olumbia Q^nibergil in ti)t Citp of ^t\ii Borfe ^ci)ool of Bental anb 0val ^urgerp Eeferente i^ibrarp 6: DISEASES OF THE THYEOID GLAND AXD THEIR SURGICAL TREATMENT Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/diseasesofthyroiOOberr DISEASES OF THE THYROID GLAND AND THEIR SURGICAL TREATMENT BY JAMES BERRY B.^.hosv., F.E.C.S. SL'KGEOX TO THE ROYAL FREE HOSPIT.Ai AND LECTURER OX SURGERY AT THE LONDON (ROYAL FREE HOSPITAL) SCHOOL OF aiEDICIXE FOR TTOMEJi ; SURGEON TO THE ALEXANDRA HOSPITAL FOR HIP DISEASE PHILADELPHIA P. BLAKISTON'S SON & CO. 1012 WALNUT STREET 1901 Printed in Great Britain TO IX GRATEFUL AND AFFECTIONATE RECOGNITION OF MUCH VALUABLE HELP IN n> PREPARATION THIS BOOK IS DEDICATED PREFACE. This book is based upon the Essay to which the Jacksoiiian Prize of the Royal College of Surgeons for 1886 was awarded. The essay in its original form was never published because I felt that at that time I had had so little personal experience of thyroid operative surgery, that it was undesirable to commit my observations to print. During the last fourteen years, however, I have enjoyed unusual facilities for the study of this branch of surgery, and much of what was written- in the original essay has been entirely rewritten, by the light of farther experience. The Hunterian Lectures, which I had the honour of deliver- ing at the Royal College of Surgeons in 1891, have also been incorporated in the present work. I am fully aware of the many imperfections in, and omissions from, the book, and should have liked to wait for further ex- perience before publishing it. But further waiting seems undesirable, as there would always be something wanting, something new to be added. I trust that those who read the book will deal gently with it, and remember that it is an honest attempt to set forth as clearly and concisely as possible what is known by myself and others about a difficult and somewhat obscure branch of surgery. I have to thank numerous friends for the help they have afforded me ; some by sending cases for treatment, or for examination, others by supplying local information about the distribution of endemic goitre. The illustrations are mainly from my own photographs, supplemented by some others taken by friends. To Mr. Charles viii PRP^FACE. Cosens I am especially indebted for all the micro-photographs, and for much invaluable help in photography. The drawings are mainly by Miss G. Bulkeley-Johnson, who has bestowed an amount of care and attention upon them for which I am most grateful. A few are from the skilful pencil of Dr. Ethel Vaughan ; for a very few I am myself responsible. The patients from whom the photographs have been taken (excepting those shown in Figs. 15 and 83) have all been under my own observa- tion, ana most of them have been under my own care. The blocks (wdth the exception of those from which Figs. 85, 111 and 112 have been taken), have been prepared by Messrs. Godart of Maiden Lane, Strand. Several of the illustrations have appeared elsewhere, illus- trating papers contributed by myself to the British Medical Journal, PolycVmic Journal, Tranmctions of the Pathological Society, and St. Bartholomew's Hospital Reports, and for per- mission to use these I have to express my thanks. To Mr. Ernest Shaw I am indebted for much help in the preparation of microscopic sections. My best thanks are due to my friends Mr. Anthony Bowlby and Mr. Edmund Roughton for much valuable advice, and for the trouble they have taken in revising the proof sheets. 21 WiMPOLE St., London, W. Feb. 1901. CONTENTS. CHAPTER I. ANATOMY. Lateral lobes — Upper and lower horns — Isthmus — Pyramid — Relations — Arteries — Veins — Lymphatics — Nerves — Internal structure — Accessory thyroids — Parathyroids ........ Pp. 1-13 CHAPTER II. CONGENITAL AFFECTIONS. Congenital malformations — Complete absence — Absence of one lobe — Absence of isthmus — Accessory thyroids — Congenital goitre in man, in lower animals — Treatment of congenital goitre . . . . Pp. 14-19 CHAPTER III. ATROPHY AND HYPERTROPHY. Atrophy: in old age — Myxoedema — Treatment — Cretinism — Sporadic and endemic — Fatty tumours of cretinism. Hypertrophy : Compensatory — Physiological — Relation to menstruation — Pregnancy — Puberty — Thyroid of stout and thin persons ....... Pp. 20—35 CHAPTER IV. GOITRE AND ITS VARIETIES. Meaning of the word goitre — Parenchymatous — Cystic — Fibrous — Adenoma- tous (foetal and cystic adenomata) — Malignant — Exophthalmic — Hfemor- rhagic — Colloid — ' ' Vascular '" — Endemic — Sporadic — Epidemic — Acute — Suffocating — Substernal — Intra-thoracic — Retro-tracheal — Retro-i esopha- geal ........... Pp. 36-48 x contents. c'haptj:r v. ENDEMIC GOITRE-CAL'SATION AND DISTRIBUriON. Alleged causes — Climate — Physical configuration of soil — '' Want of air and sunshine "' theory — Erroneous nature of — Relation to geology — Geological and geographical distribution in England — Relation to calcareous rocks and waters derived from them — Lime — Magnesia — Iron — Organic impuri- ties — Epidemic goitre — Goitre wells — Artificial production of goitre — Goitre in lower animals — Habits of life, exertion, strain, &c. — Heredity — Conclusions Pp. 49-71 CHAPTER VI. SYMPTOMS AND DIAGNOSIS OF THYROID ENLARGEMENTS —PHYSICAL SIGNS. Mobility — Shape — Size — Position with regard to muscles, great vessels, sternum — Pulsation — Diagnosis from aneurism — Consistence — Pressure effects, on veins, recurrent laryngeal nerve, sympathetic, cervical and brachial plexuses, larynx and trachea, ctsophagus and pharynx Pp. 7-.^-104 CHAPTER Vn. THE DYSPNCEA CAUSED BY GOITRE. Frequency and importance — Pressure upon trachea — Lateral compression^ Scabbard-shaped trachea — Effect on trachea of bilateral goitre, unilateral, median — Softening of tracheal wall — Pressure upon recurrent nerves — Direct extension to trachea — Rupture of cyst or abscess — CEdema of glottis — Swelling of tracheal mucous membrane— Varieties of goitre most likely to cause dyspntea ; relation to age and sex — Danger of bilateral goitre of puberty and of deeply seated goitres — Table of cases of goitre causing death by suffocation ..... Pp. 105-129 CHAPTER Vni. INFLAMMATION,. Acute idiopathic inflammation — Typhoid fever — Rheumatism — Pyasmia — Trau- matic inflammation — Symptoms — Results of suppuration — Diagnosis — Treatment. Chronic inflammation — Primary chronic inflammation — Diagnosis from malignant disease — Treatment . . . Pp. 130-14.5 CHAPTER IX. TUBERCLE AND SYPHILIS. Tubercle : Miliary — Usually secondary — Caseating — Rarity of— Extirpation of tuberculous goitre. Syphilis : frequently affects thyroid in form of slight general enlargement — Gummata rare — Congenital syphilis Pp. 146-1.51 CONTENTS. xi CHAPTER X. CYSTIC DISEASE. Frequency — Age — Modes of origin — Transition of adenomata into cysts — Single and multiple cysts — Hsemorrhagic cysts — Structure of cyst wall — Of contents — Vacuolation of colloid — Intra-cystic growths — Malignant nature of — False intra-cystic growths .... Pp. 152-164 CHAPTER XI. HYDATIDS. Karity of — Museum specimen — Age — Sex — Absorption of gland by pressure — Symptoms — Suppuration — Diagnosis — Urticaria — Eupture into trachea — Treatment — Table of cases Pp. 165-175 CHAPTER Xn. EXOPHTHALMIC GOITKE AND ITS TEEATMENT. (GEAVES'S DISEASE; BASEDOW'S DISEASE.) Age — Sex — Pathology — Morbid anatomy — Characteristic appearance on sec- tion — Microscopical appearance — Absence of accumulated colloid — Secondary changes — Exophthalmos — Cause of — Enlargement of thymus — Symptoms and Diagnosis — "Formes frustes " — Treatment : Medical, Sur- gical — Operations upon the thyroid — Extirpation — Eesults — Exothyropexy — Operation upon vessels — Operation upon sympathetic — Section — Eesec- tion — Unilateral — Bilateral — Eesults — Mortality — Prognosis without operation — Conclusions ....... Pp. 176-196 CHAPTER Xin. MALIGNANT DISEASE AND ITS TREATMENT. Affects both normal and goitrous thyroid — Age — Sex — Varieties — Sarcoma and carcinoma — Eelative frequency — Symptoms and diagnosis — Infiltra- tion of neighbouring parts — Skin rarely involved — Duration of the disease — Mode of death — Unusual forms of malignant disease — " Malignant adenoma " — Papuliferous cyst — Treatment — Extirpation — Difficulties and dangers — Of ten incomplete — Eesults of operations — Recurrence — Statistics — Slowly growing forms — Palliative treatment — Partial removal — Simple incision — Tracheotomy — Difficulties — Dangers of sepsis — Treatment of dysphagia- and pain — Conclusions . . . . . Pp. 197-226 CHAPTER XIV. TEEATMENT OF INXOCEXT GOITEE— NON-OPERATIVE. General — Eemoval of cause — Medicinal — Iodine — Thyroid extract — Other drugs — Cases suitable for — Local — External applications — Indian method Pp. 227-230 xii COXTKNTS. CHAPTER XV. TREATMENT BY TAPPING— INJECTION— INCISION— SETOX— LIGATURE OF THYROID ARTERIES— EXOTHYROPEXY. Tapping : For cystic goitre — Occasionally cures — Risks of — Hiemorrhage. Injection : Of parenchymatous goitre — Directions — Risks — Fatal cases — - Of cystic goitre — Directions — Risks — Results. Incision : Rarely desirable — Cases suitable for. Seton : Dangers of. Ligature of thyroid ar«^^eries: Historical — Recent revival — Methods of operating. Exothyropexy : Historical — Objects of — Objections — Methods of operating — Results — Complications— Mortality Pp. 231-249 CHAPTER XVI. DIYISIOX OR RESECTION OF THE THYROID ISTHMUS. Early cases — ''Atrophy" of later.il lobes — Explanation of — Dyspntta not due to backward pressure of isthmus — Results of the operation — Re-appear- ance of goitre — Conclusions . . . . . . Pp. 250-256 CHAPTER XVn. TREATMENT BY EXTIRPATION (THYROIDECTOMY). Difference between extirpation and enucleation — Partial extirpation — Pre- paration of patient — Question of general anaesthetic — Local anesthetic — Position of patient — Skin incision : oblique, vertical, transverse — Treat- ment of infra-hyoid muscles — Recognition of gland — Isolation of lobe — Ligature of thyroid vessels — Veins often thin and liable to tear — Treat- ment of inferior thyroid artery — Avoidance of recurrent nerve — Treatment of isthmus — Arrest of haemorrhage — Cleansing of wound — Asepsis better than antisepsis — Suture of muscles, of skin — Question of drainage — Dressings — Use of sponge — Fixation of head and neck — Position of patient after operation — After-treatment — Convalescence . . Pp. 257-274 CHAPTER XVHI. MODIFICATIONS OF EXTIRPATION- RESECTION- RESECTIOX- EXTIRPATION— AMPUTATION. Mikulicz's resection — Description — Results — Kocher's resection-extn-pation — Comparison of the two operations — Advantages over other operations — Amputation Pp. 275-279 CHAPTER XIX. TREATMENT BY INTRA-GLANDULAR ENUCLEATION AND ITS MODIFICATIONS. Intra-glandular enucleation : History — Cases suitable for — Description of operation — Htemorrhage — Suture of gland. Resection-enucleation ; Cases COXTEXTS. xiii suitable for — Description — Advantages and disadvantages. Intra-capsular enucleation. ■'Bloodless'' enucleation. •' Evidement '' : Cases suitable for . Pp. 2S0-294 CHAPTER XX. COilPLICATIOXS OF OPEEATIONS FOR EEMOYAL OF XOX-ilALIGXANT GOITEE. I. Accidents occurring during the operation : Sudden death — Causes of — Cases — Importance of avoiding tracheotomv, if possible — Primary haemor- rhage in extirpation, in enucleation — Injury to nerves — Recurrent laryngeal nerve, sympathetic, vagus — Injury to trachea, pleura, pharynx and oesophagus. II. Complications occurring shortly after the operation : Secondary haemorrhage — Recurrent liaemorrhage — Sepsis — Treatment of — Rapid pulse with restlessness — Causes of — Late compression of recurrent nerve by scar — Tetany ....... Pp. 295—317 CHAPTER XXI. REMOTE COjIPLICATIOXS— CACHEXIA STEOIIPEIYA. Historical — Reverdin and Kocher — Horsley's experiments — Early observation of Paul Sick — Symptoms — Relation to complete removal, to partial removal — Hypertrophy after partial removal — Treatment of cachexia strumipriva . . . . . . . - . Pp. -315-327 CHAPTER XXII. RESULTS OF OPERATIONS. Gradual improvement — Mortality after removal of innocent goitre — Liebrecht's and Reverdin's statistics — Mortality after partial extirpation, after enucleation — Complicated cases — Author's results — Causes of death — Relief from dyspnosa — Question of recurrence after extirpation, after enucleation — EfEects upon voice — Effect upon general health — Healing of the wound — Scar. Appendix : Table of the last 100 operations performed by the author for removal of goitre ....... Pp. 32S-3.53 Index Pp. 3.54-367 LIST OF ILLUSTRATIONS. fig: 1, 3. 4. 9, 12. 13. 14. 15, 17. 18. 19, 21. 22, 24, 26. 27. 28. 29. 30. 31. 32. 33. 34, 37. 38. 39, 41. 42. 43, 4.5. 46, 2. Parenchymatous goitre showing relation to larynx, trachea, and thyroid vessels . . . . . . . . . . 2, 3 Pyramid, not enlarged ......... 4 Pyramid, enlarged, in parenchymatous goitre ..... 5 Variations in form and size of human thyroid (from Marshall) . 6, 7 Diagram to show suspensory ligament ...... 8 Diagram of thyroid veins (from Kocher) ...... 11 Accessory thyroids, situation of ....... 12 10, 11. Congenital goitres . . . . . . . . 17, 18 Thyroid gland of myxia/i^ fuJrNoina, which will be discussed more fully in chap. xiii. on malignant disease. 40 THE THYROID GLAND. liGs. 24 and 25. — A JSihuriai (■(>itn\ iii.iinly parenchymatous- situiitei low dowu aud eventually causiug- very severe dyspua'a. (From an outpatient seen at St. Bartliolomew's Hospital.) GOITRE AND ITS VARIETIES. 41 that of the normal foetal thyroid. To the naked eye it presents a solid homogeneous appearance. Microscopically it is com- posed chiefly of masses of epithelial cells, representing undevel- FiG. 26.— Section of a Parenchymatous Goitre removed by opei-a- tiou on account of dyspnoea. Thj dark parts show colloid material distending- the thyroid vesicUs. From a boy aged 15 (Case 22*). (See Koy. Free Hosp. Miis. No. xxii. 11.) (Nat. size.) oped thyroid vesicles. Fig. 29 shows a normal thyroid gland from a six months foetus, and is introduced here for comparison with Fig. 30, which shows an ordinary foetal adenoma removed by operation from a goitrous patient aged twenty-five. Foetal * Published in Brit. Med. Juurn., July 7. 1900. 42 THE THYROID GLAND. adenomata seldom attain a large size. The largest that I have iiivself ever had to remove was not larger than an orange. They are of importance chiefly on account of their vascularity. Opei'a- Fjc. 27. — Section of Goitre removed by operation, from a woman aged 39, on account of severe dyspnoea. Numerous adenomata of various sizes are seen. The white portions show coagiilated colloid. (See Appendix, Case 30, p. 344 and Eoyal Free Hosp. 3Ius. No. xxii. 23.) ( Slightly enlarged, ^.) tions for their removal are apt to be attended by smart haemor- rhage. The cystic adenoma is by far the most common form of adenoma. It differs from the preceding in containing numerous GOITRE AND ITS VARIETIES. 43 cavities visible to the naked eye. The microscopic structure (see Fig. 31) resembles to a certain extent that of the normal th}Toid, but the vesicles are usually more irregular., and show a tendencv to run one into another, owing to the breaknig ?>.^\ . ^^ :»-a ■^^:.,^^_ Fig. 28.