
 of animals of many different species. ' These inves- 
 tigators did obtain tetany and death in a number 
 of instances after parathyroid removal, but not with 
 the same uniformity as did the other investigators 
 that we have previously quoted. These authors con- 
 clude that neither the thyroid nor parathyroids are 
 essential to life since it is frequently possible to re- 
 move either or both without causing death. Out of 
 fifteen cats on which the complete operation was 
 performed ten died with the usual "nervous symp- 
 toms." Of the five surviving animals three showed 
 grave "nervous symptoms." One cat showed no 
 symptoms, and a young cat ceased for a time to 
 grow but otherwise remained normal. These authors 
 used the term "nervous symptoms" rather than 
 "tetany." These symptoms are described as a curi- 
 
PLATE XXXVIII 
 
 P. T. PARATHYROID GLANDULES. TWO INFERIOR GLANDULES FOUND ON 
 THE LEFT; THE INFERIOR ON THE RIGHT SIDE NOT FOUND. 
 
POSTOPERATIVE TETANY 303 
 
 ous "paw-shaking" and some malaise. This is fol- 
 lowed in rapid succession by "tremors," stiffness of 
 gait and convulsions. "Even in a quiescent state, 
 the forelegs tend to be flexed, while the hind legs are 
 extended, a position exaggerated during the con- 
 vulsions." 
 
 Out of five dogs operated on by these authors typi- 
 cal tetanic symptoms were produced in all save one 
 Although these authors state that in this case there 
 cannot be the slightest doubt that thyroids and para- 
 thyroids were completely removed, the not infre- 
 quent finding of accessory parathyroids, at times 
 considerably removed from their normal situation, 
 as we have previoulsy chronicled, makes it impossible 
 for us to accept such a statement as absolute. In 
 four foxes from which thyroids and parathyroids 
 were removed all died in severe tetany, the symp- 
 toms appearing with remarkable rapidity. In seven 
 monkeys on which the same experiment was per- 
 formed none died and in only two were tetanic 
 symptoms observed. Their experiments on rats 
 while negative were too few to admit comparison 
 with the extensive work of Erdheim on this animal. 
 Finally, following the complete operation upon four 
 guinea pigs, no symptoms of any kind were observed. 
 As the authors themselves state the extreme vari- 
 ability in the anatomy of the parathyroids in this 
 latter animal has rendered their experiments rather 
 unsatisfactory. 
 
 In a later article these authors continued their 
 experiments with results similar to those just re- 
 corded. One monkey died in convulsions on the day 
 following the operation, but the authors state that 
 
304 PARATHYROID GLANDS 
 
 in this case the recurrent laryngeal nerve on one side 
 was included in a ligature. Of two prairie wolves 
 one developed a convulsive attack with typical rapid 
 respiration which lasted for two days but subsided 
 and death did not occur until thirty-eight days after 
 the operation. The other animal showed no symp- 
 toms. Two badgers exhibited no symptoms after 
 "complete ' ' operation . 
 
 A careful analysis of this work fails to show wherein 
 the authors are justified in their somewhat sweeping 
 assertion that neither thyroids nor parathyroids are 
 essential to life. While their results have not been 
 so striking as those of some of the previous investi- 
 gators, still it will be noted that a great many of 
 their experiments show the same fatal outcome that 
 we have been led to expect following the removal 
 of the parathyroid glands. Where such outcome 
 was not forthcoming it was usually in animals in 
 which the distribution of the parathyroid tissue has 
 not been carefully worked out and we can only as- 
 sume in such instances that the parathyroid glands 
 were not removed with absolute completeness. In 
 fact, since the publication of this work Harvier and 
 Morel have shown that in the cat accessory para- 
 thyroids are to be found in the thymus in fifty per 
 cent, of cases. 
 
 While it is impossible to note the opinions of all 
 authors who have thrown their argument to either 
 one side or the other of this question, we may note 
 that Munk has laid considerable stress dn the cases 
 of survival after the removal of the thyroid and 
 parathyroid glands and he states that in his opinion 
 the tetany observed in such cases is the result of 
 
POSTOPERATIVE TETANY 305 
 
 nerve injury; a statement that is disproven by the 
 numerous experiments in which a single parathyroid 
 left behind will protect the animal from tetany de- 
 spite extensive trauma. 
 
 CHRONIC DISTURBANCES DUE TO PARTIAL LOSS OF 
 THE PARATHYROID GLANDULES. 
 
 In the emphasis that has been put upon the tetany 
 following the complete loss of the parathyroid glands, 
 nutritional disturbance following parathyroid oper- 
 ations has been given scant attention, although 
 trophic disturbance following interference with, 
 but not complete loss of, these glandules has been 
 casuistically noted since the time of Gley, who stated 
 that in both dogs and rabbits he had sometimes 
 observed only nutritive disturbances after parathy- 
 roidectomy. 
 
 Vassale and Generali noted that one of their 
 parathyroidectomized cats survived for two months 
 with symptoms of chronic cachexia. Pineles de- 
 scribed trophic disturbances in the ape consisting of 
 falling of the hair, anemia, skin ulcers and oedema 
 of the upper eyelids (in these cases thyroid as well 
 as parathyroids was removed). Also in cats fol- 
 lowing similar operation apathy and trophic dis- 
 turbances were observed by this author. Walbaum 
 recounted cachexia appearing in rabbits with nutri- 
 tional disturbances, especially roughening of their 
 coats, in the course of his experiments. Segale in- 
 sisted that we must regard cachexia as depending 
 especially on the removal of the parathyroid glands. 
 MacCallum has observed cachexia as a result of para- 
 thyroid removal in certain of his dogs, and in three 
 
306 PARATHYROID GLANDS 
 
 sheep he reported that a marked emaciation and 
 apathy followed parathyroid removal. Vincent and 
 Jolly noted cachectic symptoms in a number of 
 their animals operated on. 
 
 Pinto found that while a total ischemia of the 
 thyro-parathyroid apparatus was followed by tetany 
 in from sixteen to thirty-one hours, if it was longer 
 continued, symptoms of tetany and cachexia or only 
 pure symptoms of cachexia were observed. 
 
 The work of Erdheim, who obtained chronic nutri- 
 tional disturbances, especially enamel defects lead- 
 ing to fracture of the teeth, in parathyroidectomized 
 rats, is especially significant along this line. We 
 have already quoted his results at length. 
 
 That disturbances of a trophic nature may occur 
 in connection with partial loss of parathyroid tissue, 
 then, is a well established fact, and its occurrence, 
 apart from tetany, has been especially studied by 
 Thompson and Leighton, in twenty dogs. In these 
 animals the parathyroids were gradually destroyed 
 by mass ligation instead of excising them as had 
 been done by previous experimenters. These authors 
 state: "Following the ligation of the parathyroid 
 glandules in the dog one of two things may happen : 
 (a) Functioning islets of gland tissue may persist, 
 keeping the dog alive for a considerable length of 
 time ; (b) The glandules may eventually be replaced 
 by dense fibrous tissue and the dog die. In either 
 event a train of symptoms of a trophic nature arises, 
 entirely different in character from the severe acute 
 tetanic manifestations that follow complete para- 
 thyroid excision in these animals." This brings two 
 facts into prominence that are worthy of note. 
 
POSTOPERATIVE TETANY 
 
 307 
 
 First, which is important for practical surgery, that 
 ligation of the parathyroids, whereby they are left 
 in situ with their usual blood supply destroyed, does 
 not always destroy the glandules and is not the same 
 thing as excision. Second, that by this ligation of 
 the parathyroids, disturbances of nutrition, which 
 may ultimately end in death, can be brought about 
 without producing any tetanic symptoms whatso- 
 
 Fig. 72. Complete destruction of parathyroid by mass ligation, 
 forty-eight days. Death in cachexia with no tetany followed this 
 gradual complete destruction of parathyroid tissue. 
 
 ever, although the death can be definitely proven 
 to be due to loss of the parathyroid glands. 
 
 In these experiments the glandules, after partial 
 separation from thyroid or capsule and identification 
 of the parathyroid artery, were lifted up by wide rat- 
 tooth forceps, which were crushed into the under- 
 
308 PARATHYROID GLANDS 
 
 lying thyroid tissue, and a strong linen ligature passed 
 around the whole mass. This procedure seemed to 
 approximate the conditions of accidental injury that 
 might occur in connection with thyroid operations 
 whereby granulation tissue could form from in- 
 jured tissue about the parathyroids. 
 
 The following is a brief summary of the results ob- 
 tained in these dogs where chronic death with nutri- 
 tional disturbances replaced the tetany that usually 
 occurs subsequent to loss of the parathyroids: 
 
 Operation: ligation of two parathyroids on right 
 side. Removal of thyroid (with parathyroids) on 
 left side. Dog recovered from operation and showed 
 no symptoms for several days. On fifth day ani- 
 mal slept a good deal and took food sparingly. 
 On the sixth day dog appeared weak and refused 
 food. Died on the seventh day very quietly, but 
 with the development of a slight tremor just before 
 death. Microscopic examination of the ligated para- 
 thyroids showed them to be replaced by fibrous 
 tissue. 
 
 Operation: ligation of two parathyroids on right. 
 Removal of thyroid (with parathyroids) on left. 
 Dog recovered perfectly from the operation and 
 lived thirty-three days. During this time it pro- 
 gressively lost in weight and strength. The animal 
 lay curled up in his cage in an apathetic condition, 
 refused food, and was finally found dead. At autop- 
 sy the ligated glandules were found completely re- 
 placed by fibrous tissue. 
 
 Operation: five parathyroids found (the left ex- 
 ternal double) and all ligated. Despite the appar- 
 ently complete operation the dog showed no acute 
 
POSTOPERATIVE TETANY 309 
 
 symptoms. The animal lost rapidly in weight, how- 
 ever, and a slight conjunctivitis developed. Forty- 
 four days after first operation neck was again opened 
 and a large (hypertrophic?) parathyroid found on 
 the right (evidently analogous to the double glandule 
 of the left side) that had escaped at the first opera- 
 tion. This was ligated. Ligatures of the previous 
 operation in place and only connective tissue thick- 
 ening to be seen macroscopically about them. Neck 
 closed up. Dog soon began to show marked weak- 
 ness, could scarcely stand on his feet a few days 
 after the operation, and took food sparingly. De- 
 spite this great emaciation and weakness the dog 
 remained in this condition for eighteen days, getting 
 toward the end so weak it was difficult to tell whether 
 it was living or dead. The animal lay curled up and 
 sleeping for days without change of position and with- 
 out taking food. Finally found dead in this position. 
 
 The conclusions reached as a result of this work, 
 are : "Following the gradual destruction of the para- 
 thyroid glandules in the dog a train of symptoms 
 arises different from those obtained by parathyroid 
 excision. After ligation of all parathyroid tissue the 
 dog passes the time limits of tetanic death that 
 occurs after excision of the glandules, practically 
 without symptoms. Gradually, however, chronic 
 symptoms, trophic in nature, arise. These consist 
 in gradual but progressive loss of weight and strength, 
 greatly diminished resistance to infection, and a final 
 stuporous condition ending in death without tetany. 
 
 These nutritional disturbances are as marked when 
 the thyroid is not injured as they are when the thy- 
 roid is removed on one side. 
 
310 PARATHYROID GLANDS 
 
 These observations should lead to a modified con- 
 sideration of diseases that are supposed to be hypo- 
 parathyroid in origin, and suggest a revision of the 
 epitomized statement of Jeandelize, "that insuffi- 
 ciency of the thyroids causes nutritional disturbances, 
 while insufficiency of the parathyroids causes 
 acute convulsive troubles." The preferable state- 
 ment regarding the parathyroids as the result of 
 this work is, that while sudden loss of the parathy- 
 roids results in acute convulsive troubles, slow de- 
 struction of the same gives rise to chronic nutritional 
 disturbances, which eventually end in death without 
 tetanic manifestation. 
 
 The recent observations of Iselin on the disturb- 
 ances of nutrition, and even the prevention of devel- 
 opment, in young rats following partial parathy- 
 roidectomy make necessary the consideration of 
 these bodies as having an influence on retarded body 
 development. 
 
CHAPTER XVIII. 
 
 SURGICAL ACCIDENTS IN MAN DUE TO 
 
 REMOVAL OF THE PARATHYROID 
 
 GLANDULES. 
 
 Let us now return to the more practical side of 
 this question, namely: what role do the parathyroid 
 glands play in the tetany sometimes observed after 
 operations on the thyroid gland in man ? Accidents 
 following such operations, to which we have already 
 casually referred, have fortunately been reduced 
 to a minimum, but formerly they were not so rare. 
 
 Weiss, in 1883, was able to collect thirteen cases 
 of postoperative tetany from the literature. He 
 maintained that the symptoms were the result of 
 injury to the blood vessels and their accompanying 
 sympathetics. Because of the injury to these an 
 irritation was set up in the anterior horn of the spinal 
 cord which expressed itself in the tetanic symptoms. 
 This theory, with certain modifications, had some 
 supporters until the work of Reverdin and of Kocher 
 appeared. 
 
 Reverdin and Kocher demonstrated that the symp- 
 toms were a result of the goitre removal and that one 
 was able to escape tetany and cachexia strumipriva 
 by leaving in place a part of the thyroid gland 
 The part naturally left behind was the posterior bor- 
 der and therefore by this method the parathyroid 
 glands were not sacrificed. The importance of this 
 
312 PARATHYROID GLANDS 
 
 observation may be emphasized by the fact that 
 before that time such observations as the ten cases 
 of tetany in thirty-eight thyroidectomies by Billroth, 
 three cases out of seventeen operations by Reverdin, 
 and four cases out of seven by Mikulicz were re- 
 ported. 
 
 It was no. longer ago than the early eighties that 
 such reports as the preceding, and such graphic 
 descriptions as follows, might be read as the result 
 of thyroid operations: "Some days after thyroid- 
 ectomy, ordinarily on the third or sixth day, some- 
 times a little earlier or later" (at the end of four 
 months in a case of Kocher's), "the patient was 
 seized with convulsions of the extremities, more often 
 the superior, which were sometimes preceded by 
 tingling in the fingers "or twitching of the muscles. 
 Usually chronic contractions appeared, the hands 
 closed with such violence that the nails often pene- 
 trated the skin. The limbs were sometimes con- 
 tracted so that it seemed they were going to break; 
 even the diaphragm was at times involved." 
 
 Kocher has noted epileptiform crises of short 
 duration, followed by loss of consciousness. Crises 
 renewed themselves as often as fifteen times a day. 
 Sometimes the tetany ceased rapidly after a duration 
 of eight to fifteen days, or at times it was prolonged 
 for months and years with remissions. Death in 
 these cases seemed to result from a dyspnoea which 
 was not allayed by tracheotomy. 
 
 It was sometime before the fact was brought to 
 light that these postoperative tetanies in man were 
 due not to the loss of the thyroid gland, but to the 
 loss of the parathyroid glands. And the acceptance 
 
SURGICAL ACCIDENTS IN .MAX 313 
 
 of the functional significance of the parathyroids 
 has been brought about only by a great amount of 
 work; to the finishing touches of which we are es- 
 pecially ■indebted to the Vienna School. Biedl, 
 Eiselsberg, Erdheim, and Pineles may be mentioned 
 among those who have given special attention to 
 this question. 
 
 Among the first to study the relation of the para- 
 thyroids to goitre was Benjamins, who examined the 
 parathyroids in twenty cases of goitre which had been 
 dealt with surgically. While he found no histologic 
 changes in the parathyroids, as we have previously 
 noted, nevertheless he brought forward certain clini- 
 cal observations relating to the removal of these 
 glands. Out of nine cases in which clinical histories 
 were obtained, parathyroids were found in five that 
 had been removed with the thyroid; in the other 
 four cases the parathyroids had not been removed.' 
 Of the former five cases only one failed to develop tet- 
 any ; of the latter there was no tetany in any of the 
 cases. 
 
 This was in 1902, and it was about this time that 
 Jeandelize made his significant statement that in- 
 sufficiency of the thyroid causes chronic nutritional 
 disturbances,, while insufficiency of the parathyroids 
 causes acute convulsive disturbances. This state- 
 ment was at once upheld by Biedl, Pineles and 
 Kocher. 
 
 Pineles collected from the literature sixteen cases 
 of tetany following partial parathyroidectomy and 
 with a clear idea of the relationship of the parathy- 
 roid glands to postoperative tetany in mind, this 
 author has given us a very complete discussion of 
 
314 
 
 PARATHYROID GLANDS 
 
 this question. He discusses separately the total and 
 the partial thyroidectomies, and has collected fifteen 
 cases in which partial removal of the thyroid gland 
 was followed by more or less severe symptoms of 
 tetany. These cases are tabulated as follows: 
 
 Observer 
 
 Szuman... 
 Hoffman.. 
 Turetta. . . 
 
 Czyhlarz. . 
 Eiselsberg . 
 
 Westphal. 
 
 Eiselsberg 
 
 Eiselsberg 
 Eiselsberg 
 Meinert. . . 
 
 Kummer... 
 Eiselsberg. 
 Schilling. . . 
 
 Bruns 
 
 Eiselsberg . 
 
 Operation 
 
 Lateral thyroid lobes .... 
 
 Both thyroid lobes 
 
 Both thyroid lobes 
 
 Both thyroid lobes 
 
 Both thyroid lobes 
 
 Sparing of isthmus and 
 upper pole 
 
 Sparing of isthmus and 
 one upper pole 
 
 Sparing one upper pole. . . 
 
 Sparing one upper pole. . . 
 
 Right lateral lobe 
 
 Right lateral lobe 
 
 Right lateral lobe 
 
 L. lateral and middle 
 lobes 
 
 Nodules and cysts extir- 
 pated 
 
 Tumor 
 
 Tetany 
 
 appeared after 
 
 Operation 
 
 Fourth day. 
 Third day... 
 Fifth day.... 
 
 Third day... 
 Third day... 
 
 Second day. 
 
 Second day. 
 Fourth day. 
 Fourth day. 
 Fourth day. 
 
 Third day 
 
 Four months. . 
 Fourteen days . 
 
 Second day. . . 
 
 Tetany — Con- 
 tinued 
 
 Four months. 
 Fifteen days. 
 Died on eighth 
 day. 
 
 Death on six- 
 teenth day. 
 
 Six months. 
 
 Seven days. 
 
 Ten days. 
 
 One year. 
 
 Fourteen days 
 and recur- 
 rence with 
 pregnancy. 
 
 One year. 
 
 Nine days. 
 
 Eight days. 
 Death on 18th 
 
 day. 
 Mild facialis 
 
 tetany. 
 
 It is to be noted that in the first six cases only the 
 isthmus of the thyroid was left behind. The lateral 
 lobes of the gland on both sides were removed where- 
 by a good opportunity for removal of parathyroids 
 was offered. Likewise in the second group where 
 the isthmus and the uppermost part of a thyroid 
 lobe were spared parts were unfortunately selected 
 that were not in relation with the parathyroid glands 
 
SURGICAL ACCIDENTS IN MAN 315 
 
 and no protection was offered these bodies by leaving 
 such portions of the thyroid behind. Why tetany 
 should arise in the last three cases where a lateral 
 thyroid lobe was spared in one side is not easily 
 accounted for, but an examination of the detailed 
 reports of these cases shows that in the first the oper- 
 ation was undertaken during the course of preg- 
 nancy; in the second the thyroid lobe left behind is 
 described as very small ; and in the third only a mild 
 tetany was present which cleared up completely in 
 nine days. 
 
 From these observations Pineles concluded that 
 it is the same in man as in animals, that when the 
 parathyroids are spared no tetanic symptoms follow 
 a thyroid operation. The cases developing tetany 
 are those in which such parts of the thyroid only 
 were spared as did not protect from removal of the 
 parathyroid glands. This view was supported by 
 Escherich who clinically confirmed the rarity of 
 tetany following operations, in which loss of these 
 glandules was more carefully guarded against. 
 
 Kocher has strongly differentiated between the 
 symptoms arising from thyroid insufficiency, and 
 those the result of parathyroid insufficiency. The 
 latter symptoms he classifies as an intoxication, 
 making its appearance as a tetania parathyropriva . 
 
 Perhaps the most practical contribution to this 
 important question is the work of Erdheim, who 
 examined histologically in serial sections the neck 
 organs in three cases from patients dying of tetany 
 after partial double thyroidectomy. In all three 
 cases, although some of the thyroid had been left 
 behind, all four parathyroids had been removed 
 
316 PARATHYROID GLANDS 
 
 (in one case two very tiny accessory parathyroids 
 were present). From this unequivocal result Erd- 
 heim concludes that it is the plain duty for the sur- 
 geon of the future to assure himself that the para- 
 thyroid glands are spared in thyroid operations. 
 
 The rarity of tetany today following such opera- 
 tions is due to the technical methods by which the 
 thyroid is now removed. Especially to be com- 
 mended is the subcapsular procedure of Dr. C. H. 
 Mayo, which was suggested primarily to avoid injury 
 to the recurrent laryngeal nerve, and the ultra liga- 
 tion of the thyroid arteries as is recommended by 
 Halsted. So it has come about, as we have noted 
 in detail in the first chapter, that tetany following 
 thyroid removal has been reduced to less than one- 
 half of one per cent for all cases. 
 
 In discussing the paper of Erdheim, Eiselsberg re- 
 ports that up to 1890 there were in his clinic twelve 
 cases of tetany as a result of complete thyroid ex- 
 tirpation. In four of these cases the patients died 
 with violent symptoms; three had chronic tetany 
 which kept recurring, and one recovered. In eighty 
 partial extirpations there were only two cases of 
 tetany and those were not severe. Since 1890 he 
 had observed only one case of deadly tetany but 
 there had been sixteen light tetanies following goitre 
 operation. 
 
 In this country postoperative tetany is less fre- 
 quently encountered. Frazier reports the result of 
 personal inquiry from fifty-four surgeons represent- 
 ing from 1,500 to 2,000 goitre operations. Only 
 eight cases of tetany were reported, three of which 
 were fatal. Of the remaining five, one was transi- 
 
SURGICAL ACCIDENTS IN MAN 317 
 
 tory, and one was described as a slight case. C. H. 
 Mayo had had but one slight tetany in connection 
 with his numerous goitre operations. 
 