— KigliT LoljL- of a Thyroid Glaud sliowiuo- at the lower part a lnvge soUd Adenoma. (Koyal Free Hosp. Mas. Xo. xxiL 31.) ( Enlarg-ed ±.) down of the intervening tissue. The connective-tissue between the vesicles is usually more abundant than in the normal thyroid. Cysts of various sizes are seen in the tumour. They contain colloid matter and frequently blood. Fibrous Goitre. — Occasionally a general increase in the 44 THE THYROID GLAND. amount of connective^tissue in the gland forms the bulk of the goitre. To such the name of fibrous goitre may be applied. The purely fibrous goitre is, however, a very much less common form than is generally believed. All the above-mentioned varieties may run one into another, so that we frequently meet with mixed forms. Thus the paren- chymatous goitre almost always contains small cysts, and frequently one or more large ones. So do many adenomata. Both parenchymatous and cystic goitres frequently contain Fig. 29. — Tbyroid i Gland l)-om ;i FcetuS of Six Mouths. Tlie gland is arranged iu lobnles and is almost solid. The rudimentary vesicles contain very little colloid. ( x 90 di:im.) much fibrous tissue, and adenomatous nodules may be found in association with any of the preceding varieties. Fig. 32 shows an old goitre with several adenomata and much fibrosis. There are two other important varieties of goitre that stand somewhat apart from all the preceding. These are malignant goitre, in which the tumour consists wholly or in part of malignant disease (carcinoma or sarcoma), and exophthalmic goitre or the goitre of Graves's disease. Both these forms of goitre differ widely, both structurally and clinically, from the preceding varieties. There are several other minor varieties which have received GOITRE AND ITS VARIETIES. 45 Fig. 30. — A Pcetal Adenoma fi-om a. Udy agei 2.5. it consists cliiufly of solid masses of cells, with immcrous vascular spaces (white). Thei'e are hardly auy vesicles and uo colloid, (x 90 diam.) (Case 25.) Fig. 31. — Portiou of a Cystie Adenoma from a woman aged 21. Numerous small cysts of various sizes and full of colloid are seen lying' in a matrix of coniiestive and glaudular tissues. (Appendix, C:ise 99, p. 350.) ( X 90 di.im.) 46 THE THYROID GLAND. separate names. H£emorrhagic goitre is a term used to signify a condition in which haemorrhage takes place into a V , .;, » ^«?■^5" Fig. 32.— Section of part of a Goitre removed by operation from a woman aged 43, on account of severe dyspnoea. Several Adenomata are seen imbedded in a Parenchymatous Goitre which has under- gone much fibroid idegeneration. (See Appendix, Case 34, p. 3i4, and Koyal Free Hosp. Mus. Xo. xxii. 25.) (Slightly enlarged.) goitre, generally a cystic one, or in which an innocent goitre causes ulceration of the skin over it and bleeds externally. {See Fig. 33.) Colloid goitre is a term applied by some authors to paren- GOITRE AND ITS VARIETIES. 47 chymatous goitres in which the colloid material is unusually abundant and obvious.* The term vascular goitre is one that is frequently heard, and is often applied to the goitre of Graves's disease. The term Fig. 33. — " Haemorrhagie Cyst." The right lobe of the thjroid is occupied by a large cyst, Tvhich, after removal, was found to be filled with uearly pure blood. Several severe haemorrhages had taken place from the ulcerated opening on the surface. (From a woman, aged 60, seen at the Kensington Infirmary with Mr. H. P. Potter, under whose care she was. The tumour is noT\' in tlie Museum of the Royal College of Surgeons, Xo. 2905a.) is, however, a bad one, and should, in my opinion, not be employed. If it be intended to signify a goitre composed mainly of blood-vessels, then it is a name for what probably does * A good example of such a goitre may be seen in the Eoyal College of Sm-geons' Museum, No. 2908D, 48 THE THYROID GLAND. not exist, for there is no evidence of the existence of any such o-oitre. If it be used for the goitre of Graves's disease, it conveys a false impression that the enlargement that is present in that form of goitre is mainly due to unusual vascularity in the gland. This is an erroneous but widespread belief. Amyloid, syphilitic, and tuberculous goitre are all of them extremely rare ; the names explain themselves. It is to my mind doubtful whether the cases described as amyloid disease of the thyroid are really of that nature.* The terms endemic and sporadic goitre refer, not to pathological varieties of the disease but to its distribution and causation. The same may be said of epidemic goitre, a term that is used for goitre when it attacks a number of people in the same place and at or about the same time. Acute goitre is a term used to denote a goitre that develops rapidly, es})ecially in young subjects. Suffocating goitre is naturally any goitre that produces much dyspnoea. Substernal, intra-thoracic, retro -tracheal, and retro -oesophageal goitre are terms that explain them- selves. * See remarks on pp. 34, 35. concerning- the yellow waxy looking thyroid found in emaciated persons. CHAPTER V. ENDEMIC GOITRE— CAUSATION AND DISTRIBUTION. Alleged causes — Climate — Physical configuration of soil — "Want of air and sunshine " theory — Erroneous nature of — Eelation to geology — Geological and geographical distribution in England — Eelation to calcareous rocks and waters derived from them — Lime — ilagnesia — Iron — Organic impurities — Epidemic goitre — Goitre wells — Artificial production of goitre — Goitre in lower animals — Habits of life, exertion, strain, etc. — Heredity — Conclusions. Thehe can be but little doubt that, in the great majority of cases, goitre is to be regarded as an endemic disease. It is well known that in some parts of the world, the endemicity is present in a high degree. In other parts where the cause or causes are less powerful, the disease is less common and the endemi- city is not so obvious. It is exceedingly difficult to know where to draw the line between endemic and sporadic goitre. Probably in this country, most goitres mav fairlv be considered to belong to the endemic class, but the endemicity is so widely spread oyer the country while at the same time it is so slight, that it easily escapes notice, and cases of goitre are often considered to be sporadic which should more coiTectly be classed as endemic. One kind of goitre, however, the exophthalmic variety, stands quite apart from all others, both structurally and in its geogi'aphi- cal distribution. This form will be dealt with subsequently in chap. xii. With the exception of exophthalmic goitre, there is no structural difference between sporadic and endemic goitre. But although goitre, in most cases, is to be regarded as an endemic disease, caused bv a definite poison, whatever that poison may be, it is impossible to assert that all cases of goitre originate from the same cause. To cite an analogous example : D 50 THE THYROID GLAND. there are many malarious districts in which a considerable number of the inhabitants suffer from enlargement of the spleen caused by the malarial poison. But enlaro-ement of the spleen may be due to other causes than malaria ; and just as we do not consider every case of enlargement of the spleen to be malarious in its origin, so we need not consider every case of goitre, even when it is found in a markedly goitrous district, to be due to the same poison that usually produces the disease. The number of theories that have been advanced to account for the causation of endemic goitre is very great. St. Lager * in his classical work upon the subject mentions more than forty and occupies no less than four pages of his book in simply enumerating these different theories and the names of the authors who have supported them. In endeavouring to ascertain the relative frequency of goitre in different parts of England, one is met by this great difficulty that there exists no source from which reliable statistical infor- mation can be obtained. In France, Germany, Switzerland and many other foreign countries, there does exist such a source, namely the official returns of the number of young men who have been exempted from military service on account of goitre. From the statistics thus obtained, maps have been constructed which show fairly accurately the distribution of goitre in these countries. Excellent maps of this kind have been published, for example, in Switzerland by Bircher and in France by Baillarger and Nivet. In this country, however, there exists no such means of obtaining information. The alleged causes of endemic goitre may be conveniently discussed under the following heads : (1) Climate and other atmospheric conditions. (2) Physical configuration of the soil. (3) Geological structure of the soil, and its influence upon drinking water. (4) Habits of life, exertion, strain, etc. (5) Heredity. (1) Climate. — That climate has little or no influence upon the production of goitre is shown by many facts. Although the * "Etudes siir les Causes du Cretinisme et du Goitre Endemique," J. St. Lager, Paris, 1867. ■ ENDEMIC GOITRE. 51 disease appears to be, on the whole, most prevalent in temperate zones, yet it is by no means limited to them. It has been found in extremely cold regions such as the north of Siberia and in the Hudson's Bay Territory of North America, and also in the tropics. My friend Dr. Sidney Davies, late of Cairo, informs me that he has seen it among the Egyptians. Accord- ing to other observers, it occurs also in the Soudan and in the Andes near the equator. It is also well known to be common in some of the hottest parts of India. That heat and cold have no share in the production of the disease, there can thus be but little doubt. Some authors have endeavoured to show that the prevalence •of goitre is dependent upon the amount of rainfall, but I have failed to confirm this statement. The map published in the Sixth Report of the Rivers Pollution Commission shows that in England the annual rainfall is greatest in the centre of Devonshire and in the Lake district, being over fifty inches in each of these localities. Now the neighbourhood to the south-east of Dartmoor is one from which I know goitre to be almost entirely absent. Similarly, in the neighbourhood of Windermere, goitre is, as I am informed by my friend Dr. John Mason, distinctly rare. On the other hand I have found goitre to be common in parts of Buckinghamshire and Bedfordshire, where the annual rainfall is less than twenty-five inches. Probably the real reason why goitre has been associated with excessive rainfall is because it is chiefly in mountainous regions that goitre is most common, and it is also on mountains that we expect to find the greatest amount of rain. Rarity of the atmosphere has been assigned as a cause of goitre, chiefly also on account of the known prevalence of the disease in certain mountainous districts such as the Alps, Pyrenees and Himalayas. But here again, closer examination shows that it is not to the rarity of the atmosphere that goitre is due. In Switzerland it has been shown that in manv of the highest inhabited parts of the Alps goitre is absent. In this country I have not been able to find that the disease bears any definite relation to the altitude of the district in which it occurs. It has been stated by some that goitre is unknown upon the sea coast, but I have myself observed cases among people who lived 52 THE THYROID GLAND. and had always lived close to the shores of the Burry estuary in Glamorganshire. Some of these goitrous people lived but a few feet above the sea-level. (2) Physical Configuration of the Soil. — Allusion has already been made to the prevalence of goitre upon most of the great mountain chains of the world. In F)'ance, especially, is this connection apparently striking. Nivet, in his excellent mono- graph upon goiti'e,* gives for each department of France, the number of recruits rejected from military service on account of this disease. The four departments for which the figures are highest, are Hautes Alpes, Hautes Pyrenees, Aisne and Vosges (9-28, 3-33, 2-84 and 2-77, per thousand, respectively). It is worthy of notice that three out of four of these departments are occupied, as the very names imply, by well-known mountain chains. In our own country, too, there are many hilly parts in which goitre is common. The Pennine range in Derbyshire and other countries in the centre and north of England is well known to be a great seat of goitre. Less known, but never- theless well marked, is the prevalence of the disease among the Cotswold Hills of Gloucestershire and neighbouring countries. But on the other hand, there are many mountainous countries in which goitre is very rare or altogether absent. One of the best examples that can be adduced of a mountainous country almost entirely free from goitre, is Norway. In the highlands of Scotland, too, goitre appears to be almost unknown. It is not, then, the mountainous nature of a country alone that causes goitre. If one of the mountainous districts in which goitre is prevalent be examined more closely, it will often be found that it is only in certain parts of the mountains that the disease occurs. Thus in Switzerland, the higher parts of the Alps are much less affected than the lower, and, speaking generally, it may be said that goitre is more often found at the foot of a hill or mountain than near the summit. Bircher of Aarau has constructed, from the military statistics of Switzerland, an excellent map showing the exact distribution * Nivet "Traite du goitre," Paris, 1880. ENDEMIC GOITRE. 53 of goitre in everv part of that country. It may be seen from this map that in some parts of the country, especially in the cantons of Berne and Fribourg, the percentage of goitre is eighty or eyen ninety. Now, the highest gi'ound in Switzerland is that occupied by the main chain of the Alps in the southern and south-eastern part of the country. But the district in which goitre is most preyalent is that \vhich lies to the north of the Alps, stretching from the canton Fribourg in a north- easterly direction towards Lake Constance. It has been asserted that goitre is not so preyalent on the most exposed parts of mountains, but occurs rather in the valleys upon the slopes of the mountains, and this is to a certain extent true. Perhaps, nowhere in the world, is the disease so common as it is in some of the deep yalleys of North Italy, on the southern side of the Alps, in that of Aosta, for example. In Sayoy, at the western end of the Alps, a similar distribution may be noticed. The Rhone yalley, especially between Brieg and Martigny, is a well-known example. In our own country a similar prevalence of goitre in valleys may be noticed. Among the Cotswolds, the villages situated in valleys appear to be chiefly affected. This marked prevalence of goitre in valleys, and especially in the valleys of mountainous regions, has led to a widely accepted, but an entirely erroneous theory of the cause of goitre, namely, that it is due to zcant of air and sunshine. At first sight, the theory seems plausible enough. No one Avho has visited the valleys in Switzerland, in which goitre is so prevalent, can have failed to notice that many of them are deep, narrow, and gloomy. But if the depth, the naiTowness, and the gloominess, of valleys and the consequent lack of air and sunshine in them, were the real cause of the goitre, then Ave ought to find the disease prevalent in all similar vallevs in other parts of the world. Norway may be cited as a country in which such valleys abound. Yet evidence is quite wanting to show that goitre is at all common there. In the course of four visits to the western parts of Norway, I failed to see a single case of goitre. Again, if want of air and sunshine w^re the cause of goitre, the disease ought to be connnon among printers and others oi THE THYROID GLAND. whose occupations often compel them to work at night in crowded and ill-ventilated work-rooms. ^Miners, too, can hardly be supposed to get their full share of sunshine and of good air. But inquiry among them has not shown that they are particularly liable to the disease.* The horses, too, that work for years in mines, and never see a rav of sunshine, are not especially liable to the disease. Yet horses, as well as other animals, are, like man, subject to goitre, in districts where it is prevalent. Some of our text-books state that goitre is especially common in the overcrowded and poorer parts of our great cities, but the statement does not rest upon any solid foundation of fact. Indeed, it may confidently be asserted that in the east end of London, as well as in the poorer parts of most of the largest English towns, goitre is not nearly so common as it is in many country villages situated far more favourably as regards pure air and sunshine. In the village of Chacombe, in Northamptonshire, I found numerous cases of o-oitre. This villao-e is situated in a more or less sheltered hollow among the hills, and it might be supposed that its position alone was the cause of the goitre. But a mile away is a farmhouse situated upon the very top of the hill, in an exposed and open situation ; in this house several members of one family have suffered from goitre ; one of them actually died from suffocation caused by the disease. A similar example is afforded by the village of Oberbalm in the canton of Berne. Here the percentage of goitre among the recruits is twenty-three. The village is situated near the top of a hill ; on the very summit is a farmhouse ; among the inhabitants who had always lived in it during the whole of their lives, I found well-marked goitre. So exposed is the situation of this farm, that from it I could see, on the one side, the glaciers of the Bernese Oberland, forty miles away, while in the opposite direction was visible the equally distant range of the Jura in France. A^^ere it necessary to do so, many more similar examples * It should be remembered that some mines naturalh- exist in goitrous districts, as in the carboniferous limestone regions of Derbyshire and Yorkshire and that in these regions ■\ve find goitre just as common among miners as among other inhabitants of the same districts, but not more so. ENDEMIC GOITRE. 55 might be cited, pointing towards the fact that endemic goitre may be found in elevated and exposed situations, where good air and sunshine are abundant. It seems clear that, although certain valleys contain a great deal of goitre, yet the disease is quite absent from others which are equally deep, narrow, and gloomy, equally devoid of pure air and sunshine. (3) Geological Structure of the Soil in relation to goitre. — The true explanation of the association of goitre with hills and valleys is to be found, I believe, not in the mere external con- figuration of the ground but in its geological structure and the influence which this has upon the drinking water of the district. Water which has percolated through thick masses of pervious and more or less soluble rock contains, cateris paribus, more mineral constituents than water which has not done so. Hence water issuing at the foot of a hill composed of such rock is likely to contain a considerable quantity of mineral matter. The nature and quantity of the minerals will naturally depend upon the nature and solubility of the constituents of the rock. The close connection between goitre and limestone was pointed out long ago. MacClelland especially has brought forw^ard striking facts to illustrate this point.* Now it is in limestone and sandstone districts especially that we meet with deep and narrow valleys. At the foot of a great mountain chain we generally find extensive deposits of these rocks, the upper parts of the mountains being often composed of granite, gneiss, and other crystalline rocks. Such is the structure of the Alps. The mountain streams descending rapidly from the higher levels will generally cut deep and narrow valleys in the limestones and sandstones which they meet, and thus are formed the typical valleys in which goitre is most abundant. When the valleys occur among rocks which do not readily allow of percolation and solution such as those in the West of Norway there we find that goitre is not common in them. A vast amount of work has been done by those who have laboured to trace a causal connection between goitre and * " Observations on Goitre," 2>«w.s". M. and Pliyy. Sor. Calcutta, 1834, vii. 56 THE THYROID GLAND. geology. That there is a more or less direct connection cannot, I think, be denied. If a comparison be made of two maps of Switzerland, one geological, the other showing the distribution of goitre, it cannot fail to be observed that the area over which goitre is most common corresponds roughly with the region of that great deposit of sandstones, marls and limestones known as the molasse. Further, it is especially upon the marine molasse that the disease is seen to be most plentiful, although there are also other deposits upon which it occurs. It is scarcely possible to resist the conclusion that in Switzei'land at least, there must be an intimate causal connection between goitre and the geological nature of the soil upon which it is found, and that the marine molasse is one at least of the geological formations that give rise to goitre. The conclusions arrived at by Bircher who has studied the subject very carefully in Switzerland are as follows : (1 ) Goitre occm's only upon marine deposits and especially upon the marine sediments of the palaeozoic, triassic and tertiary periods. (2) Free from goitre are eruptive rocks, the crystalline rocks of the Archaean group, the sediments of the Jurassic, cretaceous and post-tertiary seas as well as all fresh water deposits. With these conclusions I am on the whole disposed to agree, although as far as England is concerned, it is not correct to assert that Jurassic and cretaceous rocks are wholly free from goitre. Endemic goitre does undoubtedly occur upon both these formations, although somewhat sparselv, especiallv as far as the chalk is concerned. It may be well to point out that in investigating the relation of geology to goitre, care should be taken to bear the following facts in mind. Geological formations are classified according to the period at which they were formed and not necessarily accordingly to their chemical composition or mineralogical structure. Hence two rocks totally different in composition may bear the same geological name. It would obviously be wrong to draw conclu- sions from them respecting goitre, as if they were the same. On the other hand sometimes even large formations such as the chalk are tolerably uniform in composition and structure ENDEMIC GOITRE. 57 over wide areas, and these are particularly well suited for purposes of investigation. Again, the occurrence or not of goitre upon a particular formation depends not merely upon the formation but upon the water supplying the people who live upon it. Thus a village mav be seated upon soil not usually the seat of goitre and may yet be affected with the disease. The converse is equally true ; a village or town situated in a goitrous district upon rocks usuallv associated with the disease mav remain exempt if it derives its water supply from some distant source, from rocks not associated with the disease. Again, the drinking water supplying any particular village or district may be derived from some verv deep seated source quite unconnected with the rocks at the surface. In this case, if the water be such as will produce goitre, it matters not in the least whether the surface rocks are or are not those on which the disease is usually found. Great care must therefore be taken lest erroneous conclusions be drawn.* The relation between geology and water supply is an exceed- ingly complex subject and is especiallv complicated in our own country in which so many different geological formations occur, few of them occupving anv very extensive region. + Geological and geographical distribution of goitre in England and Wcdes.X The extent to which goitre is associated wdth each of the geological formations of England will now be briefly discussed. The various geological formations will be taken in descending order. The tertiary rocks of England occur in two areas forming the * I cannot lielp thinkinjj that some harm has been done by those, who, without any practical knowledge of geology, have drawn hasty conclusions from the simple comparison of surface geological maps, and maps showing distribu- tion of goitre, wiithout taking sufficient care to consider whence the water supply is derived. 7 The subject has been investigated by the Eivers Pollution Commission fi'om whose sixth Eeport I have derived much valuable information. I am also considerably indebted to De Eance's " Water-supply of England and Wales," Woodward's " Geology of England and Wales," and several other books on similar subjects. % The following account of the distribution, of goitre in these counti'ies does not pretend to be complete : concerning many large areas I have at present no information at all. 58 THE THYROID GLAND. London and Hampshire basins. Taking the former first, the disease occurs very sparingly over the Bagshot sands in some of the villages between Aldershot and Chertsey, for example at Windlesham, Bagshot and Pirbright. In Essex it does not occur at Loughton or Chigwell, nor in the neighbourhoods of Harwich, Colchester or Chelmsford. In the Hampshire basin, it is said to occur at Romsey, but it is certainly absent from the neighbourhoods of Lymington, Poole and Bournemouth. Over the extensive region of the chalk, goitre appears to prevail to a very slight extent but tolerably uniformly. I have found a few cases near Hatfield, Hitchin and Hadham in Hert- fordshire, and at Luton in Bedfordshire, and I have been informed that the disease occurs to a slight extent at villages in the north of Essex (Sible Hedingham, AVethersfieid) and on the boi-ders of Suffolk, especially in parts of the valley of the Stour (Cavendish Melford, Sudbury and Xayland). It has been asserted that part of Norfolk is affected. Some of the villages a few miles to the west of Swaft'ham are however certainly not affected. I am informed that goitre occurs also upon the chalk in the neighbour- hood of Driffield in Yorkshire. In the villages situated upon the chalk of the North Downs there is very little goitre and the same may be said of those upon the South Downs. The chalk is the source of such an abundant water supply that it is worth while to draw attention to the rarity of goitre in connection with it, especiaUy as some text-books even now assert that it is especially prevalent in the " chalky parts of England.'' Coming next to the upper greensand and gault which under- lie the chalk and come to the surface as a comparatively narrow band, extending from Devonshire to Yorkshire and also skirting the Weald district of Kent, Surrey and Sussex, we find that goitre is rarely present upon either of these rocks. The lower green- sand area, on the contrary, is one upon which I have found a considerable amount of goitre. In the south of Bedfordshire it forms the low sandy hills in the neighbourhood of Ampthill, itself a known seat of the disease. I have seen cases at Aspley Guise, Ridgmount and Woburn — all villages in this neighbour- hood. Examination of the books of the Bedford Infirmary * * Kindlv undertaken for me bv mv friend Dr. Skeldino; uf Bedford. ENDEMIC GOITRE. 59 showed that a considerable proportion of the cases of goitre treated there came from these villages and from others such as Moulsoe, Eversholt, and Maulden, all similarly situated. I have been unable to find any goitre in many of the villages situated upon lower greensand in the south of Surrey, but it is said to occur at Haslemere. With regard to the Wealden area, goitre appears to be tolerably common over the central and more hilly parts. Several cases came under my notice at Cuckfield, and I have heard of many others from other parts of the same area. I have reasons for believing that the disease is distributed tolerably uniformly, although not very thickly, over the whole of the central (Hastings sand) area of the Weald. I have been told that it is common at Horsham, but I have not personally examined this district. Villages situated upon the Weald clay appear to be slightly affected. I found several cases at Hadlow, and in neighbouring villages. From a similar district further to the east, a small number of cases have been reported to me. I have made personal inquiries at most of the villages on the tract of country extending from near Eastbourne to Steyning, immedi- ately north of the South Downs. These villages are situated upon greensands, gault and Weald clay. I saw no cases of goitre and heard of only an occasional one here and there. Those of the inhabitants who knew what ffoitre was ao-reed in saying it was much commoner further north in the Hastings sands area. Underlying the cretaceous strata, and appearing on the surface in this country to the west and to the north-west of these rocks, comes the great series of the oolites. It has been stated by most of those who have written upon the subject of the distribution of goitre in England that goitre does not occur upo7i the oolites, except at Helmsley in Yorkshire. ]\ly own experience does not lead me to endorse this statement. I have on the contrary found that goitre is tolei'ably common upon certain members of the oolite series, and is especially frequent in the villages situated just at the junction of the oolites with the lias. In Somersetshire it is prevalent at Chinnocks, Stoke-under- Ham, and Chiselborough ; the latter village has long been noted 60 THE THYROID GLAND. as a seat of cretinism. Further north I have found it at Corton Denhani and neighbouring vdlages. It is said to be common at ^Vootou-under-Edge in Gloucestershire. I have seen many cases at and near Stroud,* and in many of the villages situated on the oolites to the east of Cheltenham. Still further east I found that in many of the villages round Xorthleach,* as well as in Northleach itself, the disease was common. In Yorkshire it is known to occur at Helmsley and I have been informed that it is found also in several villages to the east of Easingwold. I have seen a few cases near Malton. The next formation that we have to consider is the lias. The upper members of this series he immediately mider the oolites, and goitre occurs in numerous villages alreadv mentioned, just at the junction of the two formations, being most common apparently upon the sands that are now considered to be the lowest members of the oolites.-*- Upon the middle lias, the disease, so far as mv observations extend, is less common. I have found a few scattered cases to the west of Chiselborough and Stoke-under-Ham. In the south of Northamptonshire and the neighbouring parts of Warwickshire, m districts where the oolites are absent, I have nevertheless found a considerable amount of goitre. The village of Chacombe, where goitre is decidedly prevalent, rests upon marlstone (middle lias). The Warwickshire villages of Warm- ingtou and Avon Dassett, where the disease prevails to a slight extent, are situated at the foot of hills of similar rock. !My friend Dr. Bernard Rice has kindly examined the outpatient books of the Wharncliffe Hospital in that town, in order to ascertain the distribution of the disease in that neighbourhood. He found that out of twentv-two cases that had come from surrounding villages, no i'ewer than eighteen came from the liassic district to the east and south-east of Leamington. On the other side of the town is the new red sandstone, and only four cases came from this district. A village in which the dis- ease appears to be especially prevalent is Napton, situated at the * Two of the patients upon whom I have operated for goitre had always lived within a few miles of Stroud and a third came from the neighbourhood of Xorthleach. t H. B. "Woodward, " Geology of England and Wales," 1887, p. 287. ENDEMIC GOITRE. 