 Kocher reports that in his last 1,000 goitre opera- 
 tions tetany has been observed only five times. 
 Moreover, these five cases were all secondary opera- 
 tions where firm connective tissue adhesions compli- 
 cated the operative technic. 
 
 Even when tetany has occurred following goitre 
 operation a means is now offered for its control by 
 the administration of parathyroid gland extracts, 
 calcium salts and transplantation; the details of 
 which will be considered in a later chapter. 
 
CHAPTER XIX. 
 
 THE RELATION OF THE PARATHYROID 
 GLANDS TO MEDICAL TETANY. 
 
 A loss of parathyroid function was first suggested 
 by Jeandelize as the cause of tetany in adults and 
 later emphasized by Pineles, who grouped together 
 thyroid tetany, occupation tetany, tetany of child- 
 birth, children 's tetany, and gastric tetany. This identi - 
 tyof different forms of tetany was accepted by Chvos- 
 tek, who stated that for all, only one cause could be 
 considered, namely, functional diseases of the para- 
 thyroid glands. 
 
 It is well to have a definite subdivision of these 
 various tetanies in mind for purposes of discussion, 
 and the following grouping of Frankl-Hochwart is 
 perhaps the best. This author divides the tetanies 
 as follows: Tetany following or accompanying cer- 
 tain infectious diseases. Tetany in cases of gastric 
 dilatation with stagnation of the stomach contents. 
 Tetany in infants and children. Tetany occurring in 
 connection with certain trades (Arbeiterstetanie) . 
 Tetany associated with osteomalacia, and rickets. 
 Tetany occurring in the course of pregnancy and 
 lactation. 
 
 In all these tetanies there is an increased excitabil- 
 ity of the central nervous system which is shown by 
 quantitative tests with faradic and galvanic currents, 
 
MEDICAL TETANY 
 
 319 
 
 hypersusceptibility of the facial nerve being usually 
 easily demonstrable. There may be spasmodic rigid- 
 ity of the muscles, sometimes with such violent 
 twitchings as to constitute an epileptiform convulsion. 
 
 thymus 
 
 M . faff'fs- er. /909 
 
 Fig. 73. On the left, masses of thymus tissue are seen in con- 
 nection with the parathyroid glandules. These aberrant thymus 
 fragments are not uncommon in infants and may be mistaken for the 
 parathyroids themselves". 
 
 Fibrillary tremors of the tongue and rigidity of the 
 jaws may be present. Quickening of the pulse and 
 elevation of the temperature are sometimes observed. 
 
320 PARATHYROID GLANDS 
 
 Pineles was one of the first to call attention 
 to the uniformity of symptoms in postoperative 
 tetany in mam and animals on the one side, and in 
 the different forms of idiopathic tetany on the other 
 side. This uniformity, according to Pineles, points 
 towards a specific intoxication common alike to all 
 these various tetanic forms, and he brings forward 
 as the causal factor in these conditions insufficiency 
 of the parathyroid glands. 
 
 Chvostek has accepted the view of Pineles con- 
 cerning the general identity of all forms of tetany, 
 the cause of which may be found in the functional 
 disturbances of the parathyroid glands brought 
 about usually by disturbances of circulation in these 
 organs. The typical symptoms can arise through 
 a special poison which so acts that a specific tetanic 
 reaction may be brought about in a susceptible in- 
 dividual by an injury, which in another person 
 would not give rise to tetany. This susceptibility 
 to tetany may be congenital or acquired. 
 
 Chvostek also believes that tetany, just like goitre, 
 is epidemic in certain localities and preponderates 
 especially at certain definite seasons. Tetany is 
 frequent, for instance, in Vienna and Heidelberg, 
 while it is rare in Paris, although some years ago it 
 was common in that place. In Vienna tetany is 
 most frequently observed in the months of March 
 and April, occurring most frequently in shoemakers 
 and tailors. Chvostek states that there is a definite 
 antagonism between goitre and tetany; tetany being 
 rare in regions where goitre is endemic. In the 
 Tyrol, where goitre is endemic, tetany is extremely 
 rare. In a later article Chvostek states that he re- 
 
MEDICAL TETANY 321 
 
 gards mechanical hypersusceptibility of nerves, first 
 the facial, as an easily demonstrable and essential 
 symptoms of disease of the parathyroids, a fine test 
 which shows functional disturbance of these bodies. 
 The appearance of the facial phenomenon in cases 
 of pulmonary tuberculosis can be explained by the 
 view that tuberculous lesions are in the apex and. 
 thus affect the parathyroids. Chvostek's view is 
 supported by the case of Stumme in which a distinct 
 facialis phenomenon was benefited by the removal 
 of a tuberculous parathyroid during thyroidectomy 
 on account of goitre. 
 
 In this connection a case that can be included in 
 the tetany accompanying infection is reported by 
 Carnot and Delion, who observed during the terminal 
 period of a pulmonary phthisis various convulsive 
 movements, with loss of consciousness, which lasted 
 several days. The autopsy showed absence of men- 
 ingitis, the kidneys were practically normal, the 
 thyroid was sclerosed, but especially interesting was 
 the condition of the parathyroids. The inferior 
 glandules showed sclerosis and infiltration, the right 
 superior was not found, the left superior showed ex- 
 tensive caseation. 
 
 Frankl-Hochwart has called attention to the fact 
 that persons who have had tetany usually continue 
 to show some symptoms during the rest of their 
 lives. 
 
 Gastric Tetany. — In gastric tetany MacCallum 
 has found what appears to be evidence of hyper- 
 function of the parathyroids. In this case five glan- 
 dules were found, rather large in size, which showed 
 especially large groups of functioning cells, as well 
 
322 PARATHYROID GLANDS 
 
 as a considerable development of mitotic figures in 
 the principal cells. The author suggested that in 
 this case the enormously dilated stomach elaborated 
 more material than the parathyroids were normally 
 called upon to neutralize, and that this failure of 
 neutralization of the toxin gave rise to the severe 
 tetany from which the patient died. 
 
 Koenigstein also reported a case of gastric tetany 
 in which similar changes in the parathyroids were 
 found, as well as characteristic tinctorial reactions 
 to iodine and Best's glycogen stain that could not 
 be observed in normal glands. 
 
 In opposition to this concept Erdheim found the 
 parathyroid glands perfectly normal in two cases of 
 gastric tetany. The first patient was a thirty-eight 
 year old woman, the second a fifty-four year old 
 woman. Autopsy showed marked stomach dilata- 
 tion in both cases and in both cases the functioning 
 cells of the parathyroids (in contradistinction to the 
 previous cases), were relatively few. 
 
 Kinnicutt has reported a case of gastric tetany 
 in which the parathyroid glandules (examined by 
 Opie), exhibited no abnormality. In this case the 
 tetanic symptoms were promptly relieved by cal- 
 cium salts, but parathyroid nucleoproteid given by 
 the mouth had practically no effect on the nervous 
 system. 
 
 Pfeiffer and Mayer have tried to produce gastric 
 tetany in the dog but without success. 
 
 Children's Tetany. — We have already noted cer- 
 tain lesions (hemorrhage) of the parathyroid glands 
 that have been found in children exhibiting tetany. 
 It appears that the parathyroids of the infant are 
 
MEDICAL TETANY 323 
 
 disposed toward hemorrhage, which may especially 
 be brought about by intrauterine asphyxia. Erd- 
 heim has observed hemorrhage in three cases of in- 
 fant's tetany, and suggests that while the lesion 
 does not necessarily bring on this condition it pre- 
 disposes to it. In one of this author's cases, dying in 
 typical tetany, hemorrhage was found in all four 
 parathyroid glands. 
 
 Koenigstein has also observed changes in the para- 
 thyroid glands in two cases of children's tetany con- 
 sisting in relative increase in size, hemorrhage and 
 tinctorial differences in the iodine and glycogen re- 
 actions. 
 
 Thiemisch found the parathyroids normal in three 
 cases of children's tetany. These cases have been 
 criticised, however, as not being representative cases 
 of this condition. 
 
 Verebely describes two cases of hemorrhage in the 
 parathyroids of children in which there was no tetany. 
 Escherich describes a case of tetany in a seven year 
 old boy, occurring in the course of a tuberculous men- 
 ingitis, in which the parathyroids showed marked 
 degenerative changes which might well have led to 
 impairment of function. This author believes that 
 the parathyroid theory of tetany explains in a very 
 positive manner the enormous frequency of tetany 
 in the earliest period of life, and he calls attention 
 to the fact that it is not necessary to demonstrate 
 anatomic changes in the parathyroids in all instances, 
 for a functional deficiency may easily occur without 
 histologic changes being demonstrable. 
 
 One of the most valuable studies, and one of the 
 most convincing as regards the parathyroid origin 
 
324 
 
 PARATHYROID GLANDS 
 
 of tetany, is that contributed by Yanasse. He ex- 
 amined the parathyroids in eighty-nine children 
 showing tetanoid conditions, particularly galvanic 
 changes in the peripheral nerves. Hemorrhages in 
 parathyroids were found in thirty-three cases, (37 
 per cent). Yanasse asserts that the hemorrhages are 
 acquired mainly in postfetal life, perhaps as with 
 
 Fig. 74. A parathyroid glandule of the sclerotic type, from a case 
 of infantile atrophy. The dark masses represent the parenchyma; 
 the light areas the increased connective tissue. Above (6) is thyroid 
 gland. Below (c) is a remnant of the tissue continuous with the inter- 
 scapular gland. (Magnified 105.) 
 
 pleural and pericardial ecchymoses, at the time of 
 birth. Hemorrhages in these glands can be demon- 
 strated with certainty only during the first year of 
 life; after this the possibility progressively becomes 
 
MEDICAL TETANY 325 
 
 smaller and after the fifth year one cannot say from 
 histologic study that hemorrhage had ever occurred. 
 Late hemorrhage, in older children or adults, seldom 
 occurs. Yanasse divides the fifty cases in which the 
 electrical reaction was determined into four groups : 
 Normal galvanic reaction, thirteen cases. In twelve 
 there were four each, in one three parathyroids. 
 Hemorrhage was found in none. Group 2. Anodal 
 irregularity, twenty-two cases ; hemorrhage in twelve 
 or 54 per cent. In the ten other cases the age must 
 be considered. Of the twenty -two, nine were in the 
 first year of life and all showed hemorrhages. Thir- 
 teen were above one year and hemorrhage was found 
 sparely in three and was absent in ten. Therefore, 
 all ten of the negative cases were of such age that 
 signs of hemorrhage could have disappeared. Hem- 
 orrhage was found in eight, or 61 per cent. The other 
 five were all over one year. Group 4. Two cases, 
 one of tetany with meningitis in a child of two and 
 a half years, and one of muscle cramp in a child of 
 three months. Hemorrhage was found in both. 
 Eleven (ten under one year), of thirty -nine cases in 
 which the electrical reaction was not taken showed 
 hemorrhage. Certainly it was not accidental that 
 all cases with normal reactions had normal parathy- 
 roids and that all cases with hemorrhage, that were 
 tested electrically, showed abnormal reactions, or 
 clinically forms of spasm. Yanasse concludes that 
 between parathyroid hemorrhage and tetany there 
 is doubtless a connection. The question is, what is 
 this connection? His explanation is as follows: 
 It has been proved experimentally that the parathy- 
 roids are poison-destroying organs whose principal 
 
326 PARATHYROID GLANDS 
 
 function most probably is to neutralize metabolic 
 poisons which are detrimental to the nervous sys- 
 tem. Therefore we must recognize in metabolism 
 the origin of the so-called tetany poison, in the nerves 
 the principal tissue attacked by it, and in the para- 
 thyroids the organ that neutralizes this poison. The 
 total loss of parathyroids causes in man and animals 
 tetany -of which the clinical picture is essentially 
 like that of other forms of tetany. Hemorrhage in 
 the parathyroids does not totally destroy, but only 
 partly damages the glands, hence it is not the actual 
 cause or alone the cause of tetany but it can so act 
 as finally to produce that affection. The poison in- 
 creases because the parathyroids damaged by hem- 
 orrhage no longer exert their usual function. Only 
 in this way can be explained how parathyroid hem- 
 orrhage early in postfetal life leads in many cases to 
 tetany much later in the life of the affected in- 
 dividual. 
 
 Rickets and Osteomalacia. — It is quite recently 
 that the suggestion has been made that there may 
 be some relationship between the parathyroid gland 
 and these diseases. In the course of both diseases, 
 as is well-known, tetany may occur. The most im- 
 portant fact that has been developed in this line is 
 the observation of Erdheim, who noted the changes 
 in the teeth of rats which we have previously chron- 
 icled. Moreover, in these diseases there is obviously 
 some profound disturbance of calcium metabolism, 
 and MacCallum has shown the intimate relation that 
 exists between the parathyroid glands and calcium 
 metabolism. It is from this latter observation that 
 we may hope to solve this question rather than from 
 
MEDICAL TETANY 327 
 
 any distinct changes that have been observed in 
 the glands, although such have been noted. Erd- 
 heim found in an autopsy on a case of osteomalacia 
 a noticeable hypoplasia of the parathyroids, but in 
 a second case these glandules were entirely normal. 
 Hecker, who has discussed this relationship, thiriks 
 that there is probably some disturbance of the para- 
 thyroids in both osteomalacia and rickets and calls 
 attention to the fact that lack of calcium in the or- 
 ganism leads to tetany and that calcium metabolism 
 is doubtless influenced by the parathyroid glands. 
 
 Kassowitz has suggested that rickets might be the 
 underlying basis of the tetany of children and Esch- 
 erich has suggested congenital parathyroid hypo- 
 plasia as an etiological factor in rachitis. 
 
 Weichselbaum states that he has found noticeable 
 enlargement of the parathyroid glandules in rachitis. 
 
 The chronic nutritional disturbances on which we 
 have laid so much emphasis that have been proven 
 in animals to be a result of the impairment of the 
 function of the parathyroid glands must also be 
 borne in mind in considering the parathyroid etiology 
 for these diseases. From a morphological stand- 
 point, however, we have little ground for such as- 
 sumption. Schmorl who has examined the para- 
 thyroids in six cases of rickets found no changes. 
 In three out of four cases of osteomalacia the para- 
 thyroids were also normal, but in the fourth case one 
 hypoplastic glandule was found. 
 
 Eclampsia, Tetany of Pregnancy and Lacta- 
 tion. — The role of the parathyroids in the tetany 
 of pregnancy was one of the first suggestions point- 
 ing towards the function of these bodies. Vassale 
 
328 PARATHYROID GLANDS 
 
 and Generali, in 1896, noted that partially parathy- 
 roidectomized animals, which usually showed only 
 light and transitory tetanic symptoms, were apt to 
 develop severe tetany during pregnancy and the 
 puerperium. Vassale removed from a dog three of 
 the four parathyroids. Eighteen months after the 
 operation the dog gave birth to eight puppies. On 
 the fifth day of lactation it was taken with severe 
 convulsions which seemed to be relieved by taking 
 away several of the puppies and feeding with thyroid 
 extract. The convulsions were renewed, however, 
 and combated anew with the thyroid extract, 
 which was continued to the end of lactation and the 
 dog recovered. 
 
 Verstraeten and Vanderlinden had previously 
 noted in a thyroidectomized cat, (partial para- 
 thyroidectomy), the appearance of eclampsia at the 
 time of parturition, three months after the operation. 
 The symptoms were severe but were ameliorated by 
 subcutaneous injections of fresh sheeps' thyroid, and, 
 following accouchement, the animal recovered. 
 
 Lanz has also observed, without any apparent 
 thought of the parathyroids, that pregnant cats 
 can not withstand so great a loss of thyroid as the 
 non-pregnant animals. He noted that after a con- 
 siderable amount of the thyroid gland had been re- 
 sected (which probably included several of the para- 
 thyroids), the pregnant cats frequently developed 
 severe tetany. Halsted found that a pregnant dog 
 .from which the thyroid had been removed (thyro- 
 parathyroidectomy), was taken near the end of 
 pregnancy with tetany and died. 
 
MEDICAL TETANY 329 
 
 Lange, also operating on cats, who removed four- 
 fifths of the thyroid (including of course a consider- 
 able amount of parathyroid tissue), noted that out 
 of ten pregnant animals five died in coma, three 
 after having shown convulsions. The author de- 
 scribed renal and hepatic lesions in these animals. 
 
 Moussu criticised the preceding experiments on 
 the ground that the thyroidectomy probably pro- 
 voked renal lesions which were responsible for the 
 eclampsia. He performed the same experiments on 
 four goats (thyroidectomy), three of which came to 
 accouchement without accident save for a transient 
 albuminuria in one; the fourth suffered from severe 
 convulsions during the third month of the preg- 
 nancy (twenty-five days after the operation). These 
 experiments of Moussu are in favor rather than 
 against the parathyroid theory of eclampsia for in 
 the goat one can remove very frequently the entire 
 thyroid without notable interference with the para- 
 thyroid function. His experiments are more to be 
 criticised, as well as those of Pineles, Gross and Zan- 
 frognini, on the ground that they were undertaken 
 on already pregnant animals. 
 
 Perhaps the most important contribution to this 
 question is the extensive work of Thaler and Adler, 
 who operated on forty female rats, which they ob- 
 served carefully for two hundred days. The animals 
 m gestation suffered always a severe tetany following 
 even a relatively small loss of parathyroid tissue, 
 while the non-gravid animals suffered little or no 
 tetany from a similar operation. In another series 
 of experiments non-gravid rats were parathyroid- 
 ectomized and watched for the appearance of grav- 
 
330 
 
 PARATHYROID GLANDS 
 
 idity. Out of four of the animals from which one 
 parathyroid was removed, three later became gravid 
 and two of them died from tetany. Of twenty ani- 
 mals with only half a thyroid fourteen became gravid 
 and died without exception in typical tetany. The 
 tetany usually began in the last third of the pregnancy 
 and the non-fatal cases ended with parturition. 
 
 Fig. 75. Chronic parathyroiditis. The epithelial cells are crowded 
 together with loss of original structure and connective tissue greatly 
 increased. 
 
 This significant work of Thaler and Adler was 
 suggested by the work of Erdheim on rats which we 
 have previously quoted. In that work Erdheim ob- 
 served one animal, having a large accessory para- 
 thyroid (both parathyroids had been removed), 
 which remained free from tetany until it became 
 
MEDICAL TETANY 331 
 
 pregnant, when it suffered typical tetany and pre- 
 mature delivery. In a following gravidity the tetany 
 recurred and stopped with parturition. 
 
 Frommer, after partial removal of the parathy- 
 roids in rabbits has injected normal human placental 
 tissue into the abdominal cavity, with the result that 
 severe disturbances followed. In a gravid dog three 
 parathyroids were removed and some tetanic symp- 
 toms occurred ; five days after the operation, twelve 
 grams of human placenta was introduced into the 
 peritoneal cavity; four days later during parturition 
 severe tetanic symptoms appeared but the animal 
 later recovered. The three offsprings died although 
 apparently healthy at birth. He assumes from this 
 that the parathyroids have an antitoxic function 
 and that the placental tissue was toxic in this ex- 
 periment because the antitoxic function that should 
 have been supplied by these glands was removed. 
 
 In a later article Vassale states it has been shown 
 that in death from eclampsia either changes in, or 
 congenital absence of, one or two parathyroids is 
 found. Also clinical observations show that para- 
 thyroid therapy gives relief against the convulsions 
 in eclampsia. Moreover, work on cats and mice 
 shows that latent parathyroid insufficiency in the 
 last third of pregnancy produces experimental eclamp- 
 sia. In two out of three dogs in which the para- 
 thyroids were removed the author was able to pre- 
 vent the eclampsia of pregnancy by means of admin- 
 istration of strong doses of parathyroids by mouth. 
 The author believes the effects on the parathyroids 
 in childbirth to be mechanical and not autotoxic 
 
332 PARATHYROID GLANDS 
 
 and that the longer the duration of the birth the 
 more danger there is of eclampsia. 
 
 Gross adds to a rather lengthy discussion of the 
 relation of functional disturbances of the parathyroid 
 glands to tetany the following two experiments: 
 In two pregnant cats he removed three of the para- 
 thyroids and left one behind. In the first cat mus- 
 cular twitchings in the facial region were observed 
 twenty-five days after the operation. Twelve days 
 later the animal gave birth to healthy young, and 
 the twitching ceased. The second animal showed 
 no symptoms. 
 
 We have already referred to rather slight anatomi- 
 cal changes found in the parathyroids in cases of 
 eclampsia by Pepere, Zanfrognini and Erdheim. 
 These are too minute, however, to be given any 
 marked consideration. 
 
 Mossaglia, on the ground of experimental work, 
 believes that the eclampsia is secondary to kidney 
 changes. He states that parathyroid deficiency leads 
 to diminished kidney function and albuminuria, and 
 that it is the influence of the parathyroid, not di- 
 rectly, but on the kidney that is responsible for this 
 condition. Quadri holds a similar view. 
 
 The recent work of MacCallum offers the most 
 plausible theory for these forms of tetany. This 
 author states that in the tetany that accompanies 
 pregnancy and lactation the drain of calcium in the 
 production of the fetus or on the secretion of milk 
 may be so great as to cause tetany without lesion of 
 the parathyroid glands. If, however, the function- 
 ing power of these organs is impaired just so much is 
 
MEDICAL TETANY 333 
 
 the calcium content of the tissues diminished and 
 tetany thus the more liable to express itself. 
 
 As to the general relationship between tetany and 
 the parathyroid glandules, Rudinger has given the 
 opinion, based on his own work as well as a study of 
 the literature of the subject, that all forms of tetany 
 rest upon a parathyroid insufficiency. To substan- 
 tiate this theory the author removed the outer para- 
 thyroids of cats after injecting them with such 
 poisons as calomel, morphine, atropine, tuberculin 
 and ether. Although the injection of the substances 
 mentioned gave rise to no "nervous" symptoms, such 
 as increased electrical excitability or other indica- 
 tions of tetany, the injection plus the partial para- 
 thyroidectomy, did give distinct tetany in some ani- 
 mals and increased susceptibility to tetany in others. 
 
CHAPTER XX. 
 
 PARATHYROID THERAPY. 
 
 The evolution of our knowledge of the parathy- 
 roid glands has come along in logical sequence. At 
 first we were concerned with the anatomy of these 
 bodies ; then came the experimental work in animals 
 revealing the results of their loss. This work was 
 followed by a consideration of the application of 
 this experimental knowledge to symptoms, post- 
 operative and other, in the human, and finally we 
 arrive at the stage when effort centers itself in an 
 attempt to combat or modify these symptoms. 
 Naturally with our present knowledge of organo- 
 therapy at hand the use of the parathyroid glands 
 themselves was first offered for such combat. 
 
 Diet. — It was found after the first parathyroidec- 
 tomies were performed that the severe metabolic 
 disturbances arising from parathyroid excision could 
 be modified by diet, to a slight extent at least. Fast- 
 ing animals, it was found, failed to develop tetany 
 as soon or with such severity as well fed animals. 
 Feeding on a diet of bread, or of bread and milk 
 seemed to be more favorable to the animal than a 
 meat diet. Berkeley and Beebe state that they have 
 observed symptoms in an operated animal from one 
 to five hours after a heavy meal of meat, and that 
 they have occasionally made use of this method to 
 
PARATHYROID THERAPY 335 
 
 bring on tetany at a favorable time for experimental 
 work. These authors use this point to emphasize 
 the toxin hypothesis of parathyroid tetany, bring- 
 ing in as collateral evidence the fact that a meat diet 
 predisposes to convulsions in those cases of preg- 
 nancy which have disturbances of metabolism char- 
 acteristic of the preeclamptic state. These authors 
 state: "The nitrogen partitions in the urine in such 
 patients are in most cases abnormal, with relatively 
 high ammonia, high rest nitrogen, notable quanti- 
 ties of kreatinin, but with diminished urea and 
 kreatinin excretion. Such findings indicate severe 
 nutritional disturbance, and the possibility of meta- 
 bolic toxins being responsible for the symptoms in 
 such cases is commonly accepted. The means of 
 relief in acute conditions by the very active stimu- 
 lation of excretion through skin, bowel, and kidney, 
 through the use of the hot pack, diaphoretics, purga- 
 tion, the high saline irrigation, vigorous diuresis, and 
 occasionally by bleeding and saline infusion are all 
 based on the belief that the symptoms are caused 
 by an active toxic substance in the circulating blood. 
 A similar method of treatment is of clinical value in 
 the treatment of parathyroid tetany. The fact that 
 under disturbed conditions of nitrogenous meta- 
 bolism a meat diet gives rise to metabolic products 
 which may provoke convulsions suggests that the 
 meat diet has more than a passive role in producing 
 the symptoms of parathyroid tetany." 
 
 Parhon and Goldstein have found that maternal 
 milk feeding prolongs life after thyroparathyroidec- 
 tomy. Suckling kittens did not die so soon after this 
 operation as kittens fed on a partial meat diet. 
 
336 PARATHYROID GLANDS 
 
 MacCallum supports the calcium deficiency hypo- 
 thesis by the suggestion that the high content of 
 calcium in milk is the factor that makes it a more 
 favorable diet than meat for parathyroidectomized 
 animals. 
 
 We have already referred to the fact that in the 
 early study of the function of the thyroid the error 
 was made that carnivora could not withstand the 
 loss of that gland while herbivora bore its loss fre- 
 quently without acute symptoms. This observa- 
 tion, however, had nothing to do with diet but rested 
 on a lack of knowledge of the anatomy of the para- 
 thyroids. In the dog (carnivora) removal of the 
 thyroid included removal of all the parathyroids, 
 while in the rabbit (herbivora) such removal did not 
 include the two external parathyroids which are 
 quite separate from the thyroid and therefore pro- 
 tected the animal from tetany. 
 
 Transfusion has also been tried in animals exhi- 
 biting tetany, on the ground that some poisonous 
 material was circulating in the blood of the operated 
 animal. MacCallum and Davidson introduced the 
 blood of a normal dog into a dog with tetany with 
 the result that the symptoms rapidly and completely 
 disappeared. The tetany recurred the next day and 
 the dog was bled and a considerable quantity of 
 salt solution allowed to run into its veins. This 
 again stopped the tetany, but again it returned on 
 the following day. The infusion was repeated with 
 success, but the dog passed gradually into a state of 
 cachexia and died after several days. 
 
 Colzi, Fano and Zanda and Cannezzaro have also 
 noted the favorable influence of bleeding and trans- 
 
PARATHYROID THERAPY 337 
 
 fusion of blood from a normal animal on the symp- 
 toms of tetany produced by thyroidectomy (thyro- 
 parathyroidectomy) . Fano and Zanda have also 
 observed the same effects from infusion of salt solu- 
 tion. These experiments were made before the re- 
 lationship of tetany to the parathyroid glandules had 
 been suggested. 
 
 Pfeiffer and Mayer injected a parathyroidectom- 
 ized dog with ox serum, beginning the day after the 
 operation, during the latent period and again on the 
 second, fifth and eighth day. Following the second 
 and third injection, done while the animal was appar- 
 ently at the point of death, was combined bleeding 
 and the subcutaneous injection of warm salt solu- 
 tion. This gave almost immediate relief which was, 
 however, only temporary and the dog died. 
 
 Parathyroid Therapy . — The therapeutic use of the 
 glands themselves has been practiced extensively from 
 the time the symptoms resulting from parathyroid- 
 ectomy were first established. Vassale obtained 
 results from the use of thyroids in. which parathy- 
 roids were included in 1890, and his work was con- 
 firmed by Gley in 1891. 
 
 One of the most striking results, and one that later 
 investigators have not been able to repeat, was that 
 obtained by Lusena. This author kept a dog alive 
 for four months after removal of the parathyroids 
 by subcutaneous injections of parathyroid emulsions 
 for eight days followed by transplantation of one 
 parathyroid subcutaneously every fifteen days. It 
 is to be questioned in this case whether the parathy- 
 roids were completely removed. 
 
338 PARATHYROID GLANDS 
 
 Edmunds reports feeding a large quantity of para- 
 thyroids to an animal in tetany practically without 
 result, and Vincent and Jolly state that they were 
 unable to prevent the onset of symptoms in the 
 complete operation by the use of thyroid or para- 
 thyroid tissues. In general, however, the results of 
 parathyroid feeding and injection show that the 
 symptoms of tetany may be temporarily stopped by 
 this measure, and even repeatedly, but that eventu- 
 ally the animal succumbs. 
 
 MacCallum and Davidson report the following re- 
 sults on four dogs. In the first, three parathyroids 
 from the cow were introduced intraperit one ally after 
 tetany had begun ; symptoms continued followed by 
 emaciation, apathy and death in five days. In the 
 second, beef parathyroid and morphine were in- 
 jected subcutaneously; next day there was no tetany 
 but the following day tetany recurred and the animal 
 died. In the third, one intravenous injection of 
 parathyroid emulsion stopped the symptoms of tet- 
 any but five days later the dog died from an infec- 
 tion. The history of the fourth animal is interesting. 
 After the development of tetany the parathyroids 
 of twenty dogs were injected into the jugular vein. 
 This stopped the tetany but it recurred and the para- 
 thyroids of thirty-seven dogs were injected. The 
 symptoms did not return for three days and then 
 the parathyroids of twenty-two dogs were injected 
 into the peritoneum. Again symptoms ceased only 
 to recur four days later when the parathyroids of 
 eighteen dogs were injected with the usual cessation 
 of symptoms. Three days later the symptoms again 
 recurred and no further supply of parathyroids be- 
 
PLATE XXXIX 
 
 p.t..__ 
 
 
 P. T. INFERIOR PARATHYROIDS ON ANTERIOR INFERIOR SURFACE OF THE 
 THYROID (A RARE SITUATION). 
 
PARATHYROID THERAPY 339 
 
 ing available the animal died of tetany. This ex- 
 periment seems to show very conclusively that the 
 life of a dog can be maintained temporarily after 
 complete parathyroidectomy by the use of a great 
 amount of material, but that when therapy stops the 
 symptoms recur and the animal dies. Cases that 
 are reported as recovering permanently from symp- 
 toms of tetany after the injection of one or two para- 
 thyroid glands are undoubtedly cases in which the 
 parathyroids were not entirely removed. 
 
 Moussu was able to arrest postoperative tetany in 
 dogs by the subcutaneous and intravenous injection 
 of extracts of the horse parathyroid. His results 
 were only temporary as nearly all the dogs died 
 later in a cachectic condition. Alquier and Theun- 
 veny report similar results in dogs. 
 
 Esterbrook was probably the first to administer 
 parathyroid glandules to the human subject. He 
 employed ox parathyroids in insane patients with 
 no particular reference to symptoms of tetany, but 
 merely to compare the results of parathyroid feeding 
 with those obtained from the use of the thyroid 
 gland. Esterbrook first gave one dried ox parathy- 
 roid by the mouth every day for a week ; two glands 
 a day were given the next two days, and three on the 
 next three days. Then hypodermatic injections were 
 administered. These were followed by glycerine 
 extracts of the glands. In one case as many as nine 
 parathyroids were given daily. From this treat- 
 ment practically no effects were obtained; tempera- 
 ture, pulse and respiration remained normal, urinary 
 nitrogen and phosphoric acid showed no change. 
 Only a slight increase in pulse tension was observed. 
 
340 PARATHYROID GLANDS 
 
 These results were so different from the striking 
 symptoms following the use of thyroid extract that 
 the author assumed that the symptoms arising from 
 parathyroidectomy were due to injury to the thyroid 
 or its nerve connections rather than to removal of 
 the parathyroids. 
 
 In 1901 Moussu and D'Ausset at the Congress of 
 Gynecology in Nantes, reported cases of tetany bene- 
 fited by thyroid therapy (the internal parathyroids 
 being included in the thyroid extract.) 
 
 Scanning the literature since this time we find 
 many favorable reports on the use of these glands 
 in a wide range of diseases showing symptoms of 
 tetany. And while in many instances it does appear 
 that their employment has been of real value, never- 
 theless the suggestive effect of such treatment must 
 be borne in mind. 
 
 Vassale by the use of a parathyroid extract pre- 
 pared in a special manner, the details of which he 
 fails to disclose, reports beneficial results when used 
 either by mouth or subcutaneously on cases of 
 eclampsia, infantile tetany and epilepsy, and thinks 
 it would be equally efficacious in all varieties of tetany. 
 
 Berkeley has employed parathyroid therapy on 
 eleven cases of paralysis agitans in various ' stages 
 of the disease. He reports that nine of these patients 
 showed improvement, the earlier cases especially, 
 and one very early case considered himself nearly 
 relieved while under the influence of the treatment. 
 ' 'All the patients remarked upon a curious increase in 
 courage, comfort and mental energy, while taking 
 the remedy." Castelvi has reported equally good 
 results in this disease by the use of thyroid extracts. 
 
PARATHYROID THERAPY 341 
 
 Zanfrognini has employed parathyroid therapy in 
 five cases of eclampsia with general improvement of 
 symptoms. Michelazzi also reports favorable results 
 in eclampsia from the use of parathyroids. 
 
 Rensburg arid Rey obtained completely negative 
 results with parathyroid therapy in infant's tetany; 
 and Spieler likewise had no result following the use 
 of parathyroid tablets in this disease. 
 
 Loewenthal and Wiebrecht have reported good 
 results in many instances following parathyroid feed- 
 ing in tetany. Marinesco has reported favorable 
 results following the use of ox parathyroid in a seven- 
 teen-year-old girl, suffering from exophthalmic goitre 
 combined with intermittent tetany. 
 
 Murraron reports having suspended epileptiform 
 attacks in two goitrous cretins by the use of para- 
 thyroid extract, and Mant and Shaw apparently 
 cured by the same means a young girl of nine years 
 suffering from tetany in connection with grave gas- 
 trointestinal symptoms. 
 
 Brandan reports a case where, after the removal 
 of a colloid goitre from a girl aged fourteen years, 
 tetany developed forty-eight hours after the opera- 
 tion. By the use of subcutaneous injections of para- 
 thyroid emulsion the symptoms disappeared, and 
 the patient has remained free from the same for one 
 year. This phenomenon is explained by the fact that 
 the parathyroids were probably not all removed at 
 operation, but were so damaged that their function 
 was suspended temporarily, and that the parathyroid 
 emulsion sustained the patient until the glandules 
 resumed their normal work, possibly by compensa- 
 tory hypertrophy. 
 
342 PARATHYROID GLANDS 
 
 Berkeley has relieved symptoms of gastric tetany 
 in a thirty-nine year old man by oral administration 
 of fresh ox parathyroid. Putnam has reported ef- 
 fective relief in a case of surgical tetany by the use 
 of a similar preparation. 
 
 Beebe was the first to prepare and administer a 
 nucleoproteid principle of the parathyroid gland, 
 which has been quite active in dispelling the symp- 
 toms of tetany. In a later paper Berkeley and Beebe 
 give in detail the methods for preparing this ex- 
 tract from beef parathyroids obtained by roughly 
 trimming out the small mass of tissue containing 
 the two superior glands. "The carefully cleaned 
 glands were cut into small pieces with scissors, and 
 the comminuted tissue was then ground to a fine 
 pulp in a large mortar with the help of enough sand 
 to give the whole mass a moist, pasty consistency. 
 The crushed glands were next shaken for two hours 
 at room temperature with six to eight volumes of 
 physiological salt solution to which had been added 
 two drops of ten per cent sodium hydroxide solution. 
 The jar was now transferred to the refrigerator and 
 the extraction allowed to continue for eighteen to 
 thirty-six hours. Filtration first through gauze, to 
 remove the fat and coarser particles of tissue, and 
 then through moderately thick paper gave a clear 
 extract which was preserved by the addition of chloro- 
 form and kept at low temperature until biologically 
 tested." 
 
 It was shown that an extract so prepared relieved 
 the symptoms of tetany in a parathyroidectomized 
 dog in ten to fifteen minutes after injection. As 
 this extract contained nucleoproteids, globulins, and 
 
PARATHYROID THERAPY 343 
 
 albumins it was decided to separate it still further, 
 and it was divided into three portions. The first 
 portion was precipitated by acetic acid, the second 
 by half saturating the filtrate with ammonium sul- 
 phate, and the third by complete saturation with 
 ammonium sulphate. The precipitate from the first 
 portion (nucleoproteid) was most abundant ; the sec- 
 ond (globulin) was about one -fifth the first ; while the 
 third (albumin) was so small that it was abandoned. 
 The activity of these proteids is summarized by 
 Beebe as follows: 
 
 "1. The nucleoproteid of the parathyroid when 
 freshly prepared is equal to the whole gland in re- 
 lieving the symptoms of acute tetany in dogs. 
 
 2. The globulin is of no value in relieving tetany. 
 
 3. Boiling the nucleoproteid solution or heating 
 it to 80 degrees C. for one-half hour completely de- 
 stroys the activity of the nucleoproteid. 
 
 4. The nucleoproteid is most active when freshly 
 prepared and rapidly deteriorates when kept in solu- 
 tion or in suspension at refrigerator temperature. 
 Freezing also destroys its activity, although not so 
 rapidly as room temperatures. 
 
 5. Tryptic digestion or the action of pepsin and 
 hydrochloric acid for forty-eight hours severely in- 
 jures, but does not completely destroy, the activity 
 of the nucleoproteid. 
 
 6. The nucleoproteid will relieve tetany if given 
 by mouth, but is much more quickly and certainly 
 effective when given subcutaneously or intraperi- 
 toneally . ' ' 
 
 The results following the use of this parathyroid 
 nucleoproteid are strikingly illustrated by its efficacy 
 
344 PARATHYROID GLANDS 
 
 in relieving tetany in thirty-two animals as detailed 
 by Berkeley and Beebe, who report positive results 
 
 Fig. 76. Transplantation of thyroid and parathyroid into the 
 tibia of a dog. Some thyroid persists (at the edge of the section), but 
 the parathyroid has undergone necrosis. The animal died of cachexia, 
 with no tetany, although all other parathyroid tissue had been re- 
 moved. 
 
 in ninety-five per cent of the trials in which a com- 
 paratively fresh preparation was used. The boiled 
 proteid, and the globulin, however, always gave a 
 
PARATHYROID THERAPY 345 
 
 negative result. The digested proteids gave relief 
 only when used in large doses. 
 
 The clinical value of the nucleoproteid has also 
 been proved in cases of post operative tetany in the 
 human subject. Halsted reports that in a patient 
 suffering greatly from subtetanic hypoparathyroid- 
 ism as the result of two operations upon a large colloid 
 goitre, tetany has for two years been averted -and 
 the condition made endurable by the use of hypo- 
 dermic injections of the nucleoproteid of the para- 
 thyroid gland (Beebe) and by parathyroid feeding. 
 
 Pool reports a case of a young woman who had 
 had two thyroid operations. Despite the use of 
 Vassale's serum and implantation of the parathyroid 
 glands a typical tetany, which developed four days 
 after the second operation, continued for thirteen 
 months. Improvement was finally secured by re- 
 peated administration hypodermatically of large doses 
 of Beebe 's nucleoproteid. 
 
 Calcium Salts. — While the development of our 
 knowledge of the parathyroid glands has been fraught 
 with dramatic incidents throughout, a fitting climax 
 was lacking until the discovery that the severe tet- 
 anic symptoms arising from their removal could be 
 instantly stopped by the administration of soluble 
 calcium salts. And thus a new field of investiga- 
 tion was opened which promises to lead to practical 
 therapeutical results and to the throwing of new 
 light on certain interesting features of metabolism 
 in the human body. 
 
 In the summer of 1907, Parhon and Urechie in 
 the Revista Stiintelor Medicale published an article 
 on the influence of the injection of sodium chloride 
 
346 PARATHYROID GLANDS 
 
 and calcium chloride into animals that have experi- 
 mental tetany. While they found that sodium salts 
 increased the tetany of parathyroidectomized dogs, 
 they made the important observation that one gram 
 of calcium chloride dissolved in one-hundred cc. 
 of water and injected into the peritoneum held in 
 check all acute symptoms. 
 
 Independently, in March, 1908, MacCallum and 
 Voegtlin published a communication on the relation 
 of the parathyroid glands to calcium metabolism and 
 the nature of tetany, which they have followed 
 (1909), by a more lengthy and detailed account of 
 their investigations in this line. 
 
 These observations rest on the clinical studies of 
 such conditions as rickets and osteomalacia which 
 have suggested that tetany might stand in relation 
 to disturbances in calcium metabolism ; and further 
 on the observations of J. Loeb and J. R. MacCallum 
 that the effects of various salts which cause muscu- 
 lar twitching may be counteracted by calcium. More - 
 over, the observation of Erdheim on the changes in 
 the teeth of parathyroidectomized rats seems to have 
 a bearing on this question. 
 
 The use of calcium salts in tetany had previously 
 been recommended, but without regard to the para- 
 thyroid glands. Quest, as well as Silvestri and others, 
 has called attention to the low calcium content 
 in the convulsive stage of tetany, and Sabbatini 
 noted that trisodic citrate solutions would cause con- 
 vulsions and muscular twitching because they com- 
 bine with the soluble calcium salts in the body fluids. 
 
 Whether we accept this calcium deficiency hypo- 
 thesis, or consider it only as a secondary factor in 
 
PARATHYROID THERAPY 347 
 
 the cause of parathyroid tetany we must admit that 
 such a deficiency exists and that the restoration of 
 calcium to the tissue will prevent the tetany due to 
 parathyroid deficiency. 
 
 The same effects can be obtained up to a certain 
 extent by the use of soluble salts belonging to the 
 same natural group as calcium, such as magnesium, 
 barium, and strontium. 
 
 MacCallum and Voegtlin were able to relieve the 
 tetany of parathyroidectomized animals by injections 
 of magnesium salts, but found it was too dangerous 
 a salt to use on account of its depressant action. 
 Berkeley and Beebe have found that the symptoms 
 of tetany are relieved with nearly the same degree 
 of promptness and completeness by strontium salts 
 as by calcium salts. They use ten c. c. of a ten per 
 cent solution of strontium chloride to a ten kilogram 
 dog. On ten animals they found the effect of stron- 
 tium salts differed practically not at all from the 
 effects obtained by the use of calcium salts. These 
 authors also found that barium salts will relieve 
 tetany, but that they should never be given as a 
 therapeutic measure because an efficient therapeutic 
 dose is too near the border line of a fatal dose. 
 
 Berkeley and Beebe, following the suggestion of 
 MacCallum and Voegtlin's first article, have tried the 
 effects of calcium salts on a number of dogs, and 
 while they agree with those authors that calcium 
 quickly stops the symptoms of tetany, they consider 
 that the symptoms are due to a metabolic poison, 
 the abnormal excretion of calcium being an accom- 
 panying phenomenon: They cite in favor of this 
 hypothesis the fact that the symptoms have a cen- 
 
348 PARATHYROID GLANDS 
 
 tral origin; that symptoms are shown best in young 
 animals, and are more severe if the animal has been 
 kept on a meat diet ; that the symptoms have a close 
 relation to certain clinical conditions which are ac- 
 companied by severe nutritional disturbances. More- 
 over, that gastric tetany is accompanied by severe 
 metabolic disturbance, it has similar symptoms and 
 is promptly relieved by intravenous calcium injec- 
 tions and by parathyroid nucleoproteid; that bleed- 
 ing, followed by intravenous infusion, relieves tetany 
 as well as does the injection of fresh parathyroid 
 nucleoproteid. In addition injection of poisons such 
 as ammonia and xanthin produce symptoms which 
 can be promptly relieved by injection of calcium or 
 strontium salts, and it is known that increased ex- 
 cretion of ammonia follows complete thyroidectomy. 
 
 The work of MacCallum and Voegtlin, which marks 
 so important an epoch in our knowledge of the para- 
 thyroid glands, is exhaustive and includes a consider- 
 able study of metabolism in parathyroidectomized 
 animals, as well as the negative effects of injection 
 of sodium and potassium salts. An idea of the 
 effects obtained by these authors by the use of cal- 
 cium salts in dogs can best be obtained by quoting in 
 detail several of their experiments. 
 