6l foot of a hill of marlstone, underlaid and surrounded by lower lias clay and limestone. So far as I can j udge, this district appears to be fairly typical of the distribution of goitre upon the lower lias. The disease is either absent altogether or is thinly diffused over it. It must not be forgotten, however, that in many parts of England, as for example in the neighbourhood of Cheltenham, the lias is thickly overlaid with drift oolite, not marked upon an ordinary geological map. The water supply in such regions is frequently derived from shallow wells in this drift and not from the lias at all. Upon the triassic division of the new red sandstone, goitre appeal's to occur very sparingly if at all. At West bury -upon - Severn, situated upon this rock near the lias, I could not hear of any. From the region of the triassic rocks of South Derbyshire, it appears to be almost absent — at least such is the case at Findern, Newton Solney, Foremark and Repton, according to information supplied to me by Dr. Cronk and from personal inquiries made in this district. Its scarcity upon the trias to the west of Leamington has already been mentioned. Over the large area in which this rock comes to the surface in Nottinghamshire, the disease appears to occur but rarely. The lower division of the new red sandstone is the Permian, often known as the magnesian limestone because a large pro- portion of its rocks is composed of that material. It occurs in this country chiefly as a narrow band extending from North- umberland to Nottingham shire. It has long been a favourite belief that magnesian limestone is especially associated with goitre, but I doubt whether there is much truth in this. In part of the magnesian limestone area of Nottinghamshire I found goitre to be distinctly rare. In other parts it appears to be less common than upon the carboniferous limestone. It is said to be common in the neighbourhood of Knaresborough, in Yorkshire. I ought to mention that the term " magnesian limestone" is used ffeolooi- cally, to denote a large series of marls, sandstones, and lime- stones, and that it consists by no means wholly of magnesian limestone in the chemical or mineralogical sense of the word. 62 THE THYROID GLAND. Magnesian limestone — using the terin in the latter sense — is found in other rocks besides those of the Permian series. The next series of rocks that engages our attention is the carboniferous. At the top of this series come the coal measures, and upon them goitre appears to occur to a moderate extent. The counties best known to me in which this foruiation occurs are Derbyshire and Yorkshire, and in both of them I found that goitre was fairly common upon the coal measures. I have also foLuid it near Llanelly in Glamorganshire. The millstone grit, on the contrary, appears to be much more free from the disease. I have been informed that at Ilk ley goitre does not occur in places upon, or supplied by water from this formation, whereas on the carboniferous limestone not far away, the disease is not uncommon. At the Saltaire Hospital in one year, out of 780 patients applying for treatment only four did so on account of goitre. At Chapel-en-le-Frith, in Derbyshire, I was informed that cases of goitre were more often seen in the districts to the south- east of the town, where the carboniferous limestone prevails, than in other districts where millstone grit and Yoredale rocks are found. I was also told that since the introduction of a new water supply from the millstone grit goitre has become less common. It has been stated that goitre is common in the Peak district of Derbyshire, where the rocks consist chiefly of millstone grit and Yoredale rocks (grits, sandstones and shales with thin earthy limestones). Upon inquiry at Castleton, upon the southern edge of this district, I was assured that goitre was much less prevalent in the Peak district than on the carboniferous lime- stones further south. The millstone grit formation is the source of water supply to so many of the towns in the north of England that the absence of goitre from it becomes a matter of consider- able importance. The carboniferous limestone regions of England have been described as a very hotbed of goitre, and I am inclined to believe that this is a tolerably accurate statement. Over the whole of this area in Derbyshire, but especially along the eastern border of it, I found numerous cases, for example, in the neighbourhoods of Cromford, Matlock, Youlgreave, Bakewell, Baslow, and Stony ENDEMIC GOITRE. 63 Middleton. The same may be said of the region on the north side of Ashbourne, and I am told that the disease is also common over the similar districts in the east of Staffordshire. In Somersetshire it occurs, I am informed, upon this forma- tion at Clevedon, and I have heard of a number of cases upon various parts of the carboniferous limestone of the Mendip Hills. In Northumberland, on the other hand, it appears to be less common, but it is worth noticing that, in the north of England, this formation loses its markedly calcareous character and is represented largely by sandstones and shales. In the Forest of Dean goitre is said to be common, but I do not know whether upon the carboniferous limestone or upon the other rocks of this region. With regard to the occurrence of goitre upon Devonian and. old red sandstone rocks, my information is chiefly of a negative character, but such information as I have tends to show that the disease occurs but rarely upon either of them. At Ilfracombe and probably over the north of Devonshire generally, goitre does not occur. The same may be said of the western extremity of Somersetshire. I am informed also that in the neighbourhood of Talgarth, in Brecknockshire, the disease is not prevalent. Of the Silurian and Cambrian and pre-Cambrian rocks which form so large a portion of Wales, I have scarcely any practical knowledge, and consequently cannot say much about the occur- rence or otherwise of goitre upon them. The little information I have obtained, how^ever, tends to show that here also goitre is rare. In Anglesea, for example, I am informed that goitre does not occur at all in the north-west portion in the neighbourhood of Amlwch, and is probably absent from the whole island. With regard to granite and other igneous rocks, I believe that they are free from goitre ; at least, I have never heard of any goitre upon them, and those districts of them that I have been able to examine, such as Widdicombe on Dartmoor, are quite devoid of the disease. From the foregoing it will be seen that goitre is distributed over a very large surface of this country. Its coincidence every- where with calcareous rocks, which are also very widely dis- tributed in England, is one of the most marked features of its distribution. It is not only upon limestone but also upon 64 THE THYROID GLAND. calcareous sandstones that goitre is found. ^Vhether it ever occurs as an endemic disease upon non-calcareous rocks is at least doubtful. The igneous, metamorphic, Cambrian, Silurian, Devonian, Yoredale, and millstone grit rocks, and some of the non-calcareous parts of the coal measures and tertiaries, appear to be mainly free from the disease. Now, speaking generally, the water derived from these rocks, whether it be upland surface water or spring water, or deep well water, differs considerably from water derived from most of the other rocks in containing a smaller quantity of mineral matter and in being less hard. Of eighty-one samples of upland surface water derived from metamorphic, Cambrian, Silurian and Devonian rocks, the Rivers Pollution Commission found that the average total solid impurity was only 5.12 parts per 100,000 (or 3^ grains per gallon). The average hardness was only 2 5. Water from the Yoredale, millstone grit and non-calcareous portions of the coal measures and tertiary rocks, although con- taining rather more total solid impurity than water from the preceding, is nevertheless on the whole fairly soft, and contains rather less total solid impurity than that from the more calcareous rocks. That there is a general connection between goitre and the amount of mineral matter in the drinking-water, and its hard- ness, there seems good reason to believe. But that many waters contain a large amount of such mineral matter, and are very hard, and yet do not produce goitre, seems also to be true. Conversely, I believe that in a few instances I have found that a goitre-producing water was not particularly hard. Thus in one of the Derbyshire villages I found that a water which apparently produced goitre had not more than H" of hardness. But it is probable that goitre-producing waters always contain a large amount of total solid impurity, although the impurity may not necessarily be such as to render the water very hard. This statement appears to be, on the whole, confirmed by published analyses of goitriferous waters in Switzerland and France. As the chief hardening ingi'edients of water are bicarbonates and sulphates of lime and magnesia, it is not unnatural that ENDEMIC GOITRE. 65 these salts should have been considered to be the cause of goitre. But examination of numerous water analyses have failed to con- firm these theories. Another ingredient which is by many belie^■ed to be the essential cause of goitre is iron. This view has received the strong support of St. Lager, whose elaborate researches compel one to receive with much respect any opinion that he has expressed. At first sight the occurrence of goitre upon many ferruginous sands, such as those of the lower greensand, the Weald, and part of the oolite districts, lends support to this view. But, on the other hand, I examined in Derbyshire numerous samples of water which undoubtedly produced goitre ; in the majority of these no iron \\hatever wrs found, in others onlv the faintest possible trace. Other observers, too, have tested for iron, with similar negative results. It should be remembered that in drawing conclusions as to the cause or otherwise of goitre bv iron, care should be taken not to pay too much attention to the mere presence or absence of this metal in the rocks upon which goitre is found. A rock may abound in a particular metal, but it does not follow that the water percolating that rock will contain any of the metal, unless the latter happen to exist in a soluble form, which is often not the case. As regards metallic impurities other than iron, but more or less allied to it chemically, it is not impossible that one or more of them may be found to be the essential cause of goitre, but proof of this is quite wanting ; on the contrary the evidence we possess tends to point in the opposite direction. The suggestion that the cause of goitre may be some organic impurity of water has, within the last few years especially, attracted a good deal of attention, and received a certain amount of support. Professor Klebs* has examined microscopically the water taken from springs in goitrous districts of Salzburg and Bohemia, and has apparently found in it numerous micro-organ- isms, chiefly Infusoria. He believes that certain forms called * E. Klebs, •• Ueber die Ursache des Kropfes," Ffa/j. ined. Woclienscltr., 1877, ii. 45. 66 THE THYROID GLAND. navicuUt are the essential cause of goitre. Bircher, following Klebs, has made microscopical examinations of the water derived from different geolog-ical formations in the neighbourhood of Aarau. He examined waters from springs in the molasse, Jurassic, triassic, and crystalline rocks, and found various forms of diatoms in them. But they were not found equally in all the waters. Some of them occurred only in waters from a particular formation. Thus in waters from granitic areas, and from the Jurassic and upper fresh water molasse, he found meridion to be extremely plentiful. But in water derived from the trias and from marine molasse, it was absent, or nearly so. On the other hand, eucyonema w^as found abundantly in waters from the formations on which goitre prevails, while it was absent from those from the Jurassic and granitic areas, which are free from the disease. Bircher expressly states that he does not maintain that any of these organisms are necessarily the cause of goitre. He simply relates the fact that different kinds of diatoms w^ere found in waters derived from different geological formations. Besides the above-mentioned forms of diatom, Bircher describes a form of rod shaped micro-organism that he found in waters from goitrous districts, but not in waters taken from regions in which the disease is not prevalent. He found them in the waters of Asp, Oeschgen, Eiken, Mumpf and Habsburg on the trias ; also in those of Buchs, Aarau, Gri'michen, Suhr, and Brugg on marine molasse : thev were most numerous in two springs at Buchs(close to Aarau); here goitre is extremely common. Bircher has searched, without success, for these rod-shaped bodies in the contents of two goitrous cysts in young people. That goitre can be produced by water has, I think, been shown by experiments that have accidentally been carried out on a large scale upon man himself. I refer to the outbreaks of so-called epidemic goitre that have been so often recorded. For example, a regiment of young soldiers has been quartered in a village, and after a few months, or even weeks, a very large proportion of the men have become goitrous. A town or village has received a new water supply, and shortly afterwards goitre has broken out in a large number of the inhabitants. Conversely, a village affected with goitre has changed its water supply, and goitre has ceased to occur. On the continent there ENDEMIC GOITRE. 67 are noted goitre wells to which young men resort who wish to obtain exemption from military service. After drinking the water from these wells for a few weeks, they acquire goitres sufficiently large to enable them to obtain their wish.* Bircher f mentions several springs near Aarau which have a local reputa- tion for producing goitre in those who drink of their waters. One of these is at the village of Asp ; another is at Buren. At the latter place five children in one family who drank from this spring all became affected with goitre. In districbs where goitre is common, not only man himself but also many of the lower animals become affected with the disease. It has been observed in dogs, cats, horses, cows, pigs, sheep, goats, antelopes, camels and many other animals. Cretinism, too, Avhich always exists Avhere goitre is prevalent, has been noticed among some of the lower animals. Various attempts have been made to produce goitre artificially in the lower animals. More than thirty years ago, St. Lager carried out a series of experiments in this direction. He began by feeding two dogs with sulphate of lime and carbonate of magnesia ; this experi- ment was carried on for six months with a negative result. His next series of experiments was upon guinea-pigs, which he fed for several months with salts of various metals mixed with the animals'' ordinary food. He does not state exactly what salts were used, but the results were negative. He then tried feeding mice with metallic sulphides and sulphates ; after three months, slight swelling of the thyroid was noticed in three of them ; these three had been fed upon sulphide and sulphate of iron. Encouraged by this apparent success, he tried sulphate of iron again upon a dog, giving several centigrammes a day. At the end of four months, he thought that the thyroid had increased in size, but says that it was not prominent enough to deserve the name of goitre. St. Lager alludes to other experiments which had been performed by Bouchardat, with lime and mag- nesia, and by Maumene with fluoride of sodium, but in neither case with any marked success. * Further details upon this subject may be found in the elaborate treatises of St. Lager, Baillarger, Nivet, Hirsch, Bircher and others. J 0]). clt. p. 128. 