 "Thyropara thyroidectomy ; four days later violent 
 twitching of muscles, pulse 160, respiration labored. 
 Given ten c. c. of a five per cent solution of calcium 
 acetate into jugular vein. Respiration became rapid 
 two hundred to minute, twitching rare but sharp. 
 Twenty-five minutes after the injection, pulse was 
 eighty, very irregular and slow. Dog thought to be 
 dying, occasional slight twitches. Next day dog 
 
PARATHYROID THERAPY 349 
 
 was found walking about and fairly well but was 
 found dead the day after. In this experiment the 
 animal was apparently restored to life from a mori- 
 bund state, but the amount of calcium salt had not 
 been large enough to remove tetany instantly." 
 
 "January 9, two parathyroids and one lobe of 
 thyroid extirpated, no results. January 18, second 
 lobe of thyroid removed. January 19, violent tet- 
 any ; at 11 :30 given ten c. c. of five per cent calcium 
 lactate subcutaneously. 11:35, respiration 240 
 
 marked twitching, pulse 180, breathing very rapid 
 and labored. 12:10, still tachypncea and twitching. 
 1 :10, respiration slowed, 40 to minute, muscular 
 twitching still marked. 1 :30, respiration quiet ; 
 1:32, twitching has almost disappeared, slight mus- 
 cular tremor, walks about but looks dejected. 3 :00 
 p. m., respiration 24, pulse 124, dog is quite normal 
 in appearance, no tremor nor twitching. Respiration 
 perfectly quiet and animal has perfect control of 
 himself and eats hungrily on being taken to cage." 
 
 The effects of the administration of these salts are 
 of course not permanent. The dog last cited, for 
 instance, developed tetany again the next day. This 
 temporary relief may be of permanent value, as for 
 instance in a case of one of Halsted's dogs in which 
 tetany was tided over by the administration of cal- 
 cium until a transplanted parathyroid became able 
 to function actively enough to prevent tetany. 
 
 MacCallum and Voegtlin also cite cases in which 
 an opportunity to observe the effect of calcium upon 
 cases of tetany in human beings has been offered. 
 In a case of Musser's in which violent tetany had de- 
 veloped, following the removal of a malignant growth 
 
350 PARATHYROID GLANDS 
 
 of the thyroid, calcium lactate was administered in 
 large and frequent doses. This caused the disap- 
 pearance of the tetany in the course of one day, but 
 with the cessation of calcium medication for two or 
 three days the symptoms of tetany reappeared. 
 Again they disappeared with the renewal of the cal- 
 cium treatment. A second case occurring in the 
 practice of a New York physician, responded to the 
 administration of calcium salts in the same way. 
 And a third case, of a little girl suffering from gastric 
 tetany was completely relieved by the administra- 
 tion of calcium. 
 
 In the case previously cited of Halsted's, in which 
 tetany had been averted for two years by the use of 
 parathyroid gland extracts, the latter reports the 
 same effect for the third year by the use of calcium 
 salts. 
 
 MacCallum and Voegtlin summarize the role of 
 the calcium salts in connection with tetany as fol- 
 lows : ' 'These salts have a moderating influence up- 
 on the nerve cells. The parathyroid secretion in 
 some way controls the calcium exchange in the body. 
 It may possibly be that in the absence of the para- 
 thyroid secretion, substances arise which can com- 
 bine with calcium, abstract it from the tissues and 
 cause its excretion and that the parathyroid secre- 
 tion prevents the appearance of such bodies. The 
 mechanism of the parathyroid action is not deter- 
 mined, but the result, the impoverishment of the 
 tissues with respect to calcium and the consequent 
 development of hyperexcitability of the nerve cells, 
 and tetany is proven. Only the restoration of cal- 
 cium to the tissues can prevent this. This explana- 
 
PARATHYROID THERAPY 351 
 
 tion is readily applicable to spontaneous forms of 
 tetany in which there is a drain of calcium for physio- 
 logical purposes, or in which some other condition 
 causes a drain of calcium. In such cases the para- 
 thyroid glands may be relatively insufficient." 
 
 Leopold and Reuss found a slight increase rather 
 than a decrease of calcium in adult rats exhibiting 
 cachexia parathyropriva, including enamel defects 
 of the teeth, after parathyroidectomy. In young rats 
 after the same operation, a lowering of calcium was 
 observed as well as lack of growth and lack of weight 
 increase. 
 
 Parhon, Dumitresco and Nissipesco found in cats 
 and dogs after thyroparathyroidectomy, an increase 
 of calcium in the nerve centers. 
 
 In the tetany of infants Oddo and Sarles have 
 found an increased amount of calcium in the urine. 
 In a case of post-operative tetany Musser and Good- 
 man found a diminution of calcium in the urine. 
 
 TRANSPLANTATION OF THE PARATHYROID GLANDS. 
 
 The limitations to tissue transplantation in warm 
 blooded animals are, of course, well known. When 
 portions of various glands have been implanted into 
 regions well supplied with blood they soon lose their 
 original structure, become absorbed, and only a bit 
 of cicatrical tissue eventually marks the site of trans- 
 plantation. Certain glands have responded to trans- 
 plantation much better than others, especially the 
 thyroid. It has been found in the cat and the dog 
 that while the central parts of transplanted thyroid 
 lobes undergo necrosis, the other portions may per- 
 sist, and blood vessels from surrounding granulation 
 
352 PARATHYROID GLANDS 
 
 tissue enter and give life to an apparent new growth 
 of the gland, including even lumina filled with col- 
 loid. 
 
 It is of extreme interest then to know if such im- 
 portant organs as the parathyroid glands may be 
 transplanted with any possibility of permanent suc- 
 cess in saving a patient from tetany or death follow- 
 ing the unfortunate removal of these bodies as has 
 occurred in operations involving the thyroid gland. 
 
 The first experiments in which parathyroids were 
 successfully transplanted have to be gathered from 
 the earlier literature on thyroid transplantation where, 
 as in the dog, the parathyroids are included in the 
 thyroid lobes and transplantation of the latter glands 
 included the former. Proof of this is to be drawn 
 from the functional results that followed the removal 
 of the transplants, where, in many instances death 
 with more or less severe manifestations of tetany 
 followed the removal of the transplanted tissue. As 
 some of this work was done before we knew about 
 the relation of the parathyroid glands to tetany there 
 was no proper interpretation of the results until 
 after the work of Gley on the parathyroid glands 
 appeared. 
 
 Kocher (1883) recommended thyroid transplan- 
 tation to prevent postoperative tetany as well as 
 cachexia strumipriva, myxcedema and cretinism. 
 
 Eiselsberg (1892) transplanted one thyroid lobe 
 between the peritoneum and fascia in four cats and 
 later (five days to one month), extirpated the re- 
 maining thyroid lobe. The animal showed no symp- 
 toms following such procedure, and in from one to 
 three months after the operation the implanted thy- 
 
PARATHYROID THERAPY 353 
 
 roid was removed. As a result of the removal of 
 the transplant the animals quickly died with severe 
 tetanic symptoms. Histologic sections of the re- 
 moved tissue showed it to have the appearance of 
 normal thyroid. While there is no mention of para- 
 thyroid tissue, we must assume from the results of 
 the experiment that sufficient parathyroid to pre- 
 serve the animal from tetany was transplanted with 
 the thyroid and persisted up to the time of its re- 
 moval. 
 
 Enderlen (1898) in his transplantation experi- 
 ments in dogs and cats took into account the para- 
 thyroids and stated that they persist after trans- 
 plantation even better than thyroid tissue. 
 
 Payr extirpated the thyroid lobes of cats and dogs 
 and transplanted the same into the spleen. In some 
 instances one lobe was transplanted and the remain- 
 ing lobe removed ten or twelve days later. In other 
 cases the whole gland was removed from the neck 
 and placed in the spleen at the first sitting, and 
 twenty or thirty days later the other lobe was trans- 
 planted into the spleen in a different place. As far 
 as the functional results of these experiments went, 
 the animals in general exhibited no symptoms even 
 after many months. After extirpation of the spleen, 
 however, the animals quickly died, usually with 
 symptoms of tetany. 
 
 Examination of the transplant showed the im- 
 planted thyroid to be reduced to one-fourth or one- 
 third its normal size. The central necrosis was less 
 marked than in other reported transplants and re- 
 generation processes were prominent, so that a pic- 
 ture of normal colloid-forming thyroid tissue was 
 
354 PARATHYROID GLANDS 
 
 present. Payr concluded that a gland with an inner 
 secretion was better adapted to transplantation than 
 other functional tissue. 
 
 Christiani reported the persistence of parathyroids 
 transplanted into a cat. After five years they were 
 found practically unchanged. This author, together 
 with Ferrari, was one of the first to transplant thy- 
 roid and parathyroid and consider each separately. 
 
 Camus seems to be the first to attempt the trans- 
 plantation of parathyroid glands only. The site 
 chosen by this author was the rabbit's ear. His re- 
 sults were not satisfactory and he stated that the 
 transplanted glandules showed an early atrophy. 
 
 Walbaum attempted to transplant the parathy- 
 roids into the serosa of the stomach of a cat, but with- 
 out success. After transplantation of the superior 
 glandules, he destroyed the remaining glandules and 
 the animals promptly died from tetany or went 
 gradually into a state of chronic cachexia from which 
 they died. 
 
 Biedl reported two cases of successful auto-trans- 
 plantation of parathyroids into the dog's spleen. In 
 the first animal, thirteen days after the transplanta- 
 tion, the thyroid and remaining parathyroids were 
 removed without the dog exhibiting any symptoms 
 of tetany. The second dog, however, developed 
 tetany four days after the thyroid and remaining 
 parathyroid removal. The symptoms were con- 
 trolled by parathyroid feeding and the dog recovered. 
 In two other animals, foreign parathyroids were 
 planted in the spleen with removal of the normal 
 glands sometime after the transplantation and a year 
 later the author reported survival of one animal with 
 
PARATHYROID THERAPY 355 
 
 no signs of tetany for seven months, but death from 
 cachexia thyropriva. The two intact parathy- 
 roids were found in the spleen. The second dog was 
 still alive, the transplanted parathyroids being ap- 
 parently sufficient. Halsted has criticised this 
 work of Biedl's as he had been unable to get similar 
 results by "foreign" transplants or without creating 
 a parathyroid deficiency before transplanting. More- 
 over, functional proof is lacking in these experi- 
 ments, as transplants were not excised during life 
 to see if their removal would cause death from tetany. 
 
 Pool, following the technic of Payr, has tried 
 transplantation without success. In eight dogs, six- 
 teen rabbit parathyroids were grafted into the spleen. 
 In four dogs, ten dog parathyroids were transplanted 
 in the same manner. These transplants were made 
 from eight to twenty-eight days before removing the 
 normal parathyroids. In none of these cases did 
 the transplants influence at all the usual develop- 
 ment of tetany following parathyroid removal and 
 all the dogs died with acute tetanic symptoms. 
 
 Pepere states that after removal of the external 
 parathyroids in the rabbit (which brought on symp- 
 toms of parathyroid insufficiency), he was able to 
 control symptoms by implantation of one or several 
 parathyroid glandules. However, the graft was 
 soon absorbed. Its effect was sufficient, however, to 
 tide over a parathyroid deficiency until certain ac- 
 cessory parathyroid tissue (which this author de- 
 scribes), had had time to hypertrophy and keep the 
 animal in normal condition. 
 
 Capebelle removed transplanted thyroid from a dog 
 two hundred and forty-five days after operation, and 
 
356 PARATHYROID GLANDS 
 
 found it in good condition. The animal, however, 
 died of tetany following its removal, showing that 
 parathyroid must have been transplanted with the 
 thyroid and preserved its function. 
 
 Pfeiffer and Mayer have successfully transplanted 
 the parathyroids in two six weeks' old puppies. 
 They state that they prefer dogs to rats. for this work 
 because the outer parathyroids are well separated 
 from the thyroid in the former and because dogs 
 manifest tetany much more acutely than rats. These 
 authors transplanted one outer parathyroid gland 
 into the abdominal wall between the muscle and 
 peritoneum and extirpated the thyroid lobe and 
 inner parathyroid on that side. At the end of a 
 week they carried out the same operation on the 
 other side. Neither of the dogs operated upon ex- 
 hibited tetany following such procedure ; and at the 
 end of six weeks a functional test of the efficacy of 
 the transplants was made. Following the excision 
 of the transplants both animals succumbed to death 
 in acute tetany, the symptoms of which appeared 
 two days after excision of the transplanted tissue. 
 A similar procedure carried out in a third dog (six 
 months old), did not result successfully. The ani- 
 mal developed tetany soon after the transplantation 
 and despite the feeding of thyroid tablets died in 
 cachectic condition in about a week. Histologic ex- 
 amination of the transplanted tissue in this case 
 showed it to have undergone necrosis. 
 
 Leischner, who was the first to establish the func- 
 tional proof of parathyroid transplantation, carried 
 out his experiments on eighty rats. In about ten 
 per cent of these animals he was able to transplant 
 
PARATHYROID THERAPY 357 
 
 parathyroids and have them maintain their function. 
 He chose to place the parathyroids between the 
 peritoneum and the rectus abdominis, or in the 
 muscle itself. Such transplants were made suc- 
 cessfully in four rats in which both parathyroids were 
 transplanted with an interval of ten days to a month 
 between the operations. No signs of tetany ap- 
 peared. From three to six weeks later the portion 
 of the wall containing the transplanted glandules 
 was extirpated and tetany followed the removal. In 
 four other rats both parathyroids were transplanted 
 at the same time and tetany resulted, but after a 
 time it ceased. Then, in three or four weeks, the 
 tissue containing the transplant was removed and 
 a new attack of tetany promptly occurred. 
 
 Halsted's transplantation experiments, carried on 
 for a period of two years, show sixty per cent of suc- 
 cessful results in autotransplantations with created 
 deficiency. The negative results are of value in 
 bringing out the fact that a parathyroid deficiency 
 must be created by the removal of at least two glands 
 before successful transplantation can be expected. 
 It is to be noted that auto-transplantations were the 
 only ones giving successful results. Isotransplan- 
 tation which was tried on thirty-eight dogs, was 
 uniformly unsuccessful. The isotransplantations 
 were made into the thyroid, spleen, and behind the 
 rectus abdominis but the isograft did not live in a 
 single instance. 
 
 In the first series of autotransplantations by Hal- 
 sted, five auto-grafts into the thyroid of three dogs 
 gave two successful results; eight auto-grafts into 
 the spleen of three dogs gave only one successful re- 
 
358 
 
 PARATHYROID GLANDS 
 
 suit. Functional proof of the success of these trans- 
 plantations was not attempted, but microscopically 
 and macroscopically the graft appeared successful. 
 
 Fig. 77. Transplanted parathyroid glandule in the tibia of a dog. 
 
 In the second series, auto-transplantation was made 
 behind the rectus abdominis muscle. Out of eighteen 
 such transplantations in twelve dogs, seven para thy- 
 
PARATHYROID THERAPY 359 
 
 roids were absorbed or necrotic; five to seven lived 
 and performed their function. In two of the dogs 
 the functional test was made. Both these dogs 
 died in tetany after the removal of the sustaining 
 auto-graft. Two other dogs were alive and well after 
 nine and ten months respectively, sustained appar- 
 ently by a single transplanted parathyroid gland 
 only. Both these dogs developed myxcedema, (the 
 thyroids were removed with the parathyroids) with 
 eczema and some falling of the hair. 
 
 In some of Halsted's experiments, when too sud- 
 den a deficiency was created, a beginning tetany was 
 tided over by the administration of calcium salts, 
 until the transplanted grafts acquired a circulation 
 sufficient for them to exercise their function. 
 
 Eiselsberg has reported a case in which a parathy- 
 roid was transplanted in a human subject. The 
 patient was a woman, forty-two years old, who for 
 many years had suffered from a fairly severe tetany 
 which followed total thyroid extirpation. She had 
 many times been in the clinic during goitre opera- 
 tions and at last a favorable case was operated upon 
 and a gland was transplanted; this was apparently 
 followed by good results. Von Eiselsberg believes 
 that removal of a parathyroid for this purpose is 
 permissible only when a cyst is taken out of one lobe 
 of the thyroid and the remainder of the organ appears 
 normal so that one can say with some certainty that 
 three parathyroids are left intact. Garre has also 
 reported good results following the transplantation of 
 parathyroid into the tibia in a case of chronic tetany. 
 
 The recent thyroid transplantations of Kocher 
 must be taken into accoimt in considering the ques- 
 
360 PARATHYROID GLANDS 
 
 tion of parathyroid transplantation. Kocher's trans- 
 plantations are made into the bone marrow of the 
 tibia, this bone lending itself best to such an opera- 
 tion. The process is carried out in two stages. In 
 the first stage the marrow cavity is opened, a small 
 pocket formed, and a silver ball about lxl . 5 cm. in- 
 troduced. The wound is then closed. After two 
 or three days it is reopened, the ball removed and 
 the fresh gland tissue implanted into the cavity thus 
 formed. In this way the author avoids extensive 
 hemorrhage about the implanted tissue, a layer of 
 granulations having formed about the ball. Experi- 
 mentally, Kocher found that thyroid tissue thus 
 transplanted in dogs proved efficient for the main- 
 tenance of life. If the bone containing the trans- 
 planted tissue was resected, the animal quickly died 
 with acute symptoms of tetany. 
 
 To be especially noted is the fact that in these ex- 
 periments of Kocher there were no acute symp- 
 toms of tetany following the implantation, although 
 thyroid alone was grafted and all parathyroids re- 
 moved, but as soon as the bone containing the trans- 
 planted portion of thyroid was removed acute tetany 
 leading to death resulted. Kocher considers the 
 question of parathyroid tissue having been trans- 
 planted with the thyroid in his case, but says that 
 histologically nothing but thyroid tissue was found 
 in the bone. 
 
 Thompson, Leighton and S warts have tried various 
 situations for placing transplanted glandules. The 
 method of Kocher for transplantation of parathy- 
 roid into the shaft of the tibia has been attempted, as 
 well as transplantation of thyroid alone in this situ- 
 
PLATE XL 
 
 PARATHYROID GLANDULE (WITH BLOOD VESSEL), FORTY DAYS AFTER 
 TRANSPLANTATION INTO THE NECK OF A DOG. THE ANIMAL WAS SUSTAINED 
 BY THIS GLANDULE, AS WAS SHOWN BY DEATH IN TETANY TWENTY-FOUR 
 HOURS AFTER ITS EXCISION. 
 
PARATHYROID THERAPY 36 
 
 at ion, as the authors could not understand why in 
 the case Kocher reports he should have obtained the 
 same results, including the functional test, for thy- 
 roid, that numerous experiments have shown con- 
 clusively to depend on parathyroid transplantation. 
 
 These authors found that dogs which had been 
 submitted to the tibia operation did not develop 
 tetany although all parathyroids were removed, or 
 transplanted parathyroid had been shown micro- 
 scopically to have undergone necrosis. The dogs did 
 die finally, however, from cachexia. Moreover, in 
 two animals from which the parathyroids had been 
 removed the tibia operation markedly influenced the 
 tetany parathyropriva even after the dog had de- 
 veloped severe symptoms. 
 
 It would seem, then, that there might be some 
 connection between the traumatic injury of bone and 
 the prevention of tetany. In Kocher's case this 
 seemed to be disproved by the statement that when, 
 in his dog, the transplanted thyroid (which was 
 microscopically free from parathyroid) , was removed 
 death in tetany resulted. This, if it were true in a 
 number of instances, would be indeed difficult to 
 explain, for the presence of thyroid tissue has never in 
 the least influenced the fatal tetanic results of para- 
 thyroid removal which has been practiced so many 
 times. 
 
 In the case of Thompson, Leighton and Swarts, 
 the removal of the transplanted thyroid had no effect 
 whatever in the experiment. It is to be noted, how- 
 ever, that these dogs in which a bone transplanta- 
 tion is practiced, although escaping a fatal tetany, 
 usually die in chronic cachexia. These experiments, 
 
362 PARATHYROID GLANDS 
 
 therefore, influence in no way the well-established 
 fact that the parathyroid glandules are vital organs, 
 but they suggest that the bone operation may serve 
 as a factor in checking the tetany which is usually 
 the most prominent symptom of parathyroprivic 
 death. 
 
 One of the most recent contributions to the tem- 
 porary cure of tetany after loss of the parathyroid 
 glandules has been made by Isaac Ott. This author, 
 who used . cats chiefly for his experiments, found 
 that the tetany following complete parathyroid- 
 ectomy in these animals could be controlled by the 
 administration of pituitary extract. When ten to 
 twenty grains of this drug rubbed up with distilled 
 water was injected there was a replacement of the 
 tremor by steadiness in about three hours. Tetany 
 did not reappear for twenty-four hours. In compar- 
 ing the effects of calcium lactate and pituitary ex- 
 tract in tetany, it is to be noted that while the action 
 of the former is quicker, the action of the latter drug 
 seems to continue longer. 
 
 From all that has gone before we find that tetany, 
 although it isja dramatic event in connection with 
 parathyreoprivic death, is but a symptom, that 
 usually, but not necessarily, accompanies loss of 
 these bodies. We can control tetany after parathy- 
 roidectomy, but we cannot maintain life for any 
 considerable time without the parathyroid gland- 
 ules. Deprived of these vital organs an animal or 
 an individual will die; acutely and convulsively if 
 the deprivation is sudden, slowly and quietly if the 
 
PARATHYROID THERAPY 363 
 
 loss is more slowly brought about. While in the 
 past investigation has centered itself, naturally, 
 upon the more striking phenomena of complete 
 parathyroidectomy, it is possible that future work 
 may give us a better understanding of the nature 
 of the changes incident to the gradual loss of func- 
 tion of the parathyroid glandules. 
 
PARATHYROID LITERATURE 
 
 Alquier, L.— Gazette d. Hop., 1903, June 13, 20; idem, 1906, No. 132, 
 
 p. 1527; Compt. Rend. Soc. de Biol., 1906, Oct., p. 302. 
 Alquier and Theunveny — Compt. Rend. Soc. de Biol., 1907, t. 63, p. 
 
 397; idem, 1909, t. 66, p. 217. 
 Anderson, O. A. — Arch. f. Anat. und Physiol., Anat. Abth., 1894, p. 
 
 177. 
 Askanazy, M.^Arb. a. d. Pathol. Inst., Tubingen, 1904, bd. 4, heft 3, 
 
 p. 398. 
 
 Baber, E. C— Phil. Tr. Royal Soc. of London, 1876, vol. 166; idem, 
 
 1881, No. 209, p. 279. 
 Bayon, P. C — Wurzburg, 1903. 
 
 Beebe, S. P.— Proc. Soc. for Exp. Biol, and Med., 1907, p. 64. 
 Benjamins, C. E — Ziegler's Beitrage, bd. 31, 1902, p. 143. 
 Berard, L. and Alamartine — Compt. Rend. Soc. de Biol., 1909; t. 66, p. 
 
 619; Lyon Chir., 1909, May, p. 72. 
 Berkeley, W. N.— Med. News, 1905, Dec. 2. 
 
 Berkeley and Beebe— Jour, of Med. Research, 1909, vol. 20, p. 113. 
 Biedl, A. — Wiener Klin. Wochenschr., 1907, p. 615. 
 Blum, F. — Kongress f. Innere Med., Munchen, 1906, p. 183. 
 Blumreich, L. and Jacoby, M. — Berl. Klin. Wochenschr., 1896, No. 15, 
 
 p. 327; Pfluger's Archiv., 1896, bd. 64, p. 1. 
 Botcheff — Thesis, Geneva, 1905. 
 
 Bramwell, B. — Brit. Med. Jour., 1895, June 1, p. 1196. 
 Brissaud — Presse Med., 1898. 
 
 Cadeac, C. and Guinard, L.— Compt. Rend. Soc. de Biol., 1894, June, 
 
 pp. 468, 508, 509. 
 Camus— Compt. Rend. Soc. de Biol., 1905, p. 321. 
 Canal, A.— Gazz. d. Osp. e delle Clin., 1909, vol. 30, No. 89. 
 Capobianco, Fr.— Riforma Med., 1895; Internat. Monatschr. f. Anat. 
 
 und Physiol., 1894, p. 515. 
 Capobianco and Mazziotti — Gior. Internaz. d. Sc. Med., 1899, vol. 21. 
 Carnot and Delion— Bull, de la Soc. de Biol., 1905, p. 321. 
 Caro, L.— Mitt. a. d. Grenzgeb. d. Med. und Chir., 1907. 
 Carter, W. S.— Texas State Jour., 1907, vol. 3, p. 229. 
 Castelvi— Riv. di Med. y Cir. Prat., Madrid, 1903. 
 Chantemesse and Marie— Soc. Med. d. Hop., 1893, vol. 10, p. 202; 
 
 Semaine Med., 1893, p. 130. 
 Chdnu, J. and Morel, A.— Compt. Rend. Soc. de Biol., 1904, vol. 56, 
 
 p. 77. 
 Christens, D.— Hosp.-Tid., 1904, No. 39. 
 
366 PARATHYROID LITERATURE 
 
 Christian!, H.— Compt. Rend. Soc. de Biol., 1892, Oct., p. 798; idem, 
 
 1894, Nov., p. 716; Arch, de Physiol. Norm, et Pathol., 1893, pp. 
 
 39, 164, 279; Jour, de Physiol, et Pathol. Gin., 1905, vol. 7, p. 261. 
 Christiani, H. and Ferrari, E. — Compt. Rend. Soc. de Biol., 1897, Oct. 
 Chvostek — Wiener Klin. Wochenschr., 1905, p. 969; idem, 1907, pp. 
 
 487, 625. 
 Cimdrom — Lo Sperimentale, 1907, Sept.— Oct. 
 Civalleri, A.— Policlinics, 1902, No. 3. 
 Claude, H. and Schmiergeld, A. — Compt. Rend. Soc. de Biol., 1908, 
 
 vol. 65, pp. 80, 139; idem, 1909, vol. 66, p. 131. 
 Conradi and Marchetti — Riv. di Patol., Nerv. e Ment., 1904, p. 255. 
 Cotoni, L.— Rev. de Med., 1909, vol. 29, No. 8. 
 
 DaCosta, J. C— Surg. Gyn. and Obst., 1909, p. 32. 
 Doyon— Jour, de Physiol, et Pathol. Gen., 1907, vol. 9, p. 457. 
 Doyon and Jouty — Compt. Rend. Soc. de Biol., 1904. 
 Doyon and Karefe — Compt. Rend. Soc. de Biol., 1904. 
 
 Ebner, V. — Koelliker's Handb. der Gewebelehre des Menschen, 1902, 
 
 bd. 3, p. 325. 
 Edmunds, W.— Jour. Physiol., 1895; Brit. Med. Jour., 1901, 2, p.'773; 
 
 Jour, of Pathol, and Bact., 1896, 1899, 1902; Lancet, 1908, vol. 1, 
 
 p. 811. 
 Eggers— Tr. Chicago Pathol. Soc, 1907, 'p. 102. 
 Eiselsberg, von — Langenbeck's Arch., 1894, bd. 48, p. 489; Deutsche 
 
 Ztschr. f. Chir., 1901, No. 38; Wiener Klin. Wochenschr., 1906, 
 
 Nos. 25, 26; idem, 1907, No. 21. 
 Enderlen— Mitt, a. d. Grenzgeb. d. Med. und Chir., 1898, bd. 3, p. 474. 
 Erdheim — Wiener Klin. Wochenschr., 1901, No. 41; Ziegler's Beitrage, 
 
 1903, bd. 33, p. 158; idem, 1904, bd. 35, p. 366; Ztschr. f. d. Ges. 
 
 Heilk., 1904, bd. 25; Kongress f. Innere Med., Munchen, 1906, 
 
 April; K. K. Ges. der Aerzte, Wien, 1906, June 1, vol. 1; Wiener 
 
 Klin. Wochenschr., 1906, pp. 716, 817; Mitt. a. d. Grenzgeb. d. 
 
 Med. und Chir., 1906, bd. 16, hefte 4, 5; Anatomischer Anzeiger, 
 
 1906, bd. 29, p. 609. 
 Escherich — Mitt. d. Ges. f. Innere Med. uhd Kinderheilk., 1906, Nov.; 
 
 Wiener Klin. Wochenschr., 1907, p. 614. 
 Esterbrook — Lancet, 1898, vol. 2, p. 546. 
 
 Estes, W. L. — Johns Hopkins Hosp. Bull., 1907, vol. 18, p. 335. 
 Estes, W. L. and Cecil, A. B. — Johns Hopkins Hosp. Bull., 1907, vol. 
 
 18, p. 331. 
 
 Fiori — Arch, per le Sc. Med., Torino, 1905, vol. 29, p. 428. 
 
 Flint — Amer. Jour, of Anatomy, 1904—5, vol. 4, p. 77. 
 
 Forsyth, D.— Lancet, 1907, p. 154; Brit. Med. Jour., 1907, pp. 141, 
 
 372, 1177. 
 Fraina — Pavia, 1905, ref. Guizzetti. 
 
PARATHYROID LITERATURE 367 
 
 Frankl-Hochwart — Die Tetanie, Nothnagel's Spez. Pathol, und Ther., 
 1891; Deutsche Klinik, 1905, lieferung 151, p. 933; Wiener Med. 
 Wochenschr., 1906, p. 309; Neurolog. Centralb., 1906, Nos. 14, 15. 
 
 Fromme, V.— Wiener Klin. Wochenschr., 1906, p. 818; Monatsschr. f. 
 Geburtsh. und Gyn., 1906, bd. 24, heft 6. 
 
 Fusari— Torino, 1899. 
 
 Gamier— Thesis, Paris, 1899; Gazette d. Hop., 1899. 
 
 GarrS— Ztschr. f. Chir., 1908, No. 35, beilage, p. 31. 
 
 Geis, N. P.— Ann. of Surg., 1908, p. 523. 
 
 Getzowa, S.— Virchow's Arch., 1907, vol. 188, p. 181. 
 
 Ginsburg— Univ. of Penn. Med. Bull., 1908, Jan. 
 
 Gley, E. A.— Compt. Rend. Soc. de Biol., 1891, Dec. 19, p. 843; idem, 
 
 1892, July 16, p. 666; idem, 1893, Feb. 25, p. 217; idem, 1893, 
 
 July, p. 691; idem, 1897, Jan. 9, p. 18; idem, 1897, Jan. 16, p. 46; 
 
 Arch, de Physiol. Norm, et Pathol., 1892, 1893; Brit. Med. Jour., 
 
 1901, 2, p. 771. 
 Gley, E. A. and Phisalix— Compt. Rend. Soc. de Biol., 1893, Feb. 25, 
 
 p. 219. 
 Goris — -Ann. de lTnat. Chir. de Brux., 1906, vol. 13, p. 64. 
 Gozzi, C— Boll. Soc. Med. y Cir. di Pavia, 1907, vol. 21, p. 310; Gazz. 
 
 Med. Ital., Torino, 1907, vol. 58, p. 461. 
 Groschuff, K. — Anatom. Anzeiger, 1896, bd. 12, p. 497. 
 Gross, E. — Munchener Med. Wochenschr., 1906, p. 1616. 
 Guizzetti, P. — Centralb. f. Allgem. Pathol, und Pathol Anat., 1907, 
 
 No. 3. 
 
 Halsted, W. S— Amer. Jour. Med. Sci., 1907, vol. 134, p. 1; Jour, of 
 
 Exper. Med., 1909, vol. 11, p. 175. 
 Halsted and Evans— Ann. of Surg., 1907, p. 489. 
 
 Harvier, P. and Morel, L. — Compt. Rend. Soc. de Biol., 1909, t. 66. 
 Haskovec, L. — Ref. Schmidt's Jahrbiicher, bd. 292, p. 161. 
 Hecker — Ges. f. Natur und Heilkunde zu Dresden, 1906, Dec. 15; 
 
 ref. Munchener Med. Wochenschr., 1907, p. 493. 
 Hofmeister — Fortschritte der Med., 1892; Brun's Beitrage zur Klin. 
 
 Chir., 1894, bd. 11; Deutsche Med. Wochenschr., 1896. 
 Huerthle, K.— Arch. f. d. Ges. Physiol., 1894, bd. 56. 
 Hulst, J. P. L.— Centralb. f. Allgem. Pathol, und Pathol. Anat., 1905, 
 
 bd. 16, p. 103. 
 Humphry — Lancet, 1905, vol. 2, p. 1390. 
 Hutchinson, R. — Jour, of Physiol., 1898. 
 
 Iselin, H.— Deutsche Ztschr. f. Chir., 1908, bd. 93, pp. 397, 494. 
 Ivanoff — Thesis, Geneva, 1905. 
 
 Jacoby, M. — Inaug.-Diss., Berlin, 1895; Anat. Anzeiger, 1896, bd. 12, 
 p. 152. 
 
368 PARATHYROID LITERATURE 
 
 Jeandelize, P.— Thesis, Nancy, 1902; Paris, 1903. 
 Jouty — Thesis, Lyon, 1903. 
 
 Kaydi — Arch, f . Anat. und Physiol., 1878. 
 
 Kenderdjy — Clinique, Paris, 1908, vol. 3, p. 363. 
 
 Kinnicutt — Amer. Jour. Med. Sc, 1909, vol. 138. 
 
 Kishi, K.— Virchow's Arch., 1904, bd. 176, p. 260. 
 
 Kocher, T.— Arch. f. Klin. Chir., 1883, bd. 29, p. 254; idem, 1908, bd. 
 
 87, No. 1. 
 Kocher-Kraus — Miinchener Med. Wochenschr., 1906. No. 18. 
 Kohn, A.— Arch. f. Mikr. Anat., 1895, bd. 44, p. 366; idem, 1897, bd. 
 
 48, p. 398; Ergebnisse der Anat. und Entwick., 1899, bd. 9. 
 Kollmann, J. — Lehrbuch der Entwicklungsgeschichte des Menschen, 
 
 1898. 
 Konigstein, H. — Wiener Klin. Wochenschr., 1904, p. 636; idem, 1906, 
 
 p. 778; idem, 1906, p. 1532; Mitt. d. Ges. f. Innere Med. und 
 
 Kinderheilk., 1906, Dec. 6, p. 191. 
 Kursteiner — Anat. Hefte von Merkel und Bonnet, 1898, bd. 9, heft 3; 
 
 idem, 1899, bd. 11. 
 
 Lange, M.— Ztschr. f. Geburtsh. und Gyn., 1899, bd. 40, p. 34. 
 
 Lanz — Volkmann's Vortrage, 1894, No. 87; Mitt. a. d. Klinik und Med. 
 
 Institut, Schweiz, 1895. 
 Leischner, K. — Wiener Klin. Wochenschr., 1907, p. 645. 
 Leopold, J. and Reuss, A. — Wiener Klin. Wochenschr., 1908, No. 35. 
 Livini — Monitore Zool. Ital., Florence, 1904, p. 33. 
 Lowenthal and Wiebrecht — Deutsche Ztschr,. f. Nervenheilk., 1906, bd. 
 
 31, heft 5, p. 415. 
 Lundborg — Deutsche Ztschr. f. Nervenheilk., 1904, bd. 27, p. 217. 
 Lusena — Fisiopathologia dell'Apparecchio Tiro-Paratiroideo, Florence, 
 
 1899. 
 
 MacCallum, W. G.— Med. News, 1903, Oct. 31; Johns Hopkins Hosp. 
 
 Bull., 1905, vol. 11; Centralb. f. Allgem. Pathol, und Pathol. Anat., 
 
 1905, bd. 76, p. 385; Brit. Med. Jour., 1906, Nov. 10, p. 1282. 
 MacCallum and Davidson — Med. News, 1905, p. 625. 
 MacCallum and Voegtlin — Johns Hopkins Hosp. Bull., 1908, vol. 19, 
 
 p. 91; Jour, of Exper. Med., 1909, vol. 11, No. 1, p. 118. 
 MacCallum, Thomson and Murphy — Johns Hopkins Hosp. Bull., 1907, 
 
 vol. 18, p. 333. 
 Manca, P. — Lo Sperimentale, 1905, vol. 6, p. 835. 
 Mant and Shaw — Clin. Soc of London, 1906, Jan. 26. 
 Maresh — Ztschr. f. Heilkunde, 1898. 
 Marinesco, G. — Semaine Medicale, 1905, p. 289. 
 Maselung — Arch. f. Klin. Chir., 1879, vol. 24. 
 Mattauschek, E. — Wiener Klin. Wochenschr., 1907, No. 16. 
 
PARATHYROID LITERATURE 369 
 
 Maurer, F. — Hertwig's Handbuch d. Vergl. und Exp. Entwick., 1902, 
 
 bd. 2, abt. 1. 
 Mayo, C. H.— Surg., Gyn. and Obst., 1907, /vol. 5. 
 Meuron, P. — Diss., Geneva, 1886. 
 Michand, L.— Virchow's Arch., 1908, bd. 191, p. 63. 
 Michelazzi — Ref. Miinchener Med. Wochenschr., 1907, p. 397. 
 Mironesco — Compt. Rend. Soc. de Biol., 1908, p. 515. 
 Mobilio, C— Arch. Sci. d. r. Soc. de Accad. Vet. Ital., Torino, 1908. 
 Morat and Dyon — Traite de Physiol. 
 
 Mossaglia, A. — Gazz. degli Osped., 1906, Sept. 2, No. 105. 
 Moussu, G.— Compt. Rend. Soc. de Biol., 1892, Dec; idem, 1893, 
 
 March, p. 280; idem, 1893, April, p. 394; idem, 1897, Jan., p. 294; 
 
 idem, 1898, July, p. 44; idem, 1899, March, p. 242; Thesis, Paris, 
 
 1897; Thesis, Cambridge, 1898. 
 Mttller, L. R.— Ziegler's Beitrage, 1896, bd. 28, p. 127. 
 Mailer, W. — Jenaische Ztschr. f. Med. und Naturw., 1891, bd. 6. 
 Munk, H. — Akademie der Wissensch., 1888. 
 Murraron — Policlinico (Section Practique), 1905, p. 974. 
 
 Nagel and Ross — Ref. Cotoni. 
 
 Nicolas, A. — Bull. Soc. des Sc. de Nancy, 1893, p. 13; Bibliographic 
 
 Anatomique, vol. 4, 1896. 
 Nubiola, P. and Alomar, J. — Compt. Rend. Soc. de Biol., 1909, t. 66. 
 
 Ott, I. — Introd. Lecture, Phila., 1909. 
 
 Paladino — Atti della Reale Accad. Med. Chir. di Napoli, 1893. 
 Parhon and Urechie — -Ref. Munchener Med. Wochenschr., 1908, March. 
 Parhon and Goldstein : — Compt. Rend. Soc. de Biol., 1909, t. 66. 
 Parhon, Dumitresco and Nissipesco — Compt. Rend. Soc. de Biol., 
 
 1909, t. 66, p. 792. 
 Payr, E.— Arch. f. Klin. Chir., bd. 80, p. 780. 
 Pepere, A.— Centralb. f. Path., 1906, p. 313; Turin, 1906; Arch, de 
 
 Med. Experim., 1908, No. 1. 
 Pepere, A. and Saviozzi — Lo Sperimentale, 1905, vol. 5. 
 Peterson — Virchow's Arch., 1903, bd. 174, p. 413. 
 Peucker, H.— Ztschr. f. Heilk., bd. 20, 1899. 
 Pfeiffer and Mayer — Wiener Klin. Wochenschr., 1908, No. 22; Mitt. a. 
 
 d. Grenzgeb. d. Med. und Chir., 1908, vol. 18, p. 379. 
 Pineles, Fr. — Sitzungsb. der Kais. Akad. der Wissensch., Wien, 1904; 
 
 Wiener Klin. Wochenschr., 1904,' p. 517; Mitt. a. d. Grenzgeb. d. 
 
 Med. und Chir., 1904, bd. 14, p. 120; Archiv. f. Klin. Med., 1906, 
 
 bd. 85, p. 491; Wiener Klin. Wochenschr., 1906, p. 691. 
 Pool— Ann. of Surg. , 1907, vol. 46, p. 507. 
 Prenant, A.— Compt. Rend. Soc. de Biol., 1893, May 27, p. 546; La 
 
 Cellule, 1894, vol. 10, No. 1; Paris, 1896. 
 
370 PARATHYROID LITERATURE 
 
 Quadri, G.— Gazz. Med. Ital., 1906, No. 7. 
 Quervain, F.— Virchow's Arch., 1893, bd. 133. 
 Quest — Wiener Klin. Wochenschr., 1906, p. 830. 
 
 Reverdin — Revue Med. de la Suisse Roruande, 1882, 1883. 
 
 Rogers and Ferguson— -Amer. Jour. Med. Sci., 1906, p. 811. 
 
 Rogowitz — Arch, de Physiol. Norm, et Pathol., 1888. 
 
 Rossi, R. — Soc. Med.-Chir., Modena, 1909, April. 
 
 Rouxeau, A. — Compt. Rend. Soc. de Biol., 1895, July, p. 638; idem, 
 
 1896, Nov., p. 970; Arch, de Physiol., 1897, t. 29, p. 136. 
 Rudinger— Ztschr. f. Exp. Pathol, und Ther., 1898, bd. 5, p. 205. 
 
 Sacerdoti — Arch. f. Anat. und Physiol., 1894. 
 
 Sandstrom, J. — Ref. Schmidt's Jahrbiicher, 1880, bd. 187, p. 114. 
 
 Santi — Internat. Centralb. f. Laryngol. und Rhinol., 1900, p. 5. 
 
 Schaper, A. — Arch. f. Mikros. Anat. und Entwickl., 1895, bd. 44. 
 
 Schiff, M.— Rev. Med. de la Suisse Rornande, 1883, 1884. 
 
 Schilder, P.— Ziegler's Beitrage, 1909, bd. 46, p. 602. 
 
 Schlesinger, H. — Neurol. Centralb., 1892, p. 66; Ztschr. f. Klin. Med., 
 
 1891, bd. 19, p. 468. 
 Schmorl — Miinchener Med. Wochenschr., 1907, No. 10, p. 494; idem, 
 
 1908, No. 8, p. 421. 
 Schreiber, L. — Inaug.-Diss. and Arch. f. Mikros. Anat., 1898. 
 Silvestri — Gazz. diegli Osp. e delle Clin., 1909, vol. 30, No. 106. 
 Simon — These de Nancy, 1895; Revue Biol, du Nord de la France, 
 
 t. 6. 
 Soulie, A. — Jour, de l'Anat. et Physiol., 1897, t. 33. 
 Spieler, Fr. — Mitt. d. Ges. f. Innere Med. und Kinderh., Wien, 1907, 
 
 Feb. 14. 
 Stieda — Untersuch. iiber die Entwickl. der Glandula Thymus, Glandula 
 
 Thyreoidea und Glandula Carotica, 1881. 
 Strada, F. — Pathologica, 1909, vol.*'l, p. 423. 
 
 Thaler and Adler — Wiener Med. Wochenschr., 1906, p. 779. 
 
 Thiemisch — Monatsschr. f. Kinderh., 1906, bd. 5, p. 165. 
 
 Thompson,. R. L. — Jour, of Med. Research, 1906, vol. 15, p. 399; 
 
 Amer. Jour, of the Med. Sc, 1907, Oct.; Centralb. f. Pathol., 1909, 
 
 bd. 20, p. 916. 
 Thompson, R. L. and Harris, D. L. — Jour, of Med. Research, 1908, 
 
 vol. 19, p. 135. 
 Thompson, R. L. and Leighton, W. E. — Jour, of Med. Research, 1908, 
 
 vol. 19, p. 121. 
 Thompson, R. L., Leighton, W. E. and Swarts, J. L. — Jour, of Med. 
 
 Research, 1909, vol. 21, p. 125; idem, 1909, vol. 21, p. 135. 
 Torretta — Ann. d. Mai. de 1' Oreille, Paris, 1901, t. 27. 
 Tourneux, F. — Jour, de l'Anat. et de la Physiol. Norm, et Path., 1897, 
 
 t. 30. 
 