68 THE THYROID GLAND. Bircher experimented upon five puppies three months old, feeding them upon condensed milk diluted with water taken from the spring in which Bircher found his characteristic micro- organisms. At the end of five months, the animals were killed and it was found that their thyroids had not undergone any enlargement. Another series of experiments was carried on in 1890, for nine months, by my brother, Mr. Edward E. Berry, F.C.S., and myself. We took four sets of guinea-pigs. To the first set we gave a mixture of various salts of lime, magnesia, potash, and soda ; the salts chosen were those obtained by the analysis of waters from two districts in Auvergne where nineteen and ten per cent, respectively of the male popidation are afi'ected with goitre. To the second set we gave sulphate of lime only ; to the third carbonate of iron in the form of saccharated carbonate. The fourth set formed simply a control series of experiments and received nothing but their ordinary food and drink. The animals were all weighed accurately every few weeks, and the doses of salts regulated in proportion to the weights of the animals. After death each thyroid gland was weighed accurately and subsequently examined microscopically. The results were entirely negative as far as the production of goitre is concerned, but they tend at least to show that neither sulphate nor carbonate of lime, nor carbonate of magnesia, nor carbonate of iron is capable of producing goitre in guinea-pigs.* Lustig and Carle have published some interesting and careful experiments upon the artificial production of goitre in the lower animals.f They made use of water from certain infected parts of the valley of Aosta in North Italy. The subjects of the experiments were a young horse and several dogs. The horse after drinking for several weeks water suspected of being capable of producing goitre, developed a slowly progressive and perfectly evident swelling of one thyroid. This was removed by operation and the experiment with water was continued. After some weeks the remaining thyroid became still larger. After the adminis- * Fui'tlier details of these experiments will be found in the Brlt'isli Medical Jovrnal for June 13, 1891. t " Sull .■Mi()log;ia del gozzo endemico." Lustig e Carle, 6-'/('r«. d. R. Accad.d. med. dl Tormo, 1890, p. 689-717. ENDEMIC GOITRE. 69 tration of this water bad ceased, the size of the thyroid gradually diminished until eventually the swelling could no longer be felt. Thirteen dogs, mostly young, were given water from the Buthier stream, a suspected source of goitre. In one of these and perhaps in another, some swelling of the thyroid was produced. From the first of these animals the enlarged left thyroid was then removed and the experiment continued. A month later the right thyroid was visibly enlarged. The ad- ministration of natural Buthier water was then discontinued and the same water freed from bacteria was given instead. The result was that the swelling gradually diminished and finally became imperceptible. In some of the thirteen animals, swelling of the lymphatic glands was noticed and in some of them diarrhoea occurred. Ten young and healthy dogs treated solely with Buthier water, boiled and filtered, did not show any alteration in their thp'oids, A young puppy born in an infected region, and the subject of a considerable goitre, was removed to a region free from the disease. Water supposed to be capable of producing goitre was given to it and the goitre became larger ; the ad- ministration was discontinued in favour of filtered water and the goitre disappeared completely. These experiments, if confirmed, tend to prove that goitre can be produced artificially by the administration of certain waters. Further, boiling and filtration seem to deprive the water of its goitre-producing elements. Further experiments in the same direction and upon a larger number of animals are however necessary before they can be considered conclusive. The authors themselves seem fully aware of this and speak with praiseworthy hesitation. Dr. Grasset ''•' has recently stated that the cause of goitre is to be found in certain hsematozoa which he has found in the blood of patients recently affected with the disease. This micro- organism is said to resemble Lavaran's ha?matozoon found in ague, but differs from it in certain minor details. Grasset's observations are interesting but require confirmation. (4) Habits of Life, Exertion, Strain, etc. — A popular theory attributes goitre to violent muscular exertion such as carrying * La France Medicale, .July IS, 1898, and Glasgow Medical JuurnaJ. Jau. 1899. 70 THE THYROID GLAND. weights on the head, straining, couohing, and blowing wind instruments. It is at least doul)tful whether any of these habits ever cause enlargement of a previously healthy gland. The habit of carrying weights on the head is common in many countries where goitre exists and also in many Avhere it does not. The disease frequently shows itself in quite young children who have never can'ied upon their heads anything heavier than a hat. I have several times examined large numbers of school children in affected districts* and found a considerable proportion of them affected with the disease. The occurrence of the disease in the lower animals is another proof that carrying weights on the head is not the cause of goitre. It is possible that although muscular exertion does not itself produce goitre it may aggravate the disease. A thyroid gland already somewhat enlarged may be injuriously pressed upon by ^■iolent action of the muscles of the neck. In this manner extravasations of blood within the gland may be produced and cysts may be formed. Nearly all very large goitres contain cysts, and it is possible that some of them may have originated in the manner described. Intermarriage as a cause of goitre is hardly worthy of serious discussion. Intermarriage is doubtless common in many isolated villages where goitre abounds but is equally noticeable in many similar villages where the disease is quite unknown. (5) Heredity is supposed by many to play an important part in the causation of goitre. Undoubtedly goitre is often found to occur in many members of one family. Numerous instances in which every member of a family was affected with goitre have been found by myself both in Switzerland and in this country ; also many instances of goitre existing for generations in the same family. But such facts, however numerous they may be, do not afford proof that mere heredity is in anv way responsible for the disease. There is good reason to believe that the cause that produced the disease in one member of a family caused it in all the others. It is well knoMU that the apparent heredity of goitre is most marked in places where the endemicity is highest. * e.fj., at Triora in X. Italy, and at Clii.selboroii2:li in Somersetshire. ENDEMIC GOITRE. 71 In order to place beyond dispute the hereditary nature of goitre, it must be shown that the goitre in the child is not due to the influence of the same exciting causes that produced it in the parent. It is obvious that so long as we are in doubt as to the exact nature of the goitre-producing poison, so long will it be difficult to prove definitely that the disease is cr is not hereditary. Nevertheless the evidence that we at present possess tends to show that heredity ought not to be considered as one of the probable causes of goitre. Although mere heredity cannot be considered to be a cause of goitre, it is conceivable that some hereditary tendency may render a person more suscep- tible to the influence of the goitre-producing poison, but there is little or no evidence of this. Summing up, there can be no doubt that climatic and atmo- spheric conditions have little or no share in the causation of goitre. That want of air and sunshine has absolutely nothing whatever to do with it is equally certain. Habits, such as carrying weights on the head, violent exertion and the like, play but a secondary part in the production of the disease. That heredity is a cause of goitre is extremely doubtful. Interniarriaice has certainly no share in its causation. That there exists some definite relation between endemic goitre and some poison in the soil upon which it is found is tolerably clear, and there can be no doubt that in the vast majority of cases drinking water is the vehicle by means of which that poison obtains access to the body. Such water is usually, if not always, derived from calcareous soils, but it is probable that the goitre-producing poison is not a salt of lime or magnesia. It has not yet been proved satisfactorily that any sail of iron is the essential constituent. The same mav be s;iid of micro-oru;anisms. CHAPTER VI. SYxMPTOMS AND DIAGNOSIS OF THYROID ENLARGE- MENTS—PHYSICAL SIGNS. Mobility — Shape — Size — Position with regard to muscles, great vessels, sternum — Pulsation — Diagnosis from aneurism — Consistence — Pressure effects, on veins, recurrent laryngeal nerve, sympathetic, cervical and brachial plexuses, larynx and trachea, oesophagus and pharynx. The thyroid gland may be the seat of various diseases, each of which has some chai'acters peculiar to itself. There are many characters, however, which are more or less common to all forms of enlargement of this organ. These will be discussed in this and in the following; chapter. In most cases it is not a difficult matter to determine whether a given swelling in the neck does or does not belong to the thyroid. Occasionally, however, the most marked characteristics of a thyroid swelling are absent, or are closely simulated by other conditions, and thus mistakes may occur. The diagnosis of an enlargement of the thyroid is made partly by examination of the physical signs of the swelling itself and partly by the pressure effects which it exerts upon surrounding structures. To a very small extent the effect of the disease upon the function of the gland may produce signs and symptoms which are of some help in diagnosis. Physical Signs. — Among these we have to consider, (1) Mobility; (2) Shape ; (3) Size; (4) Position ; (5) Pulsation ; (6) Consistence. (1) Mobility. — Owing to the close connection already described which exists between the larynx and the thyroid gland, the latter follows the former in all its movements. Hence one of the SYMPTOMS AND DIAGNOSIS. 73 most important signs of a thyroid tumour is that if rises and falls loitli the larynx and trachea during deglutition. In the great majority of cases the presence of this sign alone is sufficient to enable us to form a correct diagnosis of the thyroid nature of the swelling under examination. Care must be taken, however, not to rely too implicitly in all cases upon this sign only. For there are two sources of fallacy with regard to it, that may lead to mistakes. In the first place a swelling which is not of thyroid origin may present the above sign ; and in the second place one which is really thyroid may not present it. The cases which come into the former category are fortunately rare ; and most of them are generally easily distinguished, because the tumour will be found not to occupy exactly the same situation as a tumour of the thyroid. Such are cysts of the subhvoidean region which lie in the middle line on a level with the upper border of the thyroid cartilage. It is possible that a very large cyst of this kind might be mistaken for a tumour of the upper horn, or of the pyramid of the thyroid, but its high situation in the middle line would almost invariably be quite enough to distinguish it.* In 1893 I saw with Mr. Bowlby at St. Bartholomew's Hospital a man who had a rounded prominent swelling covering the whole of the front of the thyroid cartilage and firmly fixed to it. It was almost exactly in the middle line, and at first sight closely resembled a subhyoidean bursa. A careful examination, how- ever, showed that it was connected with the left lobe of the thyroid gland. Tumours, both innocent and malignant, spi'inging from the larynx or trachea and growing outwards, may occasionally simulate swellings of the thyroid gland. They are, however, rare. Mr. Percy Furnivall has kindly given me notes of the follow- ing case that came under his notice in 1893 : '' A gentleman aged 55 had had for thirteen years a swelling on the right side of the neck. In 1887 he had seen Sir Morell Mackenzie, who wished to aspirate and inject it. Later he was * See a paper by Larrey, Gaz. d. Hoj)., 1853, pp. 212. 22.5. 74 THE THYROID GLAND. seen by another surgeon who also considered that it was • probably a thyroid cyst.' On the right side of the neck, close to the middle line, was a sausage-shaped swelling, situated partly under the sterno-mastoid at its lower end. The upper part lay between that muscle and the middle line and extended nearly up to the lower jaw. It was well defined, very soft and elastic, and apparently fluctuated. // mored distinctly with the larynx on deglutition. It was removed by operation and was found to be a lipoma attached to the side of the thyroid cartilage." Several cases have come under my own notice in which malig- nant growths springing from the lower end of the pharynx and upper end of the oesophagus were verv difficult to distinguish from growths in the thyroid gland itself. Tracheal hernia is said by Norris Wolfenden and others to simulate bronchocele very closely. Dr. Wolfenden * has given an account of three cases supposed to be of this nature, and remarks that " the practitioner is not likelv to recoo-nise the true state of affairs unless he has caused the patient to voluntarily distend the tumour." On the other hand it should be remembered that some goitres are visible onlv when the patient makes an expiratory effort. Both Wolfler and myself have had to operate upon such cases. I am disposed to agree with Wolfler, who is sceptical about the existence of tracheal hernia resembling goitre. He states t that one of Wolfenden's cases was subsequentlv pro^■ed by operation to be a true goitre and not a tracheal hernia. Necrosis of a portion of one of the laryngeal cartilages may cause an abscess which sometimes can scarcely he distinguished from a cyst, suppurating or not, of the thyroid gland. Kohn I has recorded a remarkable instance of such a case : " A woman had, in the region of the right lobe of the thyroid gland, a swelling which was taken to be a chronic abscess of that organ. But after evacuation of the pus it was found that the * Jvurnal'Of Laryngology, 1888, p. 99. See also a long and very complete paper on the same subject by Dr. J. H. Petit in Reviie lie CItlnirgie, Paris, February, March, May and June 1889. f " Die chirm'gische Behandlung des Kropfes," Berlin, 1890, ii. p. 2. X " Ceber Strumitis und ThjToiditis," Allgem. Wien. 3Ied, Ze'itung. 1885, p. 215. ■ SYMPTOMS AND DIAGNOSIS. 75 abscess was due to necrosis of one of the laryngeal cartilages and was wholly unconnected with the thyroid gland." * Various swellings having their origin in tissues external to the larynx and trachea may become adherent to them secondarily and so participate in their movements. Such are affections of the cervical lymphatic glands. Some years ago while dissecting out a thyroid gland from a dead body in the post-mortem room of St. Bartholomew's Hospital, I came upon an oval swell- ing, close to the lower part of the right lobe ; at first sight this appeared to be an abscess in the thyroid gland. It was firmly connected with the trachea and the recurrent laryngeal nerve was spread out over it. There can be no doubt that, had it been detected during life, it would have been found to follow the trachea in all its movements, and it would almost certainly have been taken for a thyroid swelling. It was, however, simply a chronic abscess that had originated in one of the cervical lym- phatic glands. In 1895 I saw a patient of ]\Ir. Bowlby's, a young man with a mass of enlarged tuberculous glands adherent to the side of the larynx ; the resemblance to a tumour of the thyroid was con- siderable. In St. George's Hospital ^Museum is a specimen of a sebaceous cyst situated immediately in front of the larynx.-*" During life it had been mistaken for a cyst of the thyroid, and had been injected with perchloride of iron with a fatal result. I have seen one case in which a dermoid cyst lay immediately in front of the larynx and followed its movements during deglu- tition. We come now to the second class of cases, those that fail to move with the lar^^nx during deglutition although they are of thyroidal origin. This may occur, first, when the bulk of the tumour is so great as either to conceal or to mechanically prevent the movements of the larynx and trachea ; and, secondly, when the tumour is pre- vented from moving by reason of its adhesions to neighbouring * A somewhat similar case came under my own notice some years ago ; this was one in which a swelling caused by perichondritis of the thyi'oid cartilage had been mistaken by the surgeon for tumour of the thjToid gland. f New Catalogue Xo. 2lA. 76* THE THYROID GLAND. parts. Malignant disease and inflammation are the most common causes of such adhesion. In the case of the patient depicted in Fig-. 82 deglutition failed to make the huge tumour rise as a whole. It did cause, however, what is an almost equally valuable sign, namely a peculiar shake felt in the tumour. The tumoiu" was tilted forwards each time that the larynx, to which it was attached posteriorly, attempted to rise. In cases then of large tumours that do not rise with the larynx during deglutition attention should be directed to the shaking or tilting caused by this action. Malignant tumours in their later stages frequently become quite fixed. I have seen several cases both in my own practice and in that of others, in which such tumours were firmly fixed to the vertebral colunm. In September 1885, by the kindness of Dr. Reece, then acting as one of the medical officers at the Kensington Infirmary, I had the opportunity of examining a case of what we, at first, sup- posed to be a tumour of the thyroid gland. The patient was an elderly woman who had a hard oval mass, of the size and shape of a goose's egg, apparently exactly in the position of the right lobe of this gland. It extended from near the middle line of the neck to beyond the outer border of the sterno- niastoid. It touched the larynx and trachea when these were in their natural position, but it was found possible to push them considerably to the left of the middle line without dis- placing the tumour. Indeed a finger could be laid in the groove thus produced between them. The tumour did not appear to move during deglutition. For these two reasons, then, it was concluded that the tumour was not of the thyroid gland. No operation was deemed advisable. A few days later the patient died, and on making a post-mortem examination, it was found that the tumour was a mass of malignant growth (probably starting in a lymphatic gland), secondary to disease of the mediastinum. The thyroid gland itself was small and had been flattened between the larynx and the growth. The latter had displaced the carotid artery and internal jugular vein to the outer side. It should be remembered, therefore, that a movable tumour SYMPTOMS AND DIAGNOSIS. 77 of the thyroid gland ought to follow, not only the vertical but also the lateral movements of the larynx and trachea. Large masses of malignant growth may be found in the neck Avhich are adherent to the larynx and trachea and surrounding parts. Occasionallv in such cases, it may be difficult to say whether the growth is primarily of the thyroid gland. Figs. 34, 35 and 36. — A large Bilateral Parenchymatous Goitre. The rig-ht and central lobes were removed by extirpation from a woman aged 52. {See Fig. 37.) The tumour removed weighed 3 lbs. 1 oz., and is now in the Eoy. Free Hosp. Museum, Xo. xxii. 19. (See also Appendix, Case 119, p. 352.) (From pbotogTaplis by Dr. Image.) A few years ago I had a case in the Roval Free Hospital illustrating this point. A small child had a large mass of lympho-sarcoma in the left side of the neck. The larynx and trachea were displaced to the right and so much buried in the tumour that it was difficult to ascertain Avhether they moved on deglutition or not. The tumour might easily have been mis- taken for a sarcoma of the thyroid gland. 78 THE THYROID GLAND. W. Osier has recorded a case of lympho-sarconia of the deep cervical o^lands, involving- the thyroid and simulating goitre.* Wolflerf records a case in which a tumour of the right lobe of the thyroid was mistaken by Professor Billroth for a lym- phoma. It was not until the operation for its removal was being performed, that the thyroidal nature of the tumour was dis- covered. In the notes of this case it is stated that there were Fio. 3o. — For ik'scription si'u pp. 7 7 ami 352. two tumours, each nearlv as large as a goose's egg, and they were onlv slightlv movable. It was probably the absence of the usual mobility of a thyroid tumour that led to the error in diagnosis. We will now consider some of the other less important signs and endeavour to ascertain their value from a diagnostic point of view. * JTuntrcal Gen. Hn.y). Bep. 1880, i. 340. J '• Uebei-der Entwickelung und den Ban des Kropfe.s." Anton Wolfler, Arrh. f. Jdln. C/iir., Berlin, 1883, vol. xxix. p. 788. SYMPTOMS AND DIAGNOSIS. 79 The shape of an enlarged thyroid may be very characteristic or, on the other hand, it may have no diagnostic value what- ever. When the gland is enlarged uniformly as, for example, in the early stage of the simple parenchymatous form of goitre it presents an appearance similar in shape to that of the normal thyroid gland. Allusion has already been made to the resem- blance which the latter bears to a horseshoe, with concavity Fig. 36. — For ilescviptiou see pp. 77 and 352. upwards. But every deviation from this normal typical shape may be met with when the gland is enlarged asymmetrically, by the formation of a tumour or tumours within it. A portion only of the gland may be enlarged and the resulting tumour will then probably present a more or less round or oval shape. The size of a thvroid tumour may be very great ; it may even attain that of a man's head. It is probably among the cases of cystic disease that the 80 THE THYROID GLAND. largest goitres are to be found. Alibert\s cases* are among the largest with which I am ac(|uainted. Keser f describes a goitre removed by Professor Socin at Basle ; it was as large as a man's head, and came down in front of the sternum to below the level of the xiphoid process. The largest goitres which have come under my own notice during life, are represented in Figs. 34, 39, 46 and 82. Fig. 37. — The pi-ccetliiig, two moiitlis aftci- Extirpation of tlio wliole of tlie right and middle lobes. (See Appendix, Casell9, p. 352.) (From a photograph by Dr. Image. ) The degree of prominence also varies considerably. Some tumours present scarcely any external swelling, others form huge projecting masses which may be more or less pedunculated, and may even hang down over the front of the chest for a consider- able distance. Instances of huge goitres, extending as far * " Nosologic Xaturelle," Paris, 1817, i. f Samuel Keser, " L'enucleation ou extirpation inti-a-glandulaire du goitre parenchymateux,"' Paris, 1887, p. 20. SYMPTOMS AND DIAGNOSIS. SI downwards as the waist have been figured bv Alibert.* In oiie of these, the tumour is curiously elongated and narrow, and unlike any other that has yet come before my notice. ••■ Position. — The position of a thyroid swelling naturally differs according to the part of the gland involved. The swellino; may be in the middle line of the neck. This is Fig. 38. — A "Woman, aged 38, yritli a Bilateral Goitre. Tlie right lobe, wliicli contained a solid adenoma weighing- 7j ounces, estended deeply behind the sternum and right clavicle, and was extirpated on account of severe dvspnoe:!. (See Appendix, Case .50, p. 346.) the case when the enlargement affects either the isthmus alone (which is exceedingly rare), or the whole gland, including the isthmus. * Alibert, " Xosologie Xaturelle," i. p. 466, Plates C aud D. t The same author also alludes to, but does not figure, a case in which the tumour was cylindrical and tapering and reached as far down as the middle of the thigh. " Formee comme un long cylindre qui seprolougeoit jusiiu'a la paitie nioyenne de la cuisse." — " Xosologie Xaturelle,"' p. 468. F 82 THE THYROID GLAND. ^ 3. 3 " "3 ~ 5 2 d Ji-i ■^ ~ s '^ r r- >> SYMPTOMS AND DIAGNOSIS. 83 It should be borne in mind also, that a swelling situated in the lower part only of one lateral lobe will often push the trachea over to the opposite side to such an extent that the tumour itself occupies a position in the middle line of the neck. Such a tumour may closely simulate an enlargement of the isthmus itself and is frequently mistaken for this. It is a very common condition. The correct diagnosis is easily made by a careful exaiiiination of the exact position of the larynx or trachea. {See Figs. 43, 55 and Qo.) Very frequently, however, a thyroid swelling lies more to one or other side of the middle line, one lateral lobe alone of the gland being enlarged, or the enlargement affecting one lobe more than the other. {See Figs, 87, 103.) Often, only a portion of one lobe is enlarged bv the presence within it of a cystic or solid tumour. Such a tumour may be situated in almost any part of the front of the neck. It may even lie mainly or entirely ^^■ithin the thorax behind the upper part of the sternum. In this case, the tumour has grown downwards from the lowest part of the gland. On the other hand a thyroid tumour may involve only the apex of the superior horn of the gland and lie entirely at the upper part of the neck near the angle of the jaw. Of this I have seen several cases, from one of which the photograph shown in Fig. 41 was taken. It is important to remember that a swelling of thyroidal origin may occasionally occupy such a situation. This high position is frequently a source of erroneous diagnosis. Tumours in such a position are often mistaken for lym- phatic glandular swellings or even, as in one case that came under my notice, for a tumour of the submaxillary salivary gland. In July 1894, 1 operated with Dr. Eminson at Scotter, Lincoln- shire upon a man of 30 who had had for many years a globular swelling nearly two inches in diameter which lay directly in front of the thyroid cartilage and hyoid bone and slightly to the right of the middle line. Its lowest border was on a level with 84 THE THYROID GLAND. the crico-thyroid membrane, that is, wholly above the thyroid isthmus. The lateral lobes of the thyroid gland were not enlarged. A process of thyroid gland found at the operation to run up from the tumour behind the hyoid bone, together with the subsequent microscopic examina- tion of the cyst wall,_ proved the tumour to have originated in the thyroid pyramid. The patient made an excel- lent recovery. In February 1895, a young woman was sent to me by Miss Aldrich Blake, M.D., on account of an oval tumour as large as a pigeon's ef^g situated directly over the thyroid cartilage and slightly to the right of the middle line. On account of a slight band of tissue which could be felt passing down- wards from the tumour to the inner side of the right thyroid lobe, the tumour was recognised as one of the thyroid pyramid. It may be noticed that in both these cases the tumour lay exactly in the line of the right thyroid pyramid. Sometimes enlarged portions of a thyroid gland occupy still more curious situations. In a case of multilocular cystic goitre shown to me at St. Bartholomew's Hospital by Mr. Butlin, besides a swelling of the whole left lobe of the gland there existed a portion which appeared to extend transversely across the neck at the level of the hyoid bone from the apex of the .11. \ - -- — _- ^ l<'n;. 41. — A Cxstic Tumour of the Tliyi-i>iil. iic-i-iiii,\ iiii; an nuusually high, position in the neck. (Seen at St. B:'ortliolomew's Hospital.) SYMPTOMS AND DIAGNOSIS. 85 enlarged left lobe to a point beyond the middle line of the neck. In 1892 there came under my notice another patient of Mr. Butlin's, a young woman who had a movable tumour as large as a hazel nut situated just below the tip of the right great corner of the hyoid bone ; after removal it was found to consist entirely of thyroid tissue. In the very rare cases in which tumours of thyroidal origin exist actually within the larynx it may be impossible to make a correct diagnosis. The position of a thyroid swelling with regard to the larynx and trachea has al- ready been discussed. It remains for us to consider its position with regard to (a) The muscles of the neck ; (b) The great vessels of the neck ; (c) The sternum. (a) Position with Regard to Muscles. — The position of the sterno-mastoid first demands our notice. This muscle, if the tumour be sufficiently large, is almost always displaced outwards and forwards. The tumour usually lies to its inner side and comes forwards more or less between the muscles of the two sides. If bilateral it displaces both sterno-mastoids. Now a large number of tumours of the neck, especially those of lymphatic glands which at first sight may closely resemble tumours of the thyroid gland, differ from the latter in that they Fig. 42. — All ryj I Swiss ^Vum,•.ll with :i iiromiucnt Cyst' ' Goitre of sm vll size The tumour hail existed for many yc:irs but hml c.inseJ no dyspnoea. (Seen at Fiilo ivj, Swltzerl.'.ud, in 1886.) 86 THE THYROID GLAND. o 2 B. < g a ^ 8 .if >> O o considered the disease to be malignant, and ad^■ised that no operation should be performed. The diagnosis was subsequently verified,* the patient dying in the course of the following year. * The subsetiuent history of thi.s patient has been published by Mr. Sydney Jones and Mr. Battle in St. Tlunnati's IIo- lateral flattening should be carefully borne in mind since it has an important bearing upon operative proceedings canned out for the relief of dyspnoea. In some rare cases of uniform enlargement the whole gland may be rotated to a certain extent upon its vertical axis, so that one lobe projects a little more than the other. In such cases the trachea is also slightly rotated axially with the goitre. If the gland be enlarged on both sides, but more on one side than on the other, the flattening of the trachea partakes more or less of the character described in the next paragraph, according to the disproportion between the two lobes. Unilateral Goitre. — ^Vhen the enlargement affects one lateral lobe only, the trachea is flattened upon the side next to the enlarged lobe. (Figs. 53, 58b.) In these cases the trachea is also more or less curved longitudinally and pushed over towards * " De Texcision clu goitre parenchymateux," P. Liebrecht, Brus5e''s, 1883, p. 1.').3. 7 Langenbeck's ArcJiirf. hint. Chir., 1883, vol. xxix. plate xi. 110 THE THYROID GLAND. the opposite side. There is generally also a certain amount of rotation upon a vertical axis, so that the trachea presents an oblique lateral surface against which the enlarged lobe rests. Fig. 53* was taken from a specimen Mhich I removed post Fig. 52. — Shows the ordiuary Bilateral Flattening of the Trachea prodiieed by pareueliTmatoiis yoitre and other forms of s\-imiietrical eulargemeut of the thyroid. From a girl ay ed 13. who died of suffocation c:in., i. IIIS. THE DYSPNGEA CAUSED BY GOITRE. 