PARATHYROID LITERATURE 371 
 
 Traina, R.— Bull, de Soc. Med.-Chir. di Pa via, 1905, p. 197; Arch, di 
 Biol., Florence, 1908, p. 72. 
 
 Van Ecke — Arch. Inter, de Phar., 1897, p. 81. 
 
 Vassale, G. — Riv. Speriment di Freniatria, 1897, vol. 23, p. 905; Arch. 
 
 Ital. de Biol., 1898, vol. 30, p. 49; Wiener Med. Presse, 1906, p. 
 
 364; Soc. Med.-Chir. in Modena, 1906, July; ref. Ann. di Ost. e 
 
 Gin., vol. 28, No. 10. 
 Vassale and Generali— Riv. di Patol. Nerv. et Mentale, 1896; Arch. 
 
 Ital. de Biol., 1896. 
 Verdun— Compt. Rend. Soc. de Biol., 1896; Thesis, Toulouse, 1897; 
 
 Paris, 1898. 
 Verebely — Virchow's Arch., 1906, bd. 187, p. 80. 
 Verstraeten and Vanderlinden — Mem. de T Acad, de Med. de Belgique 
 
 1894. 
 Vincent and Jolly— Jour, of Physiol., 1904, vol. 32; idem, 1906, vol. 34. 
 Virchow— Die Krankhaften Geschwiilste, 1863, vol. 3, p. 13. 
 
 Walbaum— Mit. a. d. Grenzgeb. d. Med. und Chir., 1903, bd. 12, p. 298. 
 Wassertrilling, E.— Wiener Med. Ztg., 1908, bd. 53, pp. 289, 299, 312. 
 Weichselbaum— Ver. Deutscher Naturf. und Aerzte, Stuttgart, 1906, 
 
 Sept. 
 Welsh, D. A. — Jour, of Anat and Physiol., 1898, vol. 32. 
 Winiwarter, H. von.— Scalpel, Liege, 1907, vol. 60, p. 327. 
 Winternitz, M. C— Johns Hopkins Hosp. Bull., 1909, vol. 20, p. 269. 
 Wolfler, A.— Berlin, 1880. 
 
 Yanasse, J. — Jahrb. f. Kinderh., 1908, vol. 67, Erghft. 
 
 Zanfrognini— Bol. della R. Accad. Med. de Genova, 1905; Inst. Ost.- 
 Gin. della R. U. di Genova, 1905; Clinica Ost., 1905, vol. 9. 
 
 Zeitschmann, O.— Mitt. a. d. Grenzgeb, d. Med. und Chir., 1908, bd. 
 19, No. 2. 
 
 Zielinska, M. — Virchow's Archiv., 1894, bd. 136, p. 170. 
 
 Zuckerkandl, E. — Anat. Hefte, 1902, abt. 1, bd. 19. 
 
REFERENCE TO AUTHORITIES. 
 
 Adelmann, 12 
 
 Adler, 329, 330 
 
 Alamartine, 280 
 
 Alquier, 221, 241, 252, 291, 294, 
 
 339 
 Anderson, 276 
 Apolant, 35 
 Askanazy, 274 
 
 Baber, 201 
 
 Babonneix, 255 
 
 Basedow, 12, 38 
 
 Bayon, 301 
 
 Beebe, 86 178, 179. 186, 296. 334, 
 
 342, 347 
 Benjamins, 213, 228, 235, 244, 
 
 246, 248, 265, 268, 270, 274, 313 
 Berard, 280 
 Bergmann, 20 
 Berkeley, 211, 215, 251, 252, 292, 
 
 296. 334, 340, 342, 347 
 Biedl, 313, 354 
 Billroth, 110, 205, 281, 312 
 Blum, 300, 301 
 Blumreich, 208, 300 
 Brandan, 341 
 Brissaud, 250 
 Bryson, 58 
 Burzio, 252 
 
 Cadeac, 287 
 Camus, 354 
 Cannezzaro, 336 
 Capebelle, 355 
 Capelle, 71 
 Capobianco, 287 
 Carnot, 246, 320 
 Caro, 301 
 Castelio, 252 
 Castelvi, 340 
 Cecil, 242 
 Chantemesse, 235 
 Charcot, 12, 38, 46, 85 
 Chenu, 242 
 Christens, 171, 292 
 Christiani, 202, 285, 354 
 Chvostek, 318, 320 
 Claude, 251, 280 
 Coley, 170 
 Colzi, 336 
 Crile, 91, 95 
 Curtis, 188 
 DaCosta, 278 
 
 Dana, 252 
 D'Ausset, 340 
 Davidson, 336, 338 
 Delion, 246, 321 
 DePaoli, 279 
 DeQuervain, 287 
 Desmarres, 38, 56 
 Donaggio, 291 
 Doyon, 289 
 Dumitresco, 351 
 
 Ebner, 235 
 
 Edmunds, 247, 287, 288, 291, 338 
 
 Eggers, 246 
 
 Ehrlich, 35 
 
 Eiselsberg, von, 170, 171, 175,313, 
 316, 352, 359 
 
 Enderlen, 171, 353 
 
 Erdheim, 23, 212, 231, 240, 244, 
 248, 249, 250, 254, 255, 256, 
 257, 265, 268, 269, 271, 292, 
 293, 294, 300, 313, 315, 322, 
 323, 326, 327, 330, 346 
 
 Escherich, 256, 315, 323, 327 
 
 Esterbrook, 339 
 
 Estes, 222, 242 
 
 Evans, 217, 218 
 
 Ewald, 24 
 
 Fabris, 35, 256 
 
 Fano, 336 
 
 Ferguson, 215 
 
 Ferrari, 354 
 
 Flajani, 11, 38 
 
 Flint, 238 
 
 Forschheimer, 184 
 
 Forsyth, 213, 224, 225, 237, 240, 
 
 245, 249, 263 
 Fraenkel, 21, 252 
 Frankl-Hochwart, 318, 321, 331 
 Frazier, 316 
 Frommer, 295 
 
 Gamier, 244, 256 
 
 Garre, 359 
 
 Gautiers, 76 
 
 Geis, 218 
 
 Generali, 285, 286, 328 
 
 Getzowa, 212, 231, 237, 244, 265, 
 
 270 
 Ginsburg, 218 
 Gley, 203, 208, 221, 242, 247, 283, 
 
 285, 288, 337 
 
374 
 
 REFERENCE TO AUTHORITIES. 
 
 Goldstein, 335 
 Goodman, 351 
 Goris, 272 
 Graefe, 12, 56 
 Graves, 12, 38 
 Groschuff, 228 
 Gross, 332 
 Guinard, 287 
 Guizzetti, 244, 255 
 Gull, 12 
 Gunn, 79, 82 
 
 Hagenbach, 263, 294 
 
 Halsted, 28, 188, 218, 316, 328, 
 
 345, 349, 355, 357, 359 
 Harnett, 243 
 Harris, 212, 216, 260, 263, 265, 
 
 266, 268, 269, 270, 275 
 Harvier, 220, 255, 304 
 Haskovec, 248 
 Hatai, 216 
 Hecker, 327 
 Hektoen, 21 
 Hirsch, 12 
 
 Hofmeister, 208, 284 
 Horsley, 251, 281 
 Houseman, von, 71 
 Huerthle, 202 
 Hulst, 270, 274 
 Humphry, 247 
 
 Iselin, 296, 310 
 
 Jackson, 184 
 Jacobson, 142, 157, 163 
 Jacoby, von, 208, 300 
 Jeandelize, 250, 287, 313, 318 
 Jolly, 222, 263, 302, 306, 338 
 Jonnesco, 106 
 Jouty, 289 
 
 Kareff, 289 
 
 Kassowitz, 327 
 
 Kaydi, 202 
 
 Kinnicutt, 322 
 
 Kishi, 300 
 
 Ivocher, 10, 11, 12, 14, 64, 73, 87, 
 
 95, 110, 111, 126, 127, 128, 137, 
 
 142, 155, 156, 157, 166, 170, 
 
 175, 179, 188, 281, 311, 312. 
 
 313, 315, 317, 352, 360 
 Kohn, 202, 208, 220, 227, 231, 
 
 244, 268, 285 
 Kollman, 235 
 Konigstein, 237, 243, 255, 256, 
 
 280, 322, 323 
 Kursteiner, 212 
 Landstrom, 16, 50, 57, 84, 90, 92, 
 
 95, 144, 156, 188, 189, 190 
 Lange, 329 
 
 Langhans, 271, 282 
 
 Lanz, 88, 328 
 
 Leighton, 217, 219, 221, 299, 306, 
 
 360 
 Leischner, 356 
 Lenhart, 28 
 Leopold, 351 
 Liezenska, 202 
 Litty, 222 
 Loeb, 346 
 Lowenthal, 341 
 Lundborg, 249, 251, 252, 337 
 Lusena, 288 
 Luzzato, 252 
 
 MacCallum, 206, 211, 214, 221, 
 223, 241, 246, 248, 250, 255, 
 271, 289, 305, 321, 326, 332, 
 336, 338, 346, 347, 348, 349 
 
 MacCarty, 30 
 
 Makai, 280 
 
 Manca, 292 
 
 Mant, 341 
 
 Maresch, 249 
 
 Marie, 12, 46, 47, 235 
 
 Marine, 28 
 
 Marinesco, 260, 341 
 
 Maselung, 202 
 
 Maurer, 228 
 
 Mayer, 208, 295, 322, 337, 356 
 
 Mayo, 11, 95, 110, 188, 315, 317 
 
 Mead, 184 
 
 Michelazzi, 341 
 
 Mikulicz, 188, 205, 312 
 
 Moebius, 10, 11, 12, 39, 43, 46, 54, 
 57, 86, 91, 95, 178, 179, 186, 
 187, 252 
 J Moore, 21 
 
 Morel, 220, 242, 304 
 
 Mossaglia, 332 
 
 Moussu, 221, 247, 284, 285, 329, 
 339, 340, 351 
 
 Muller, 243 
 
 Munk, 305 
 
 Murphy, 223 
 
 Murraron, 341 
 
 Musser, 349 
 
 Nagel, 242 
 
 Oddo, 351 
 Opie, 322 
 Oswald, 196 
 Ott, 362 
 
 Paladino, 287 
 
 Parhon, 206, 335, 345, 351 
 
 Parry, 11, 38 
 
 Payr, 170, 171, 353, 354 
 
REFERENCE TO AUTHORITIES. 
 
 375 
 
 Pepere, 226, 244, 256, 268, 279, 
 
 280, 355 
 Peterson, 214, 231, 235, 244, 265, 
 
 268 
 Peucker, 249 
 
 Pfeiffer, 208, 295, 322, 337, 356 
 Pianca, 221 
 Pick, 33 
 Pineles, 288, 289, 305, 313, 318, 
 
 320 
 Pinto, 306 
 
 Pool, 114, 218, 345, 355 
 Prenant, 228 
 Putnam, 342 
 
 Quadri, 332 
 Quest, 346 
 
 Rehn, 11, 188 
 
 Remak, 201 
 
 Rensburg, 341 
 
 Reuss, 351 
 
 Reverdin, 14, 205, 311, 312 
 
 Rey, 341 
 
 Rogers, 86, 186, 215 
 
 Rogowitz, 202, 263 
 
 Rosenberg, 249 
 
 Ross, 242 
 
 Rouxeau, 287 
 
 Rudinger, 333 
 
 Ruppanner, 22 
 
 Russell, 291 
 
 Sabbatani, 346 
 
 Sacerdoti, 226 
 
 Salzer, 125, 171 
 
 Sandstrom, 201, 202, 208, 211, 
 
 213, 231, 234, 243, 281 
 Santi, de, 270 
 Sarles, 351 
 Schaper, 212, 268 
 Schiefferdecker, 252 
 Schiff, 171, 281 
 Schilder, 246 
 Schirmer, 302 
 Schleich, 94 
 Schlesinger, 249 
 Schmauch, 85, 192, 195 
 Schmiergeld, 251, 280 
 Schmorl, 35, 250, 256, 257, 327 
 Schreiber, 213, 228 
 Segale, 295, 305 
 Serman, 170 
 Shaw, 341 
 Shephard, 188 
 Silvestri, 346 
 Simon, 228 
 Singer, 70 
 Soulie, 228 
 
 Spieler, 341 
 Stamm, 163 
 Steida, 228 
 Stellwag, 12, 57 
 Stumme, 320 
 Sultan, 171 
 Swarts, 219, 299, 360 
 
 Teacher, 35 
 
 Thaler, 329, 330 
 
 Theunveny, 291, 339 
 
 Thiemich, 256, 323 
 
 Thomas, 176 
 
 Thompson, 212, 215, 216, 217, 219, 
 221, 239, 245, 253, 255, 257, 
 260, 263, 265, 266, 268, 269, 
 270, 275, 280, 299, 306, 360 
 
 Thomson, 223 
 
 Tillaux, 11 
 
 Tinker, 53 
 
 Torri, 23 
 
 Tourneux, 208, 228 
 
 Trendelenburg, 98 
 
 Trousseau, 38 
 
 Tuholske, 157, 160 
 
 Urechie, 206, 345 
 
 Vanderlinden, 287, 328 
 
 Van Ecke, 287 
 
 Vassale, 250, 285, 286, 291, 305, 
 
 328, 331, 337, 340 
 Verdun, 208, 228, 230, 269 
 Verebely, 208, 213, 217, 231, 237, 
 
 243, 246, 256, 265, 266, 268, 
 
 269, 270, 272, 323 
 Verstraeten, 287, 328 
 Vincent, 222, 263, 302, 306, 338 
 Virchow, 201 
 Voegtlin, 206, 346, 347, 348, 349, 
 
 350 
 
 Walbaum, 289, 305, 354 
 
 Walther, 280 
 
 Warfield, 21 
 
 Weichselbaum, 270, 273, 327 
 
 Weiss, 281, 311 
 
 Werelins, 157 
 
 Welsh, 213, 218, 231, 234, 235, 288 
 
 Wiebrecht, 341 
 
 Wilson, 30, 31 
 
 Winternitz, 246 
 
 Wolfler, 20, 202 
 
 Yanasse, 244, 256, 265, 324, 325 
 
 Zanda, 336 
 Zanfrognini, 256, 341 
 Zielinska, 208 
 Zuckerkandl, 212 
 
INDEX. 
 
 Aberrant parathyroids, 288 
 Abnormalities of development, 18 
 Abscess, 20 
 
 of thyroid gland, 121 
 
 of thyroid gland, how located, 121 
 Accidents from anaesthesia, 90 
 
 surgical, due to removal of para- 
 thyroid glands, 311 
 Addison's disease, goitre mistaken 
 
 for, 66 
 Adenocarcinoma, 34 
 Adenoma, fcetal, 17, 29 
 Administration of iodine, 63 
 
 of ox parathyroid, 339 
 
 of thyroid extract, 63, 78, 197 
 Adrenalin, 92 
 
 chloride, 92 
 Adult myxcedema, 25 
 Air embolism, 116 
 Albuminuria, parathyroid deficiency 
 
 leads to, 332 
 Alopecia, 70 
 
 Amphibians, embryology of parathy- 
 roid glands in, 228 
 Amyloidosis, 24 
 Anaemia and emaciation, 64 
 
 cerebral, 98 
 Anaesthesia, 90 
 
 accidents from, 90 
 
 apparatus in rectal, 103 
 
 atropine and morphine to precede 
 ether in, 95 
 
 danger of, in operation, 91 
 
 local, 91 
 
 in operation on thyroid gland, 90 
 
 rectal, 100 
 
 remedies against dangers from, 91 
 
 spinal, 105 
 
 thyroidectomy under general, 95 
 under local, 94 
 Anaesthetic, choice of, 92 
 
 ether only safe, in goitre, 95 
 
 method of injecting, 93 
 Anasarca, 68 
 Anatomical consideration of thyroid 
 
 gland, 130 
 Anatomy of parathvroid glands, 209 
 
 in birds, 225 
 
 in children, 216 
 
 in mammals, 220, 225 
 
 of thyroid gland, 15 
 in mammals 220, 225 
 
 Angioma, 279 
 
 Animals, experiments on, 177 
 
 histology of parathyroid glands in, 
 240 
 
 postoperative tetany in, 295 
 
 used for experiments, 204 
 Antagonism between goitre and 
 
 tetany, 320 
 Anterior jugular vein, 134 
 Antithyroids, 86, 179 
 
 treatment with Moebius', 193 
 Aplasia, 18 
 
 Apparatus in rectal anaesthesia, 103 
 Arsenic, 88 
 
 Arteries, ligation of thyroid, 20 
 Artery, carotid, 148 
 
 external carotid, 133 
 
 inferior thyroid, 146 
 
 middle thyroid, 148 
 
 superior thyroid, 133 
 Athyreosis, 25 
 Atrophy, degenerative infantile, 257 
 
 of mammary glands, 70 
 
 primary infantile, 21, 257 
 
 sclerotic infantile, 257 
 
 of thyroid gland, 20 
 Atropine and morphine to precede 
 
 ether in anaesthesia, 95 
 Autotransplantation of parathyroid 
 
 glands, 354 
 Aves, embryology of parathyroid 
 glands in, 230 
 
 Barium, 347 
 Basedowii, morbus, 12 
 Basedow's disease, 29 
 Beaucaine, 92 
 Beebe's serum, 178 
 Belladonna, 88 
 
 Birds, anatomy of parathyroid glands 
 in, 225 
 
 parathyroidectomy fatal in, 289 
 Blood supply of parathvroid glands, 
 217 
 
 of thyroid gland, 15 
 
 toxic substance in the, 335 
 
 vessels, injury to, 311 
 Blushing, 67 
 Branchial cyst, 36, 268 
 
 Cachexia, 14 
 
 strumipriva, 12, 294 
 
378 
 
 INDEX. 
 
 Cachexia — cont'd. 
 
 thyropriva, 294 
 Calcined goitre, 23 
 Calcium chloride, diminution of, 207 
 
 injection of, 346 
 
 metabolism, connection between 
 parathyroids and, 326 
 
 in tetany, 349 
 Carbolic acid, injection of, 79 
 Carcinoma, 33, 166 
 
 of neck, 37 
 
 primary, 33 
 Carotid artery, 148 
 Cells, size of, in parathyroid glands, 
 
 231 
 Cerebral anaemia, 98 
 Changes in size of thyroid gland, 40 
 Children, anatomy of parathyroid 
 glands in, 216 
 
 rickets basis of tetany of, 327 
 
 tetany in, 205, 256, 323 
 Chronic heart affections, 261 
 
 inflammation, 21 
 
 interstitial parathyroiditis, 266 
 
 nephritis, 261 
 
 tuberculosis, 261 
 Circulatory disturbances, 18 
 Circumscribed oedema, 67 
 Cirrhosis of liver, 261, 266 
 Cocain, 92 
 
 application of, 106 
 Coley's serum, 170 
 Collapse of trachea, 116 
 
 how to avoid bad results from, 117 
 Colloid, 17, 262 
 
 goitre, 26 
 
 hypersecretion of, 23 
 Color of parathyroid glands, 211 
 Complications of symptoms, 75 
 Conditions increasing gravity, 61 
 
 intermittent, 59 
 
 occasionally present, 65 
 Congenital goitre, 196 
 
 myxcedema, 18 
 
 parathyroid hypoplasia in rachi- 
 tis, 327- 
 Congestion, passive, 20, 266 
 Conjunctivitis developed, 309 
 Connection between parathyroid 
 haemorrhage and tetanv, 
 325 
 
 parathvroids and calcium metabo- 
 lism, 326 
 
 parathyroids and osteomalacia, 
 326 
 
 parathyroids and rickets, 326 
 Convergence test in diagnosis, 58 
 Cortical irritation, 61 
 
 Cretinism, endemic, 24 
 
 sporadic, 18, 24 
 Cyst, branchial, 36, 268 
 
 retention, 268 
 Cystocarcinoma, 34 
 Cysts and tumors of parathyroid 
 
 glands, 268 
 Cytolitic serum, 186 
 
 Danger of anaesthesia in operation, 91 
 
 of operation on thyroid gland, 110 
 
 of thyroidectomy, 89 
 Deficiency, mental, 55 
 Deformities, how to prevent, 154 
 Degeneration of parathyroid glands, 
 264 
 
 polycystic, 268 
 
 and infiltration, 23 
 Depression, mental, 61 
 Diabetes, 261 
 Diagnosis, convergence test in, 58 
 
 errors in, 54 
 
 electrical test in, 54 
 
 of exophthalmic goitre, 38 
 
 of goitre, 36, 38 
 
 of thyroid gland, 36 
 Diet following parathyroidectomy, 
 
 334 
 Diffuse hypertrophy, 26 
 Diminution of calcium, 207 
 Discoloration of skin, 65 
 Disease, Addison's, goitre mistaken 
 for, 66 
 
 Basedow's, 29 
 
 Graves', 12, 29, 178 
 
 Pott's, 35 
 Diseased parathyroids, hypersuscep- 
 tibility of nerves symptoms 
 of, 321 
 
 tissues, nodules of, 138 
 Dissection of isthmus, 150 
 
 of thyroid gland, 144 
 Disturbances, chronic, due to partial 
 loss of parathyroids, 305 
 
 circulatory, 18 
 
 insufficiency of -parathyroids causes 
 convulsive, 313 
 of thyroid causes nutritional, 313 
 
 nutritive, after parathyroidecto- 
 my, 305 
 Drainage, method of, 153 
 
 provision for, 153 
 
 value of, in operation, 112 
 Dyspnoea, paroxysmal, 58 
 
 Eclampsia, 256, 327 
 
 of pregnancy prevented by para- 
 thyroids, 321 
 
INDEX. 
 
 379 
 
 Eclampsia — cont'd. 
 
 thyroid therapy relief in, 331 
 Electrical test in diagnosis, 54 
 
 treatment of simple goitre, 81 
 Emaciation and anaemia, 64 
 Embolism, 20 
 
 air, 116 
 Embryology and histology of para- 
 thyroid glands, 227 
 of parathyroid glands, 227 
 of parathyroid glands in amphibi- 
 ans, 228 
 of parathyroid glands in aves, 230 
 of parathyroid glands in mamma- 
 lia, 230 
 of thymus gland, 227 
 of thyroid gland, 227 
 Endemic cretinism, 24 
 Endothelioma, 33 
 Enlargement of lymph nodes, 71 
 
 of thymus gland, 71 
 Enucleation of thyroid tumors, 165 
 Epilepsy, 205, 250 
 Epileptiform crisis, 311 
 Epithelium, new formation of, 23 
 Ergotine, 86 
 
 and hydrobromate of quinine, 184 
 Errors in diagnosis, 54 
 Erythema, 67 
 
 Ether, method of administering, 96 
 only safe anaesthetic in goitre, 95 
 Trendelenburg position in admin- 
 istering, 98 
 Etiology of hypoparathyroid glands, 
 205 
 interest of internist in hypopara- 
 thyroid, 205 
 Excitability, nervous, 52 
 Excitation, psychic, 62 
 Exhaustion, mental, 62 
 
 physical, 62 
 Exophthalmic goitre. See Goitre, 
 
 exophthalmic. 
 Exophthalmos, 30 
 Experiments on animals, 177, 204 
 
 opposed to tetany, 299 
 Exposure, x-ray, in operation on thy- 
 roid gland, 169 
 External carotid artery, 133 
 
 parathyroids, 285 
 Extirpation of thyroid gland, 14 
 Extract, thyroid, administration of, 
 63, 78, 197 
 in congenital goitre, 197 
 efficacy of, 14 
 in fracture, 72 
 in myxcedema, 69 
 tetany benefited by, 340 
 
 Extract — cont'd. 
 
 tetany controlled by pituitary, 362 
 therapeutic use of parathyroid, 337 
 
 Extrathyroideal tumors, 271 
 
 Fat in parathyroid glands, 260 
 
 Fibrosis, 265 
 
 Fcetal adenoma, 17, 29 
 
 Fracture, administration of thyroid 
 
 extract in, 72 
 Function of parathyroid glands, 199, 
 
 206 
 of thyroid gland, 14 
 
 Gall-bladder, infection of, 262 
 Gastric tetany, 205, 324 
 Gastrointestinal symptoms, 60 
 Gauze, tamponing with, 145 
 General appearance of patients, 72 
 consideration of thyroidectomy, 88 
 pathology of parathyroid glands, 
 260 
 Gland, thyroid. See Thyroid gland. 
 Glands, parathyroid. See Parathy- 
 roid glands. 
 Glandulee parathyroidse, 202 
 Glandules, inferior (internal), 210 
 
 superior (external), 209 
 Globus hystericus, 53 
 Goats, milk from thyroidectomized, 
 88 
 serum of thyroidectomized, 86 
 Goitre, antagonism between, and 
 tetany, 320 
 calcified, 23 
 colloid, 26 
 congenital, 196 
 diagnosis of, 36, 38 
 diffuse hypertrophy of, 26 
 exophthalmic, 29, 39, 74, 205 
 diagnosis of, 36, 38 
 complications of symptoms in, 75 
 due to lesions of parathyroid 
 
 glands, 247 
 heredity in, 192 
 history blank for, 182 
 indications for operation on, 123 
 prognosis in, 178 
 prognosis of, less hopeful in 
 
 men, 179 
 statistics of, 188 
 symptoms of, developed by iodide 
 
 of potassium, 76 
 treatment of, 83, 84 
 what is, 12 
 haemorrhage in, 20 
 heart, 12 
 heredity in, 191 
 
380 
 
 INDEX. 
 
 Goitre — cont'd. 
 
 hypertrophy of, 25 
 
 minor list of symptoms of, 45 
 
 minor symptoms of, 41 
 
 mistaken for Addison's disease, 66 
 
 nodular hypertrophy of, 28 
 
 parenchymatous, 26 
 
 removal, 311 
 
 simple, 72 
 
 heredity in, 192 
 
 indications for operation in, 119 
 electrical treatment of, 81 
 treatment of, 77 
 Grsefe's sign, 56 
 
 symptoms, 50 
 Graves' disease, 12, 29, 178 
 
 prognosis in, 178 
 Gravity, conditions increasing, 61 
 Growths, histoid, 32 
 
 malignant, 166 
 
 osteoplastic, 33 
 
 Haemorrhage in goitre, 20 
 
 in operation, 110 
 
 in parathyroid glands, 265, 324 
 Heart affections, chronic, 261 
 
 lesions, 266 
 Heredity in goitre, 191 
 
 in exophthalmic goitre, 192 
 
 in simple goitre, 192 
 Histoid growths, 32 
 Histology, pathologic, of parathy- 
 roid glands, 243 
 
 of infant parathyroid glands, 239 
 
 of parathyroid glands, 231 
 
 of parathyroid glands in animals, 
 240 
 History blank for exophthalmic goi- 
 tre, 182 
 
 of parathyroid glands, 199 
 
 of surgical diseases of thyroid 
 gland, 10 
 Hydrobromate of quinine, 86 
 
 of quinine and ergotine, 184 
 Hypersemia, 18 
 
 sexual, 18 
 Hyperplasia, 28 
 
 Hypersusceptibility of. nerves symp- 
 toms of diseased parathy- 
 roids, 321 
 Hyperthyroidism, 15, 29 
 
 postoperative, 144 
 Hypertrophy, 40 
 
 diffuse, 26 
 
 of goitre, 25 
 
 nodular, 28 
 
 of parathyroids, 294 
 Hypoparathyroid etiology, 205 
 
 Hypoplasia of parathyroids, 327 
 Hypothyroidism, 21, 24, 29, 111 
 Hysteria, 53 
 
 Idiopathic tetany, 205, 320 
 Incision in thyroidectomy, 126 
 Indication for ligation of thyroid ves- 
 sels, 156 
 for operation in exophthalmic goi- 
 tre, 123 
 in malignant growths of thyroid 
 
 gland, 124 
 in simple goitre, 119 
 on thyroid gland, 119 
 Infantile atrophy, degenerative, 257 
 primary, 21, 257 
 sclerotic, 257 
 Infantile myxcedema, 25 
 Infant parathvroid glands, histology 
 
 of, 239 
 Infarction, 20 
 Infection, 114 
 
 of gall-bladder, 262 
 Inferior (internal) glandules, 210 
 
 thyroid artery, 146 
 Infiltration and degeneration, 23 
 Inflammation, 20 
 
 chronic, 21 
 Infusion of salt solution in tetany, 
 
 337 
 Injecting crushed thyroid tissue, 171 
 
 anaesthetic, method of, 93 
 Injection of calcium chloride, 346 
 of carbolic acid, 79 
 hypodermic, of iodine, 87 
 intraperitoneal, of parathyroid, 338 
 intravenous, of horse parathy- 
 roid, 339 
 intravenous, of parathyroid emul- 
 sion, 338 
 of parathyroid into jugular vein, 
 
 338 
 position of patient after, 108 
 of sodium chloride, 345 
 of stovaine and strychnine, 107 
 subcutaneous, of beef parathyroid 
 and morphine; 338 
 of horse parathyroid, 339 
 of parathyroid emulsion, 337 
 Injury to blood vessels, 311 
 
 to parathyroid glands, 113, 115 
 to recurrent laryngeal nerve, 115 
 Insane, patient may become, 55 
 Insufficiency of parathyroids causes 
 convulsive disturbances, 313 
 of thyroid causes nutritional dis- 
 turbances, 313 
 Interfollikulaeres epithel, 202 
 
INDEX. 
 
 381 
 
 Intermittent conditions, 59 
 Internal jugular vein, 133, 148 
 
 parathyroids, 285 
 Internist, interest of, in hypopara- 
 
 thyroid etiology, 205 
 Intraperitoneal injection of parathy- 
 roid, 338 
 Intrathyrodeal tumors, 271 
 Intravenous injection of horse para- 
 thyroid, 339 
 of parathyroid emulsion, 338 
 Involvement, metastatic, 280 
 Iodide of potassium, symptoms de- 
 veloped by, 76 
 Iodine, administration of, 63 
 hypodermic injection of, 87 
 internal and external use of, 87 
 ointment, application of, 78 
 use of, may do harm, 87 
 Irritation, cortical, 61 
 Ischemia followed by tetany, 306 
 Isotransplantation of parathyroid 
 
 gland unsuccessful, 357 
 Isthmus, dissection of, 150 
 
 Jaundice in fatty change of para- 
 thyroids, 262 
 
 Lactation, tetany of, 205, 327 
 Lesions, heart, 266 
 
 of parathyroid glands, exophthal- 
 mic goitre due to, 247 
 Leucocytosis, 64, 122 
 Leukaemia, 37 
 Life, parathyroid glands necessary 
 
 for, 362 
 Ligation of superior poles, 163 
 
 of thyroid arteries, 20 
 
 of thyroid veins, 160 
 
 of thyroid vessels, 155 
 
 of. thyroid vessels as preliminary 
 operation, 156 
 
 of thyroid vessels, various methods 
 of, 157 
 
 of thyroid vessels, when indicated, 
 156 
 
 ultra, 219 
 
 with catgut, 149 
 Lipoma of neck, 37 
 Liver, cirrhosis of, 266 
 Luxation of thyroid gland, 142 
 Lymph nodes, enlargement of, 71 
 Lymphocytosis, 64 
 Lymphona, 279 
 Lymphosarcoma, 37 
 Lymph spaces, 16 
 
 Magnesium, 347 
 
 Malignant growths of thyroid gland, 
 166 
 
 indication for operation in, 124 
 Mammalia, embryology of parathy- 
 roid glands in, 230 
 Mammals, anatomy of parathyroid 
 glands in, 220 
 
 anatomy of thyroid gland in, 225 
 Mammary glands, atrophy of, 70 
 Meat diet may produce tetany, 335 
 Medication, specific, 85 
 Medulla oblongata, 12 
 Mental deficiency, 55 
 
 depression, 61 
 
 exhaustion, 62 
 Metabolic toxin, 207 
 Metabolism origin of tetany poison, 
 
 326 
 Metastasis, 33 
 
 Metastatic involvement, 280 
 Milk, natural, feeding after thyropa- 
 
 rathyroidectomy, 335 
 Moebius' antithyroidin, treatment 
 with, 193 
 
 serum, 178, 186 
 
 sign, 57 
 
 symptoms, 50 
 Morbus Basedowii, 12 
 Morphine and atropine to precede 
 
 ether in anaesthesia, 95 
 Muscles, omohyoid, 136 
 
 platysma myoides, 132 
 
 sternocleido, 137 
 
 sternocleido-mastoid, 132 
 
 sternohyoid, 136 
 
 sternothyroid, 136 
 Muscular weakness, 49 
 Myocarditis, 42 
 Myoma, 279 
 Myxcedema, 12, 68, 249 
 
 adult, 25 
 
 congenital, 18 
 
 fruste, 25 
 
 infantile, 25 
 
 operative, 25 
 
 Natural milk feeding after thyro- 
 
 parathyroidectomy, 335 
 Necrosis, pressure, 152 
 Nephritis, chronic, 261 
 
 toxic glomerulo, 265 
 
 parenchymatous, 265 
 Nerve, phrenic, 133 
 
 pneumogastric, 148 
 
 recurrent laryngeal, 133, 147 
 injury to, 115 
 
 supply of parathyroid glands, 226 
 
 vagus, 133 
 
382 
 
 INDEX. 
 
 Nerves, hypersusceptibility of, symp- 
 toms of diseased parathy- 
 roids, 321 
 Nervous excitability, 52 
 Neurasthenia, 53 
 Nodular hypertrophy, 28 
 Nodules, accessory thyroid, 18 
 of diseased tissues, 138 
 pressing upon trachea, 150 
 Nomenclature of parathvroid glands, 
 
 208 
 Non-malignant diseases, 82 
 Non-surgical treatment of thyroid 
 
 gland, 77 
 Novocain, 92 
 
 Nucleoproteid of parathyroid gland, 
 342 
 clinical value of, 345 
 how to administer, 343 
 how to prepare, 343 
 Nutritive disturbances after parathy- 
 roidectomy, 305 
 
 Oedema, circumscribed, 67 
 Operation, anaesthesia in, on thvroid 
 gland, 90 
 danger of anaesthesia in, 91 
 of, on thyroid gland, 110 
 haemorrhage in, 110 
 indication for, in exophthalmic 
 goitre, 123 
 for, in malignant growths of 
 
 thyroid gland, 124 
 for, in simple goitre, 119 
 for, on thyroid gland, 124 
 parathyroids to be spared in thy- 
 roid, 316 
 shock from, 110 
 Stamm-Jacobson, 163 
 value of drainage in, 112 
 x-ray exposure in, on thyroid 
 gland, 169 
 Operations, other, on thyroid gland, 
 
 163 
 Operative myxcedema, 25 
 Osteomalacia, 72, 205, 257 
 
 connection between parathyroids 
 and, 326 
 Osteoplastic growths, 33 
 Ostitis deformans, 274 
 Ox parathyroid, administration of, 
 339 
 
 Paraparesis, 50 
 Paralysis agitans, 205, 251 
 Parathyroid, administration of ox, 
 339 
 
 Parathyroid — cont'd. 
 
 beef, and morphine, subcutaneous 
 injection of, 338 
 
 deficiency leads to albuminuria, 
 332 
 
 emulsion, intravenous injection 
 of, 338 
 
 emulsion, subcutaneous injection 
 of, 337 
 
 etiology, 205 
 
 extract, tetany benefited by, 340 
 therapeutic use of, 337 
 
 haemorrhage, connection between, 
 and tetany, 325 
 
 injection of, into jugular vein, 338 
 
 insufficiency, tetany rests upon, 
 333 
 
 intraperitoneal injection of, 338 
 
 intravenous injection of horse, 339 
 
 subcutaneous injection of horse, 
 339 
 
 subcutaneous transplantation of, 
 337 
 
 tetany, toxin hypothesis of, 335 
 
 theory of tetany, 323 
 
 therapy, 334 
 Parathyroids, aberrant, 288 
 
 chronic disturbances due to par- 
 tial loss of, 305 
 
 connection between, and calcium 
 metabolism, 326 
 between, and osteomalacia, 326 
 between, and rickets, 326 
 
 eclampsia of pregnancy prevented 
 by, 321 
 
 external, 283 
 
 haemorrhage in, 324 
 
 hypersusceptibility of nerves symp- 
 toms of diseased, 321 
 
 hypertrophy of, 294 
 
 hypoplasia of, 327 
 
 insufficiency of, causes convulsive 
 disturbances, 313 
 
 internal, 285 
 
 to be spared in thyroid opera- 
 tions, 316 
 Parathyroid gland, clinical value of 
 nucleoproteid of, 343 
 
 how to administer nucleoproteid 
 of, 343 
 
 how to prepare nucleoproteid of. 
 343 
 
 isotransplantation of, unsuccess- 
 ful, 357 
 
 nucleoproteid of, 342 
 
 transplantation of, into human 
 being, 359 
 
 transplantation of, into tibia, 360 
 
INDEX. 
 
 383 
 
 Parathyroid glands, 199 
 anatomy of, 209 
 in birds, 225 
 blood supply, 217 
 in children, 216 
 color, 211 
 
 inferior (internal) glandules, 210 
 location, 209 
 in mammals, 220, 225 
 nerve supply, 226 
 shape, 211 
 size, 210 
 superior (external) glandules, 
 
 209 
 variations in numbers, 212 
 ultra ligation, 219 
 weight, 211 
 cysts and tumors of, 268 
 angioma, 279 
 branchial cysts, 268 
 branchial polycystoma, 268 
 lymphona, 279 
 metastatic involvement, 280 
 myoma, 279 
 
 polycystic degeneration, 268 
 retention cysts, 268 
 tumors of parathyroid glands, 
 270 
 extrathyroideal, 271 
 intrathyroideal, 271 
 ostitis deformans, 274 
 embryology and histology of, 227 
 embryology, 227 
 amphibians, 228 
 aves, 230 . 
 mammalia, 230 
 thymus gland, 227 
 thyroid gland, 227 
 histology, 231 
 in animals, 240 
 of infant parathyroid, 239 
 secretion of parathyroid 
 
 glands, 241 
 tvpe 1, comparatively small 
 
 cells, 231 
 tvpe 2, comparatively large 
 cells, 232 
 history of, 199 
 
 animals used for Experiments, 
 
 204 
 function, 199, 206 
 glandulae parathyroidse, 202 
 hypoparathyroid etiology, 205 
 children's tetany, 205 
 gastric tetany, 205 
 epilepsy, 205 
 exophthalmic goitre, 205 
 idiopathic tetany, 205 
 
 Parathyroid glands — cont'd, 
 osteomalacia, 205 
 paralysis agitans, 205 
 rickets, 205 
 
 tetany of lactation, 205 
 of pregnancy, 205 
 interfollikulaeres epithel, 202 
 independent vital organs, 206 
 nomenclature, 208 
 parathyroid therapy, 205 
 restes embryonnaires, 202 
 tetany symptoms, 207 
 
 diminution of calcium, 207 
 metabolic toxin, 207 
 parathyroid therapy, 334 
 barium, 347 
 calcium in tetany, 349 
 diet, 334 
 infusion of salt solution in 
 
 tetany, 337 
 injection of calcium chloride, 346 
 of parathvroid into jugular 
 
 vein, 338 
 of sodium chloride, 345 
 intraperitoneal injection of para- 
 thyroid, 338 
 intravenous injection of horse 
 
 parathyroid, 339 
 intravenous injection of para- 
 thyroid emulsion, 338 
 magnesiuni, 347 
 meat diet mav produce tetany, 
 
 335 
 natural milk feeding after thyro- 
 
 parathyroidectomy, 335 
 nucleoproteid of parathyroid 
 gland, 342 
 clinical value of, 345 
 how best administered, 343 
 how prepared, 342 
 ox parathyroid administered to 
 
 human beings, 339 
 parathyroid glands necessary 
 for life, 362 
 vital organs, 362 
 strontium, 347 
 
 subcutaneous injection of beef 
 parathyroid and morphine, 
 338 
 of horse parathyroid, 339 
 of parathyroid emulsion, 337 
 subcutaneous transplantation of 
 
 parathyroid, 337 
 tetany a symptom, 362 
 
 benefited by parathyroid ex- 
 tract, 340 
 benefited bv thyroid extract, 
 340 
 
384 
 
 INDEX. 
 
 Parathyroid glands — cont'd. 
 
 tetany controlled after parathy- 
 roidectomy, 362 
 therapeutic use of parathyroid 
 
 gland, 337 
 thyroparathyroidectomy, 348 
 toxic substance in the blood, 335 
 toxin hypothesis of parathyroid 
 
 tetany, 335 
 transfusion in tetany, 336 
 transplantation of parathyroid 
 glands, 351 
 autotransplantation, 354 
 into human being, 359 
 into shaft of tibia, 360 
 isotransplantation unsuccess- 
 ful, 357 
 parathyroids grafted into 
 spleen, 355 
 trisodic citrate solutions, 346 
 pathologic histology of, 243 
 colloid, 262 
 degenerations, 264 
 eclampsia, 256 
 epilepsy, 250 
 exophthalmic goitre, 247 
 general pathology, 260 
 fat, 260 
 
 chronic heart affections, 261 
 chronic nephritis, 261 
 chronic tuberculosis, 261 
 cirrhosis of liver, 261 
 diabetes, 261 
 
 infection of gall-bladder, 262 
 jaundice, 262 
 pyelonephrosis, 261 
 fibrosis, 265 
 
 chronic interstitial parathy- 
 
 roiditis, 266 
 cirrhosis of liver, 266 
 heart lesions, 266 
 passive congestion, 266 
 haemorrhage, 265 
 
 toxic glomerulo-nephritis, 265 
 acute parenchymatous nephri- 
 tis, 265 
 morphological observations, 243 
 myxcedema, 249 
 osteomalacia, 257 
 paralysis agitans, 251 
 pellagra, 260 
 
 primary infantile atrophy, 257 
 degenerative, 257 
 sclerotic, 257 
 rachitis, 256 
 tetanus, 255 
 tetany, 255 
 
 of children, 256 
 
 Parathyroid glands — cont'd. 
 
 tuberculosis of parathyroid 
 glands, 246 
 relation of, to medical tetany, 318 
 antagonism between goitre and 
 
 tetany, 320 
 children's tetany, 323 
 congenital parathyroid hypo- 
 plasia in rachitis, 327 * 
 connection between parathyroid 
 haemorrhage and tetany, 
 325 
 between parathyroids and cal- 
 cium metabolism, 326 
 between parathyroids and os- 
 teomalacia, 326 
 between parathyroids and rick- 
 ets, 326 
 eclampsia, 327 
 
 of pregnancy prevented by pa- 
 rathyroids, 321 
 gastric tetany, 321 
 haemorrhage in parathyroids, 324 
 hypersusceptibility of nerves 
 symptoms of diseased para- 
 thyroids, 321 
 hypoplasia of parathyroids, 327 
 idiopathic tetany, 320 
 metabolism origin of tetany 
 
 poison, 326 
 parathyroid deficiency leads to 
 
 albuminuria, 332 
 parathyroid theory of tetany, 
 
 323 
 rickets basis of tetanv of chil- 
 dren, 327 
 tetany of lactation, 327 
 of pregnancy, 327 
 rests upon parathyroid insuf- 
 ficiency, 333 
 thyroid therapy relief in eclamp- 
 sia, 331 
 uniform tetany symptoms in 
 man and animals, 320 
 relation of, to postoperative tetany, 
 281 
 aberrant parathyroids, 288 
 cachexia strumipriva, 294 
 
 thyropriva, 294 
 chronic disturbances due to par- 
 tial loss of parathyroids, 305 
 nutritive disturbances, 305 
 conjunctivitis developed, 309 
 experiments opposed to tetany, 
 
 299 
 external parathyroids, 285 
 hypertrophy, 294 
 internal parathyroids, 285 
 
INDEX. 
 