125 The degree of prominence of the tumour is of importance in relation to dyspnoea. The more firmly a goitre is held down by resisting structures such as fascia or bone (sternum), the more likely is it to cause serious respiratory trouble. Thus, some of the most danoerous tumours are those which lie behind the sternum and which send down prolongations into this region (substernal and aortic goitres, "goitres plongeants" of French authors). In countries where goitre is prevalent one often sees huge prominent and even pendulous tumours causing comparatively little dyspnoea. Fig. 46 shows such a case. As examples of the opposite condition in which the goitre causes hardly any external swelling may be cited the case recorded on p. 105, and that of the boy whose goitre is now in St. George''s Hospital Museum.* In the latter case although gradually increasing dyspnoea had been present for sixteen months yet no external tumour was noticed until three days before death, which occurred from suffocation. Strictly median tumours, not involving the lateral lobes, are, as has already been explained, extremely rarely the cause of dyspnoea. There are some reasons for believing that the bilateral fibrous goitres of adults are especially liable to cause severe dyspnoea. Several cases have come under my observation which seem to support this view. One was that of an elderly woman seen with Dr. Favre at Fribourg (Switzerland) in 1886. This patient had a very small hard goitre which appeared to be shrinking in size and causing increasing and severe dyspnoea as it did so. Other cases are described in the following chapter. * Xo. liJB. Also case 2 in the lable. 126 THE THYROID GLAND. 'XI Oh w IX! X 3 @ o ^ < H O O en en o I— ( < ^ _ .,r^ X £ 5^ ^ ^ ■/, ■A ? ■l_ ^ '~ :; 5 S S i P ^ r 5 ^ 5: M ^ t^ '•' J" 2 M ^ ^ :^ -• CO 7*50 - '^ = ^ X X 1 'X. <:; ■3 .=- .. d -i -« ■-« ^ ^ X •" C3 > H ^."^ ^.= 1 7" 1 = — -^ •'I- X t5 -ic X 2 ^ X a ^ V. >. O cS >i _ _ , — ^ -M (1> ? *x ftl if. -f £_;. ir. ^ t; "t^ = •? - - £ 5 ^^ &(<+-( ' — bt — **-' X ^ -^ — — — X -^^ o ^ ^ ■r; - ^ -T" r — -r ~i if. a; ?'o ^ "^ \ £ If 2 -M it C - u i 5 •- r ^ a; -tJ _o c ^ ^ - £ 2 ^ C - aj 5 ;i: jt 2 "^ -t-* — 1-' "t^ — — _. ..--C ^ ■p " rQ 3 — r~ 3 — rj 1) ij 5l II 1 = r-< ^ t- H H 5 ^ ^ r. . ^ '-7- >-. ■■::■__ > := ::• ^ ^ "^ a T" ~ ^ X^ "~ " s -; 05 o^ w' — .z C — ..II !?; ^ ■^ — o "H3 ^ c — ^ ■^ 3 '"P o "^ ;^ z 2 " -75 o :^ it ■- _5 .t; -5 - '< i c r- = i >. ^ - a M ="' — ~ > ^ o 5 1^? X ■^ 53 1 It II ^ :^ 11 -r-*^ 1- ^ _i ■? ^3 3' _ijr 'Z ■Z ■' ■"5 "3 > ■S "" be f 1 ,g ^ ? 5 'X C f. p. 5 g ~ s i^TS tT c JC J6 z o S^ o 1 ^ ?^ '~' ^ ^ ■"^ .. -M ^ ~>" = -^ 2 ^, ^. 1 1 c •"— .a -/- ic 2 o 5 1 5. ^ 1 /— s s 1 1 ^ |-p ^ :; |f- 5 x 3 P ^. 3 i a ^ = ■$ 1^ ;I '>' z- '"' /- B GC b£ S 9 ■■? > Tf. 1 -= "i I- l^ " c '3'S ^ *~ v; r'- — ** ."** X 'J3 7. 5 :;; ::5 " ^ — ft t~ »;; /^> (M 3J >— 1- ri z . »— < ^H ^ a; '^^ ^- < w ^ ^ -:: ■^ ^ -^ ::. "E ?1 ^ "Z^ "H i ^ = 53 = ~r. Z g i S "-^ 33 &H :Z S i © 1—1 N cc -* .--: vc l^ X THE DYSPXCEA CAUSED BY GOITRE. 127 j; !5 3d r be C2 J- ■" a _j- " 2 S =g ^_ J •§ ^ J 'S 'S ^ 5 5 J S i ►^ ^ J J ■" So I '^ :^-= = I 2 g g i ''= 1. 2 P H»l i^f i 1^ 1 1 'it I i 1 1-| i = S 2 If 2 IfSlil 11 !^ ^ l^ll^ ^ ^ 1f^ 1-3 H "S r^ " -'- ?r •^r2 " S Ci :r :/■ .T' "ti H J- * S X - -W o "N ^ ^ Pi J i 1) "3 X > 3 be r :S 1) 128 THE THYROID GLAND. "E. ZlJ 2 "r -+- S -*■ 5 ^ H X .^ bf. g t' =^'S cc ^ ^ ^ S d -5 ~t" J> '^. f> ^ ii ^ ■z >■"? '§ ^2 o_^ ^ X K •J. a. -A -2 X X ">•. X H 1 S X ^ -f .5 u. S ■JL X >* x' V X X H X ' • _, "T" 17 ./. , li 1; s "S = 5 ;pN x".^ ^ >. g :! S-^ J 3 'x ^ •■^ ^ j3 ^ ce ^-T r^ J -^ J^ g 2 ci "x to ^ r 'i -5 5 -^ X x" •J. S ^ 8 X Q'3 c c _o . '« -r-J CC p H X = "^ 1 p S -^ 1^ 0. 3 c5 '-' -H3 x> ^ a K .^ fl a> < c - 00^ o 1 ^-^ a; c 'i^ -S 3 _0 cs t^ +^ > cS St- &| H 1 I'S e- H •p-H s-*^ 'a3 J ^.^ , , "■ i; >> (3 cs M o c o s S ^ ^ ^' X X ^0 Oj .5 S Ti S 'be >-. 'c bj; £ c^' 4 -z " 10 .- ° 'J •a, .0. 5 ^ -2 a; bi: ■" a^ "3 "5; "0 =2 c 3 X pS "3 K a < 6' 1.2 t- X b/a 1-1 X K X § /^** 5 S g CO 5 9 5' 5- a. ST 1 CO £ 1^ c; /~^ X ■' ll 1 II. ai-i CO ^,2 1^1 cc a; c: ^ ."§ ^ cc S >-' 'J. ^ B X ^ > y X i S ^_^ cS ei ■- -f '^ = 1 ,'K ^ g ^ p. ■5 5 ^ ^ = < 1* ^ CC 3 ,— CO 10 c t— ' cc CO cc (>) !— ' T— ( S5 . 1/ C^l IJ d; ■a. ^ aj ij "g ?. 5 ^ 2 % ct: 13 t ^ § ;£ il £ '^ 1 S ^ (M CC •+ ,- ._- t^ X 1= (M (M c^l IM w 55 N 5q THE DYSPN(EA CAUSED BY GOITRE. 129 &0M =4H ^ ao i'i" 11^13 «4- sis 1 bti c 0^ r^ 3 „05 iJ .-C G 05 -r .«■ o ll COl (188 890, ;^ a ^K^ (^ P-, a-3 g r "^ a '^ -i; J ^ o ?? =.£SS7?° c-ScsS cs -ecu: ^S.:i.os.S;;^, o s 0-2 "^ 1— 1 CD a OJ r-i a H 0-+^ ^--S "rQ O ^ ., n '^ ja ^ — . S o r^ bc^ S t"^ ^ '^ '^- ?■■ a:) a ' a '•'^ "^ 5 o c ^ -^ .a =s ° -s ^ ci * CD a a c :3 .2 S o -+5 -tS -s vV ? a W a c bcQ -• > cc Oj 3555^ ^ ^S '3 a&: ■^bcS, 2 "Ba ^ >"'^ & g ^. -3 ft 5|| p CHAPTER VIII. INFLAMMATION. Acute idiopathic inflammation — TAi^hoid fever — Rheumatism — Pj') shows a solid adenoma with much surrounding fibrous tissue and an abscess cavity in the centre. Still more serious is the condition of affairs when a thyroid fistula opens on to a mucous surface, the trachea or oesophagus. In the Museum of Charing Cross Hospital is a specimen * of a large solid thyroid adenoma which was removed by Mr. John H. Morgan on account of a fistula which opened both externally and also internally into the oesophagus. The patient was a woman aged 46", whose goitre had been injected four years previously at another hospital. After other methods had failed to cure the fistula, the whole tumour was removed by operation. The opening into the oesophagus which w«s just below the cricoid cartilage was closed with fine silk sutures, and the wound drained. The patient made an excellent, although somewhat tedious recovery.! Primary Chronic Inflammation. Under this name may be described a remarkable and somewhat rare affection which seems to have attracted but little attention in this country. It is characterised by the development in the thyroid gland of a tumour of exceeding density and hardness, which shows a remarkable tendency to become adherent to, and * No. 877a. t A full account of this case has been published by Mr. Morgan in the Illustrated Med. News for June 2i). 1889. 138 THE THYROID GLAND. even to surround and infiltrate, neighbouring structures. Various names have been given to the affection, the pathology of which is still somewhat obscure. Tailhefer,* in an excellent paper upon the subject, uses the name " primary canceriform chronic inflammation.*'' Bowlbyf has published a typical case under the name of " infiltrating fibroma," and seems to think that the disease is allied to sarcoma. There can, however, be but little doubt that chronic inflammation is the term that is most correct. The remarkable similarity which exists, both clinically and pathologically, between this disease and some of the harder forms of malignant disease is very striking. Indeed almost every case hitherto described has been diagnosed at first as malignant disease. To Riedel i of Jena we are indebted for drawing attention to the true nature of the disease and in the publication of two cases that came under his care. I have myself seen three cases. One of these was the case published by ]Mr. Bowlby, which was under the care of Sir Thomas Smith. The other two were under my own care at the Royal Free Hospital. The disease occurs both in men and in women. It appears to be most common in middle age but cases in childhood have been recorded. A swelling is noticed in one or other, or both, lobes, of the gland. It grows steadily and painlessly, and when it reaches the exterior of the gland it becomes firmly fixed to the trachea, carotid vessels, I'ecurrent nerves, and other structures. It exerts pressure upon all the structures and causes dyspnoea, dysphagia, dysphonia, and obliteration of the carotid pulse. If untreated it gradually compresses the trachea more and more and causes death bv suffocation. The swelling does not usually attain any great size, the lateral lobe of the thyroid being seldom larger than a goose's egg. The extreme hardness of the tumour has been likened by * " luliainmation cJiroiiique ijrimitive ' canceriforme ' de la glande thyro'idi:",'' by E. Tailhefer in Brr. de Chir., Paris, March 10, 1898, vol. xviii. p. -li-^. f " Infiltrating fibroma (.' sarcoma) of the th^Toid gland,'' Tranx. Path. Soc 1885, vol. XXX vi. p. 120. X " Die chronische znr Bildung eisenharter Tumoren fiihrende Entziindung der Schilddriise," YerhnndJ. d. JJeutxch. GexeUtwh. f. Chir., Berlin, 18'J(), i. p. 101. INFLAMMATION. 139 various observers to that of wood, iron or stone. It is quite distinct from the ordinary fibroid degeneration so commonly seen in parenchymatous and adenomatous goitres. The latter progresses extremely slowly and does not cause infiltration of, or adhesion to, surrounding parts. The following are the three cases which have come under my own notice : Mrs. Eliza D , cEt. 42^ was admitted into St. Bartholomew's Hospital on Nov. 28^ 1883, under the care of Sir Thomas Smith. Three years previously she had first noticed a swelling of the lower part of the neck. During the next year this swelling gradually inci'eased and her breathing then became affected. At this period she consulted a doctor who found that the thyroid gland was " very slightly enlarged, firm, and not at all painful."* A year later it was found that the thyroid was apparently incorporated with the trachea, the place of the gland being taken by a very hard, painless growth. She was treated with iodide of potash and biniodide of mercury ointment, but did not improve. On the contrary her breathing gradually became worse and worse, and she was liable to fits of coughing brought on by active movement. " The stony hardness of the growth was by this time very remarkable and was of such a nature as to suggest the presence of cartilage or bone. In April 1883, the patient was seen by Sir Felix Semon, who expressed the opinion that the disease was of a malignant nature. He found the trachea much narrowed, the left abductor paralysed, and the left vocal cord completely fixed in the middle line. " The dyspnoea continued to increase, and at times suffocation seemed imminent. Dysphagia and weakness of voice were now noticed. " On admission to the hospital dyspnoea was very urgent. The front of the neck was occupied by an excessively hard mass, which enve- loped the whole of the tissues from the level of the hyoid bone downwards to the episternal notch, and in which it was not possible to recognise any of the normal structures of this region. Free division of the isthmus of the thyroid failing to give any relief, tracheotomy was performed. Some temporary relief was afforded, but the dyspnoea returned and the patient died on Dec. 4." The post-mortem examination was made by Mr. Bowlby who has given the following description : " The viscera generally were healthy. There were no signs whatever of secondary growth and none of glandular affection throughout the body. The thyroid gland and * The description of this case is largeh' from the account given hy Mr. Bowlbv in the Path. Sue. Trunx., vol. xxxvi. 140 THE THYROID GLAND. adjacent parts are occupied by a large new growth. The tumour is extremely hard, and of a similar shape to the gland in which it grows, being composed of two latei*al lobes of equal size, joined by an isthmus. Its cut surface is fibrous. Each lobe reaches the level of the hyoid bone above and of the bifurcation of the trachea below ; they are joined by a bi-oad isthmus reaching from the cricoid carti- lage over the upper half of the trachea. Above, the lobes present a rounded outline, are quite separate from each other and their limits are clearly marked. Behind, beloAv and laterally, the limits of the growth are quite undefined, the surrounding parts being infiltrated by the tumour and not simply pushed aside. Thus the common carotid artery, the external and internal carotids, the internal jugular vein, the pneumogastric, recurrent laryngeal and sympathetic nerves are on each side entirely included in the tumour. The depressor muscles of the hyoid bone are infilti'ated and fixed ; the oesophagus is infiltrated and so compressed an inch and a half below the cricoid cartilage, that the tip of the little finger can barely be passed. The trachea has been compressed both laterally and in front ; in the latter situation by the isthmus of the tumour (which has been divided), while its lower portion,, which in life occupied the thorax and root of the neck, is infiltrated with new growth on each side, and so narrowed by lateral compression that the little finger cannot be passed. The aorta and all its branches, the innominate veins, with the superior vena cava and the pulmonary artery, are all incorporated in the tumour to a greater or less extent, but although the calibre of these vessels is more or less diminished by pressure, in none of them is there any ulceration or clotting of blood. The apex of the left lung is closely adherent to, and not separable from, the lowest portion of the growth. The bifurcation of the trachea, Avith both bronchi, is adherent to the tumour, as ai*e also the bronchial Ijaiiphatic glands. Neither in the neck nor in the thorax w^ere these latter at all enlarged or otherwise altered. I made a very careful examination of different parts of the tumour, sections being taken both from the centre and the periphery. The structure was entirely fibrous without the least appearance of either alveola- tion or of epithelial cells." The following case was under my own care at the Royal Free Hospital and differs from the others in that spontaneous ulcera- tion of the skin occurred, as may be seen in the accompanying photograph (Fig. 59). Mary S , a?/. 63, widow, was admitted into the Royal Free Hospital on Jan. 20, 1899, on account of dyspnoea and an enlarged INFLAMMATION. 