 185 
 
 Parathyroid glands — cont'd. 
 
 ischemia followed by tetany, 306 
 parathyroidectomy fatal in birds, 
 
 289 
 postoperative tetany in animals, 
 
 295 
 tetany due to loss of parathy- 
 roid glands, 312 
 experiments on animals, 2S3 
 surgical accidents due to removal 
 of, 311 
 epileptiform crisis, 311 
 goitre removal, 311 
 how to escape tetany, 311 
 injury to blood vessels, 311 
 insufficiency of parathyroids 
 causes convulsive disturb- 
 ances, 313 
 of thyroid causes nutritional 
 disturbances, 313 
 parathyroids to be spared in 
 
 thyroid operations, 316 
 postoperative tetanv less fre- 
 quent, 316 
 subcapsular procedure, 316 
 tabulated cases of tetany fol- 
 lowing partial thyroidec- 
 tomy, 314 
 tetania parathyropriva, 315 
 tetany due to loss of parathy- 
 roid glands, 312 
 tetany not due to loss of thvroid 
 gland, 312 
 Parathyroidectomy, diet following 
 334 
 fatal in birds, 289 
 nutritive disturbances after, 305 
 tetany controlled after, 362 
 Parathyroiditis, chronic interstitial, 
 
 266 
 Parathyroid therapy, 334 
 Parenchymatous goitre, 26 
 
 nephritis, 265 
 Paroxysmal dyspnoea, 58 
 Passive congestion, 20, 266 
 Pathologic histology of parathyroid 
 
 glands, 243 
 Pathology, general, of parathyroid 
 glands, 260 
 of thyroid gland, 14 
 Patient may become insane, 55 
 Patients, general appearance of, 72 
 Pellagra, 260 
 Perithelium, 33 
 Phrenic nerve, 133 
 Physical exhaustion, 62 
 Pituitary extract, tetany controlled 
 by, 362 
 
 Pneumogastric nerve, 145 
 Poisoning, symptoms of thyroid, 44 
 Poles, ligation of superior, 163 
 Polycystic degeneration, 268 
 Position of patient after injection, 108 
 Postoperative hyperthyroidism, 144 
 tetany in animals, 295 
 tetany less frequent, 316 
 
 relation of parathyroid glands 
 to, 281 
 Pott's disease, 35 
 Primary carcinoma, 33 
 
 sarcoma, 33 
 Pregnancy, eclampsia of, prevented 
 by parathyroids, 321 
 tetany of, 205, 327 
 Procedure, subcapsular, 316 
 Prognosis in exophthalmic goitre, 178 
 of exophthalmic goitre less hopeful 
 
 in men, 179 
 in Graves' disease, 178 
 Pseudoleukemia, 37 
 Psychic excitation, 62 
 Pulse beat varies, 40 
 Pyelonephrosis, 261 
 
 Quinine, hydrobromate of, 86 
 Quinine, hydrobromate of, and ergo- 
 tine, 184 
 
 Rachitis, 256 
 
 Rachitis, congenital parathyroid hy- 
 poplasia in, 327 
 Recognition of thyroid gland, 132 
 Rectal anaesthesia, 100 
 
 advantages of, 100 
 
 apparatus in, 103 
 
 method of application of, 101 
 
 technic of, 102 
 Recurrent laryngeal nerve, 133 
 Relation of parathyroid glands to 
 medical tetany, 318 
 
 to postoperative tetany, 281 
 Remedies against clangers from anaes- 
 thesia, 91 
 Removal of goitre, 311 
 
 of portion of thyroid gland, 69 
 Restes embryonnaires, 202 
 Retention cysts, 268 
 Rickets, 205 
 
 basis of tetany of children, 327 
 
 connection between parathyroids 
 and, 326 
 
 Sarcocarcinoma, 35 
 Sarcoma, 33, 35, 166 
 
 primary, 33 
 Scleroderma,, 70 
 
386 
 
 INDEX. 
 
 Secretion of parathyroid glands, 241 
 Septicaemia, 20 
 Serum, Beebe's, 178 
 
 Coley's, 170 
 
 cytolitic, 186 
 
 Moebius', 178, 186 
 
 of thyroidectomized goats, 86 
 Sexual hypersemia, 18 
 Shape of parathyroid glands, 211 
 Shock from operation, 110 
 Sign, Graefe's, 56 
 
 Moebius', 57 
 
 Stellwag's, 57 
 Simple goitre. See Goitre, simple.. 
 Size of parathyroid glands, 210, 231 
 
 of thyroid gland, 130 
 
 of thyroid gland changes, 40 
 Skin, discoloration of, 65 
 Sodium chloride, injection of, 345 
 
 phosphate, 87 
 Solutions, trisodic citrate, 346 
 Specific medication, 85 
 Spinal anaesthesia, 105 
 Spleen, parathyroid glands grafted 
 
 into, 355 
 Sporadic cretinism, 18, 24 
 Stamm-Jacobson operation, 163 
 Statistics of exophthalmic goitre, 188 
 Stellwag's sign, 57 
 
 symptoms, 50 
 Stovaine and strvchnine, application 
 of, 106 " 
 
 injection of, 107 
 
 preparation of, 106 
 Strontium, 347 
 Strophantus, 88 
 Strumitis, 167 
 Subcapsular procedure, 316 
 Subcutaneous injection of beef para- 
 thyroid and morphine, 338 
 
 injection of horse parathyroid, 339 
 
 injection of parathyroid emulsion, 
 337 
 
 transplantation of parathyroid, 337 
 Surgical accidents due to removal of 
 parathyroid glands, 311 
 
 consideration of thyroid gland, 9 
 
 diseases, history of, 10 
 Superior (exterior) glandules, 209 
 
 poles, ligation of, 163 
 
 thyroid artery, 133 
 
 thyroid vein, 134 
 Sutures, catgut, 149 
 
 horsehair, 154 
 
 silk, 154 
 
 skin, 154 
 
 subcuticular, 154 
 
 when to be cut, 154 
 
 Symptom, tetany a, 362 
 Symptoms, complications of, 75 
 
 developed by iodide of potassium, 
 76 
 
 gastrointestinal, 60 
 
 Graefe's, 50 
 
 list of minor, of goitre, 45 
 
 minor, of goitre, 41 
 
 Moebius', 50 
 
 Stellwag's, 50 
 
 thyroid poisoning, 44 
 
 tetany, 207 
 
 uniform tetany, in man and ani- 
 mals, 320 
 Syncope, 122 
 
 Syphilis, tertiary, of thyroid gland, 
 23 
 
 of thyroid gland, 22 
 
 Tabulated cases of tetany follow- 
 ing partial thyroidectomy, 
 314 
 Tachycardia, 38, 44 
 Tamponing with gauze, 145 
 Technic of thyroidectomy, 126 
 
 of transplantation of thvroid gland, 
 173 
 Test, convergence, in diagnosis, 58 
 
 electrical, in diagnosis, 54 
 Tetania parathyropriva, 315 
 Tetanus, 255 
 Tetany, 49, 255 
 
 antagonism between, and goitre, 
 
 320 
 benefited by thyroid extract, 340 
 calcium in, 349 
 of children, 205, 256, 323 
 of children, rickets basis of, 327 
 connection between parathyroid 
 
 haemorrhage and, 325 
 controlled after parathyroidec- 
 tomy, 362 
 controlled by pituitary extract, 362 
 due to loss of parathyroid glands, 
 
 312 
 experiments opposed to, 299 
 gastric, 205, 321 
 how to escape, 311 
 idiopathic, 205, 320 
 infusion of salt solution in, 337 
 ischemia followed by, 306 
 of lactation, 205, 327 
 meat diet may produce, 335 
 medical, relation of parathyroid 
 
 glands to, 318 
 not due to loss of thyroid gland, 
 
 312 
 parathyroid theory of, 323 
 
INDEX. 
 
 387 
 
 Tetany — cont'd. 
 
 poison, metabolism origin of, 326 
 postoperative, in animals, 295 
 less frequent, 316 
 relation of parathyroid glands 
 to, 281 
 of pregnancy, 205, 327 
 rests upon parathyroid insuffi- 
 ciency, 333 
 a symptom, 362 
 symptoms, 207 
 symptoms uniform in man and 
 
 animals, 320 
 tabulated cases of, following par- 
 tial thyroidectomy, 314 
 toxin hypothesis of parathyroid, 
 
 335 
 transfusion in, 336 
 Therapeutic use of parathyroid ex- 
 tract, 337 
 Therapy, parathyroid, 334 
 
 thyroid, relief in eclampsia, 331 
 Thymus gland, 88 
 embryology of, 227 
 enlargement of, 71 
 Thyroaplasia, 24 
 Thyroid arteries, ligation of, 20 
 artery, middle, 148 
 extract, administration of, 63, 78, 
 197 
 in congenital goitre, 197 
 efficacy of, 14 
 in fracture, 72 
 in myxcedema, 69 
 tetany benefited by, 340 
 Thyroid gland, 9 
 
 anaesthesia in operation on, 90 
 accidents, 90 
 
 atropine and morphine to pre- 
 cede ether, 95 
 ' choice of anaesthetic, 92 
 adrenalin, 92 
 adrenalin chloride, 92 
 beaucaine, 92 
 cocain, 92 
 novocain, 92 
 danger of, in operation, 91 
 ether only safe anaesthetic in 
 goitre, 95 
 method of administering, 96 
 cerebral anaemia, 98 
 Trendelenburg position, 98 
 local, 91 
 method of injecting anaesthetic, 
 
 93 
 morphine, 95 
 rectal, 100 
 
 advantages of, 100 
 
 Thyroid gland — cont'd, 
 apparatus in, 103 
 method of application, 101 
 technic of, 102 
 remedies against dangers from, 
 
 91 
 spinal, 105 
 
 application of cocain, 106 
 of stovaine and strychnine, 
 106 
 preparation of stovaine and 
 strychnine solution, 106 
 the injection, 107 
 position of patient after in- 
 jection, 108 
 upper dorsal puncture, 107 
 thyroidectomy under local, 94 
 under general, 95 
 dangers of operation on, 110 
 air embolism, 116 
 collapse of trachea, 116 
 
 how to avoid bad results, 117 
 haemorrhage, 110 
 hyperthyroidism, 111 
 infection, 114 
 injury to parathyroid glands, 
 
 113, 115 
 injury to recurrent laryngeal 
 
 nerve, 115 
 shock, 110 
 
 value of drainage, 112 
 diagnosis of, 36 
 branchial cyst, 36 
 carcinoma of neck, 37 
 changes in size, 40 
 exophthalmic goitre, 38 
 hypertrophy, 40 
 leukaemia, 37 
 lipoma of neck, 37 
 lymphosarcoma, 37 
 • minor symptoms, 41 
 myocarditis, 42 
 tachycardia, 44 
 thyroid poisoning, 44 
 minor symptoms, list of, 45 
 alopecia, 70 
 atrophy of mammarv glands, 
 
 70 
 blushing, 67 
 
 circumscribed oedema, 67 
 differentiated from ana- 
 sarca, 68 
 complications, 75 
 conditions increasing gravity, 
 61 
 administration of idoine, 63 
 administration of thyroid 
 extract, 63 
 
388 
 
 INDEX. 
 
 Thyroid gland — cont'd. 
 
 mental exhaustion, 62 
 
 physical exhaustion, 62 
 
 psychic excitation, 62 
 conditions occasionally pres- 
 ent, 65 
 discoloration of the skin, 65 
 
 mistaken for Addison's dis- 
 ease, 66 
 emaciation and anaemia, 64 
 
 decreased leucocytosis, 64 
 
 increased lymphocytosis, 64 
 enlargement of lymph nodes, 
 
 71 
 enlargement of thymus gland, 
 
 71 
 erythema, 67 
 
 general appearance of pa- 
 tients, 72 
 
 exophthalmic goitre, 74 
 
 simple goitre, 72 
 Graefe's sign, 56 
 intermittent conditions, 59 
 
 cortical irritation, 61 
 
 gastrointestinal symptoms, 
 60 
 
 mental depression, 61 
 mental deficiency, 55 
 
 insane person, 55 
 
 patient mav become insane, 
 55 
 Moebius' sign, 57 
 muscular weakness, 49 
 
 Graefe's symptoms, 50 
 
 Moebius' symptoms, 50 
 
 paraparesis, 50 
 
 Stellwag's symptoms, 50 
 myxcedema, 68 
 nervous excitability, 52 
 
 convergence test, 58 
 
 electrical test, 54 
 
 errors in diagnosis, 54 
 
 globus hystericus, 53 
 
 hysteria, 53 
 
 neurasthenia, 53 
 osteomalacia, 72 
 paroxysmal dyspnoea (Bry- 
 
 son's symptoms), 58 
 removal of portion of thyroid 
 
 gland, 69 
 scleroderma, 70 
 Stellwag's sign, 57 
 tremor, 46 
 
 tetany, 49 
 urticaria, 67 
 vertigo, 55 
 pseudoleukemia, 37 
 pulse beat varies, 40 
 
 Thyroid gland — cont'd, 
 tachycardia, 38 
 heredity in goitre, 191 
 
 administration of thyroid ex- 
 tract, 197 
 congenital goitre, 196 
 exophthalmic goitre, 192 
 simple goitre, 192 
 treatment with Moebius'antithy- 
 roidin, 193 
 indications for operation on, 119 
 abscess, 121 
 
 exophthalmic goitre, 123 . 
 malignant growths, 124 
 simple goitre, 119 
 non-surgical treatment of, 77 
 iodine, use of, 87 
 arsenic, 88 
 belladonna, 88 
 hypodermic injection of, 87 
 internal and external use of, 
 
 87 
 milk from thyroidectomized 
 
 goats, 88 
 strophantus, 88 
 thymus gland, 88 
 use of, may do harm, 87 
 treatment of exophthalmic goi- 
 tre, 83 
 antithyroidin, 86 
 ergotine, 86 
 
 hydrobromate of quinine, 86 
 serum of thyroidectomized 
 
 goats, 86 
 sodium phosphate, 87 
 specific indication, 85 
 treatment of simple goitre, 77 
 electrical treatment, 81 
 injection of carbolic acid, 79 
 iodine ointment applied, 78 
 non-malignant diseases, 82 
 thvroid extract administered, 
 78 
 other operations on, 163 
 
 enucleation of thvroid tumors, 
 165 
 operation, 165 
 ligation of superior poles, 163 
 malignant growths of thyroid 
 gland, 166 
 carcinoma, 166 
 Coley's serum, 170 
 sarcoma, 166 
 strumitis, 167 
 
 sub-acute inflammation, 167 
 thyroiditis, 167 
 x-ray exposures, 169 
 Stamm-Jacobson operation, 16 
 
INDEX. 
 
 389 
 
 Thyroid gland — cont'd. 
 
 transplantation of thyroid gland, 
 125, 170 
 
 experiments in animals, 177 
 
 injecting crushed thyroid tis- 
 sue, 171 
 
 selection of material, 175 
 
 technic of transplantation, 173 
 pathology of, 14 
 
 abnormalities of development, 
 18 
 
 accessory thyroid nodules, 18 
 
 aplasia, 18 
 
 congenital myxcedema, 18 
 
 hyperthyroidism, 15, 29 
 
 sporadic cretinism, 18 
 anatomy, 15 
 
 colloid, 17 
 
 fcetal adenoma, 17 
 
 gross blood supply, 15 
 
 lymph spaces, 16 
 cachexia, 14 
 carcinoma, 33 
 
 adenocarcinoma, 34 
 
 cystocarcinoma, 34 
 
 Pott's disease, 35 
 
 primary, 33 
 
 sarcocarcinoma, 35 
 
 sarcoma, 35 
 circulatory disturbances, 18 
 
 atrophy, 20 
 
 embolism, 20 
 
 goitre, 19 
 
 haemorrhage, 20 
 
 hyperaemia, 18 
 sexual, 18 
 infarction, 20 
 
 ligation of thyroid arteries, 20 
 
 passive congestion, 20 
 degeneration and infiltration, 23 
 
 amyloidosis, 24 
 
 calcified goitre, 23 
 
 hypersecretion of colloid, 23 
 
 new formation of epithelium, 
 23 
 extirpation, 14 
 function, 14 
 hypothyroidism, 15, 24, 29, 111 
 
 adult myxcedema, 25 
 
 athyreosis, 25 
 
 Basedow's disease, 29 
 
 endemic cretinism, 24 
 
 exophthalmic goitre, 29 
 
 exophthalmos, 30 
 
 Graves' disease, 29 
 
 infantile myxcedema, 25 
 
 myxcedeme fruste, 25 
 
 operative myxcedema, 25 
 
 Thyroid gland — cont'd. 
 
 sporadic cretinism, 24 
 thyroaplasia, 24 
 hypertrophv (goitre), 25 
 diffuse, 26 
 colloid, 26 
 hyperplasia, 28 
 parenchymatous, 26 
 nodular, 28 
 
 fcetal adenoma, 29 
 inflammation, 20 
 abscess, 20 
 septicaemia, 20 
 thyroiditis, 20 
 inflammation, chronic, 21 
 hypothyroidism, 21 
 primary infantile atrophy, 21 
 sarcoma, 33 
 
 endothelioma, 33 
 metastasis, 33 
 osteoplastic growths, 33 
 perithelium, 33 
 primary, 33 
 syphilis, 22 
 
 tertiary, 23 
 thyroid extracts, efficacy of, 14 
 tuberculosis, 21 
 tumors, 32 
 
 histoid growths, 32 
 prognosis in exophthalmic goitre, 
 178 
 antithyroidin, 179 
 Beebe's serum, 178 
 cytolitic serum, 186 
 Graves' disease, 178 
 history blank, 182 
 hydrobromate of quinine and 
 
 ergotine, 184 
 less hopeful in men than in 
 
 women, 179 
 Moebius' serum, 186 
 statistics, 188 
 surgical consideration of, 9 
 
 history of surgical diseases, 10 
 cachexia strumipriva, 12 
 exophthalmic goitre, what is, 12 
 goitre heart, 12 
 Graves' disease, 12 
 medulla oblongata, 12 
 morbus Basedow, 12 
 myxcedema, 12 
 thyroidectomy, 10 
 thyroidectomy, 126 
 
 anatomical consideration, 130 
 anterior jugular vein, 134 
 carotid artery, 148 
 deformities, how to prevent, 
 154 
 
390 
 
 INDEX. 
 
 Thyroid gland — cont'd. 
 
 dissection of isthmus, 150 
 dissection of thvroid gland, 
 
 144 
 drainage, provision for, 153 
 
 method of, 153 
 external carotid artery, 133 
 how thyroid gland recognized, 
 
 132 
 inferior thyroid artery, 146 
 internal jugular vein, 133, 148 
 ligation of thyroid veins, 160 
 
 operation, 160 
 ligation of thyroid vessels, 155 
 as preliminary operation, 
 
 156 
 various methods of, 157 
 when indicated, 156 
 ligation with catgut, 149 
 luxation of thyroid gland, 142 
 middle thyroid artery, 148 
 muscles, 136 
 omohyoid, 136 
 platysma myoides, 132 
 sternocleido, 137 
 sternocleido-mastoid, 132 
 sternohyoid, 136 
 sternothyroid, 136 
 necrosis, pressure, 152 
 nodules of diseased tissues, 138 
 nodules pressing upon trachea, 
 
 150 
 phrenic nerve, 133 
 pneumogastric nerve, 145 
 postoperative hyperthyroid- 
 ism, 144 
 recurrent laryngeal nerve, 133 
 superior thyroid artery, 133 
 superior thyroid vein, 134 
 sutures, 154 
 catgut, 149 
 horsehair, 154 
 silk, 154 
 skin, 154 
 subcuticular, 154 
 when to be cut, 154 
 tamponing with gauze, 145 
 tracheotomy, when to be per- 
 formed, 151 
 vagus nerve, 133 
 incision, 126 
 technic, 126 
 Thyroidectomized goats, milk from, 
 
 88 
 Thyroidectomy, 10, 126 
 dangers of, 89 
 general consideration of, 88 
 incision in, 126 
 
 Thyroidectomy — cont'd. 
 
 tabulated cases of tetany follow- 
 ing partial, 314 
 technic of, 126 
 under local anaesthesia, 94 
 under general anaesthesia, 95 
 Thyroiditis, 20, 167 
 Thyroparathyroidectomy, 348 
 
 natural milk feeding after, 335 
 Toxic glomerulo-nephritis, 265 
 substance in the blood, 335 
 Toxin hypothesis of parathyroid 
 tetany, 335 
 metabolic, 207 
 Trachea, collapse of, 116 
 
 how to avoid bad results from col- 
 lapse of, 117 
 nodules pressing upon, 150 
 Tracheotomy, when to be performed, 
 
 151 
 Transfusion in tetany, 336 
 Transplantation of parathvroid gland, 
 351 
 of parathyroid gland into human 
 
 being, 359 
 of parathyroid gland into tibia, 360 
 parathyroid gland restored by, 113 
 subcutaneous, of parathyroid 
 gland, 337 
 . of thyroid gland, 70, 125, 170 
 of thyroid gland, selection of ma- 
 terial for, 175 
 of thyroid gland, technic of, 173 
 Treatment of exophthalmic goitre, 
 83, 84 
 non-surgical, of exophthalmic goi- 
 tre, 77 
 of simple goitre, 77 
 
 with electricity, 81 
 with Moebius' antithyroidin, 193 
 Tremor, 46 
 
 Trendelenburg position in adminis- 
 tering ether, 98 
 Trisodic citrate solutions, 346 
 Tuberculosis, chronic, 261 
 of parathyroid glands, 246 
 of thyroid gland, 21 
 Tumors, enucleation of thyroid, 165 
 extrathyroideal, 271 
 intrathyroideal, 271 
 of parathyroid glands, 270 
 of thyroid gland, 32 
 
 Ultra ligation, 219 
 
 Uniform tetany symptoms in man 
 
 and animals, 320 
 Urticaria, 67 
 
 Vagus nerve, 133 
 
INDEX. 
 
 391 
 
 Variations in number of parathyroid 
 
 glands, 212 
 Vein, anterior jugular, 134 
 
 internal jugular, 148 
 
 jugular, injection of parathyroid 
 into, 338 
 
 ligation of thyroid, 160 
 
 superior thyroid, 134 
 Vertigo, 55 
 Vessels, ligation of thyroid, 155 
 
 Vital organs, parathyroid glands in- 
 dependent, 206, 362 
 
 Weakness, muscular, 49 
 Weight of parathyroid glands, 212 
 of thyroid gland, 130 
 
 X-ray exposure in operation on thy- 
 roid gland, 169 
 
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