141 thyroid gland. She had had for many years a swelling in the neck ■which had given her no trouble until about fifteen months before admission. At this time the swelling on tlie right side became lai-ger and eventually broke through the skin. An indolent sinus had been present ever since. In the last two months she had had much severe dyspnoea, especially at night. She had also lost flesh in the last few weeks. On admission she was found to be pale and thin. She breathed Fig. 59. — Primary Ch.ronic Infl.amm.ation ol tlie Thyroid, leading to spouMiifons ulceration of the skin. (.Tlie darkness of the skin is dtie to a photoiiTapliie error.") with much difficulty and stridor, and had to lie in a semi-recumbent position, as she could not breath while lying down. Temp. 9^' • Pulse 120, Resp. 36. There was also a good deal of bronchitis. There was little or no dysphagia. The right lobe of the thyroid formed a hard irregular mass about as large as a goose's egg. The skin over it was adherent ; in the middle of the adherent area was a shallow, narrow, ulcerated surface two inches long bv half an inch wide and extending nearly half an [42 THE THYROID GLAND. inch into the substance of the gland. On the left side of the neck was a similar but somewhat smaller swelHng not nearly so hai'd ; the skin over this was not ulcerated. The whole swelling moved Avith the larynx, but not very freely. With the laryngoscope great lateral flattening of the trachea was seen, the walls were about ^ inch wide at the narrowest part. The vocal cords moved naturally. The diagnosis of the case was not clear ; the swelling was believed to be chronic inflammation of a peculiar nature, possibly tuberculous, but the idea of malignancy could not be altogether excluded. It was clear that, owing to the fixity of the growth, no removal was possible. It was thought that tracheotomy would soon be required. The case was seen by my colleague, Mr. Battle, who agreed both with the diagnosis of probable chronic inflamma- tion and also with the impossibility of removing the tumour by operation. On June 23, the patient having had several attacks of severe dyspnoea, tracheotomy was performed without any general anaesthetic. The operation which lasted ten minutes was diflicult owing to the hardness and nodularity of the gland, Avhich made it difiicult to distinguish the trachea from neighbouring parts. A long Koenig's canula was inserted. The patient's breathing was easier after the operation. On the following day the tube was removed for cleansing and then replaced. The patient's temperature which had been 100" before the operation Avas never afterAvards quite normal : her pulse Avas generally between 120 and l60. The patient died six days after the operation Avith symptoms of septic bronchitis. The post mortem showed a bilateral parenchymatous goitre of moderate size and Avith a fcAv cysts evidently of long duration. The lower half approximately of the right lobe Avas occupied by a densely hard, yellowish-white, ill-defined mass, Avhich Avas firmlj- adherent to the trachea for about an inch and a half, and also to the left carotid vessels. In the corresponding part of the left lobe is a similar, but much smaller mass of the same nature. The resem- blance to a scirrhous carcinoma Avas Aery great, but careful micro- scopical examination shoAved nothing but dense fibrous tissue Avith remains of thyroid tissue here and there. There Avas no trace of malignancy anyAvhere.^ The third case illustrates a much earlier .stage of what I belieA'e to be the same disease, but as the dense fibrous growth had in this case not reached the capsule of the gland, there Avere * The specimen is now in the Koyal Free Hospital Miiseuni, Xo. xxii. .">. INFLAMMATIOX. 143 no adhesions to surrounding parts and complete removal of the affected lobe was possible. Mrs. Charlotte G ,* cet. 40^ was admitted under my care into the Royal Free Hospital, on account of a swelling of the right lobe of the thyroid. Five weeks before admission she had first noticed a lump in this region ; it had steadily increased in size. She complained of occasional shooting pains in the lump, and also of a slight "■'choking" feeling. Otherwise she appeared to be in good health. The extreme hardness of the lump, its slight irregularity together with the history of a rapid growth and sharp pains led to a strong suspicion of malignant disease in an earlv stage. Accordingly on May 13, 1898, extirpation of the right lobe was performed. The operation presented no unusual difficulty of any kind ; the subsequent course of the case was quite ordinary : the Avound was drained for twenty-four hours and then healed throughout by primary' union. The tempei-ature never reached 100° at any time. The patient left the hospital eleven days after the operation quite well in every respect. She came to show her- self from time to time and remained perfectly well. She was last seen about two vears after the operation. The tumour that had been removed Avas as large as a hens ^gg. The peripheral portion to a depth of about a quarter of an inch consisted of normal dark coloured thyroid tissue. All the central part however consisted of a somewhat ill-defined mass of connective tissue, which on section was found to be extremely hard, white, shiny and glistening. Microscopically it consisted of dense inflammatory tissue with remains of thyroid tissue between the bundles of fibrous tissue. Riedel t has recorded the following cases : A man aged 42 had noticed for about six months a swelling of the thjToid gland which caused considerable dyspnoea. The tumour was bilateral, not very large, but extremely hard and fixed. It was believed to be malignant and on November 30, 1883, an attempt was made to remove it by operation. After the gland had been exposed however, it was found to be intimately united on both sides with the carotid artery and jugular vein. The operation for its removal was therefore abandoned, and Riedel contented himself with cutting away a piece of growth as large as a walnut. * See Appendix, Case .56. p. 346. j Op. cit. 144 THK THYROID (JLANl). The wound healed without any trouble and the jiatient's breathing improved so much that at the end of six months his dyspnoea had entirely disappeared, he seemed quite well and was able to do his ordinary work. Fifteen months after the operation this patient died of nephritis and apoplexy. There was no post mortem. The ])ortion of tumour that had been removed was examined micro- scopicallv. There Avas no sign of sarcoma or carcinoma. The tumour was composed of chronic inflammatory tissue. There was no evidence of tubercle or syphilis. Twelve years later Riedel met with the following case : A healthy looking woman aged 23 had noticed that for a period of one year her neck had been swollen. In the last two months the swelling had increased tolerably rapidly. The patient had much dyspnoea on exertion. The thyroid gland was enlarged on the right side to the size of a hen's egg, on the left to that of a small apple. The tumour was remarkably hard and fixed. As in the preceding case the operation for removal of the tumour had to be abandoned on account of the extensive adhesions of the tumour with the blood vessels and recurrent nerves. Micro- scopical examination of a portion of the tumour showed chronic inflammatorj' tissue. The patient's breathing improved after the operation, she was able to get about and was apparently nearly well. About two months after the operation she was suddenly seized with symptoms of embolism and died in a few minutes. There was no post-mortem examination. The case that formed the subject of Tailhefer's first paper * was under the care of ]\1. Jeannel of Toulouse. Tailhefer him- self assisted at the operation. The patient Avas a man of thirty who for three months had noticed aphonia and a swelling of the neck. The left lobe of the thyroid was found to be occupied by a '• very hard, ill-defined, fixed and painless tumour, not involving the skin." The tumour was thought to be malignant and its removal was attempted. The tumour was found, however, to involve the carotid sheath and neighbouring parts so extensively that the operation had to be abandoned, a small piece only of the growth being removed. The operation was followed by secondary haemorrhage from the carotid, necessitating ligature of that vessel. Suppuration and hemiplegia followed but the patient eventually recovered. Histological * " Vuriete tres rare de tliyro'ia<;nil:!ted colloid ui:iti'ii:il (St. Bart. Hosp. Mns. Xo. 2310G.) iXat. size.) 156 THE THYROID GLAND. blood may be extra vasated as the result, either of slight injury, or, perhaps, of spontaneous rupture of a small thyroid vessel, I do not consider this, however, to be a common mode of origin. Fig. 65. — A wuului. a-ed 5u, witli a l;irg-e Cyst '>i the l!iuhr Lobe. It had been growing' slowly for more than twenty years and caused much discomfort and some dy.spna?a. It was easily removed by resectioii- eniicleation. (See Appendix, ('.ise 61. p. 346.) Haemorrhage into an adenomatous tumour is, however, very common. A convenient and simple classification of thyroid cysts is into single and multiple. An objection to this classification is that in cases of single cyst, there exist almost alwavs numerous smaller cysts in other parts of the gland. As these ho^vever may be quite small and CYSTIC DISEASE. 157 insignificant in comparison with the larger cyst, the practical value of the classification is not materially affected. In cases of multiple cysts, the whole gland is frequently found to be converted into a mass of cysts, no one of which is much laro-er than its fellows. Fig. 66. — TIk- precodiiii;. iMif week alter the operation. Single cysts form unilateral tumour.s ;* multiple cysts generally produce bilateral enlargement of the gland. It is mainlv on this account that this artificial and to some extent incoiTect classification is worthy of adoption, since unilateral and bilateral tumours frequently present much difference with regard to symptoms, prognosis, and treatment. A term frequently employed is that of Hcemorrhagic cjj.st. * Except ■when situated exactly in tlie middle line, which is not common. 158 THE THYROID GLAND. This may be of the nature above nieutioned, but is much more commonly simply an ordinary retention or adenomatous cyst into which h;emorrhage has occurred. A remarkable peculiarity of thyroid cysts is the unusual ten- dency to intra-cystic haemorrhage which they possess. In no less than six out of twelve cases mentioned on p, 152 Fig. 67. — A man, aged 5U, with a large Siuglc ThyroM Cyst siniiii;iiin' li-om the left iipper horn. It luul been gi'owiug- slowly lor more tliiiii thirtj' years. It was easily and successfully removed by Dr. Comte, and found to contain over two pounds of semi-solid, partially calcified, colloid contents. A portion of the c.yst wall and its contents are now in the Museum of St. Bartholomew's Hospital, No. 2314f. (Seen at Geneva in 1886.) distinct intra-cystic haemorrhage had occurred, and museum specimens likewise show how common it is to find blood in the interior of a thyroid cyst. In no other class of cysts is found such a marked tendency to haemorrhage. If a thyroid cyst have been tapped and clear fluid withdrawn, a second tapping is extremely likely to evacuate, not a clear but a blood-stained CYSTIC DISf^ASE. 159 fluid ; frequently indeed on the second tapping the fluid consists of nearly pure blood. It is probable that the explanation of this tendency to blood extravasation is to be found in the fact, already mentioned, that many thyroid cysts are formed from pre-existing adenomata. The soft and vascular thyroid tissue within the cyst is naturally very apt to bleed. Occasionally this unfortunate liability to haemorrhage leads to serious or even fatal results. Professor Kocher relates * the case of a lady who had a cyst of the thyroid. It was tapped ; clear fluid being withdrawn. A second tapping caused the evacuation of pure blood. The intra-cystic haemorrhage then caused such severe dyspnoea that extirpation of the cyst had to be performed. Mr. Butlin has kindly communicated to me a case in which, many years ago, a thyroid cyst was punctured in his out-patient room ; such severe symptoms were caused by the intra-cystic haemorrhage which ensued, that the patient subsequently had to be admitted to the hospital as an in-patient, and the haemor- rhage was controlled with the greatest difficulty. In the College of Surgeons Museum is a preparation f of a large thyroid cyst. The catalogue states that the cyst was full of coagulated blood, and looked like the sac of an aneurism. During life it was punctured in consequence of the dyspnoea produced by its pressure upon the trachea. A considerable quantity of fluid blood flowed from the wound, and the bleeding- continued until the patient died. The following is a case of haemorrhagic cyst that I saw in 1885, at the Kensington Infirmary with Mr. Potter and Dr. Reece. (Fig. 33, p. 47.) Mary McD , a4. 60, unmarried^ had had for many years a swelling in the situation of the right lobe of the thyroid. In the last two months it had become much lai'ger and more prominent. In the above-mentioned situation was an irregular rounded swelling measuring four and a quarter inches transversely, and three and three-quarters vertically. It projected considerably and over- lapped the sternum and right clavicle. It was of a dusky red coloui*, tense and elastic, but with softer spots here and there. At * Arehivf. Mid. C'/iir.. lSR;-5. p. 308. f ^""o- 2905. IGO THE THYROID GLAND. the most prominent part was an ulcer with a slough as large as a sixpenny-piece. Puncture gave exit to an ounce and a half of grumous fluid containing much blood. The cyst was dissected out by Mr. Potter and was found to contain a lai'ge amount of both fluid and clotted blood.* The patient made a good recovery. Haemorrhagic cysts of other parts of the body sometimes afford a presumption of malignancy, but this is by no means the case with those of the thyroid. Malignant cysts of this organ like those of other parts, may, of course, be accompanied by intra-cystic haemorrhage. But it is important to bear in mind that the finding of blood in the interior of a thyroid cyst ought not in itself to be taken as pointing towards the existence of malignant disease. On the other hand malignant disease of the thyroid may produce cysts containing clear fluid. Two examples of this have come under my own notice. The situation in which cysts are most often found is the lower part of one or other lateral lobe, but the only apparent reason for their more frequent occurrence in this part is that the main bulk of the organ is situated here. The isthmus and the comparatively slender upward prolongation of the lateral lobes form but a small part of the whole organ, t The structui'e of thyroid cysts may conveniently be considered under two heads : (a) Structure of the cyst-wall. (b) Structure of its contents. (a) Cyst-wall. — In small recently formed cysts, the wall has the same structure as that of the normal vesicle ; it consists of an exceedingly thin and delicate layer of connective-tissue lined by a single layer of epithelial cells. In larger cysts it is more fibrous and tough, being composed mainly of dense layers of fibrous tissue closely packed together. Sometimes when the cvst is large the wall may measure several lines in thickness. In these cases there may often be * This specimen is now in the Museum of tlie Koyal College of Surgeons. No. 290oA. j For specimens of cyst in upper part of lateral lohe. see St. George's Hosp. Mus. No. 20A : in isthmus. St. Mary's Hosp. Mus. 1031. ,'^ X E-i O w Q < G >^ O w G G Pi O Cj O o •2 ^i; O r- • ^ .• -H OC '^ ^'' •> l-S CO 30 l4 , "Cases an il Remarks ," etc., 2nd orwich, 17( £■ » ■= C >-.'?^ T '^ '•'^ " - * A* ^■^ . . S 5 "-f .J ._• ^^1 ~ "^ '"' ~t^ ~" 'X J ^-- 1 a: ;; bo a: a: 4S S K HJ ■^ i _CD ^ 3.S C ^ y. O -w S C-C o >?-r r. O '^ '-^ ~ ^ ... r^. ^^ |.| .= ^ r; •oof a: '-" ^ S .S '"• ocS'J-tiS'^..,"",.^- " f 1 " "B-' " ^ "5 ^ 53 2P IT f^ "^ qT :; LT 2 -i: )=^ a; S ?-f X ^ O — IJ 3 ;_ .-. ^ - - J -e o cs 2 t^ o ^ . ■ 'ipS---i s's a?' P '-fi g o ~ p S-=" F^cf-S .2 s j: : O 5 Vj i:^ ... o£i ^ p -tJ . 2 II .| ^ .t' E 3 S -^ 2 ai Q 2 3 f= ^•2 a 2^^ 3 ^ ■■*::; 2' ^ 5= C ^ .„ a CD 'rt.S ■ p > 9 E 1 3 % ■0 > ? cS cT 3j g r^ i c ^ ^ bCcS . 'f-- •^ .1; >.•'- i a S 8 d ■X w ti s >."S s s >~. '^ r- be s =^ ^ = ?^ -^ -ji ID aj t3 . 9 % a "a; -^ '? ^"^ • ' .t: be 3 3 GC CC ^ CD o.S 111 :e bxj ■^- TJl CO ■3 o.s cc in Q (M •~a -* .0 03 -3 a (D -H CO a m (U fe g 1; S HYDATIDS. 173 £ - y- sq; ^ > o 1 Y. -ti .^ ^ ^. - c^ -*-*'""' r^ c^ ^ >.-2^ . s S"^ -5 oj^ b 5 c5 -2 S -/: ^ '-^ ^ ^ -" 5"^ :i -1 1 ? §-| 1^- 1 ^ ~ 1 1 J |-- -^ I ^ I ^ I I'f ' gcp-^ = -3 = ;= 2 :"•" 174 THE THYROID GLAND. OO , 1. •^ • ' fCi **r ^ 1— < « X o g P. o 'x ^ — CC ^ o _5 d 5 i^ X '^ _ ■> ^ IN U 2 ^2 j^ 1^; i'« X X c^ ~ C^ H g h S If C r c3 S 6 X 3D bt 5^ " Si 1 an CC > c 33 15 & Is OJ ■ij S •= -^^ c c , — /- c3 •-- , C e: =* S ^ ^- -§ t ^ -r. < 53 o It 5 § 2 "t: :- — 15 ^ X It? 'II S c "rt -^ J ^s be K r- "^ "Pa S 33 .— 2 w -- ' 5 ^~^ ^ -, :3 -^ r^ ;> o; oj C3 U( 5 ■> 1"? f .-g ■= ^ 1 s X J "o ^ H 0' ^ 'c °S rt •r. -g ■x ^ X 15 >■ ^ "-^ ■^ r; cc ,—1 ^_^ -- J — - Z. ?^ t-H P ■" ^ .~ ""■ a — o 6 s IS :£ i X 5 5 11 = 1 s 1 S it"" "S ct o .§ X ■■■ i >~.:^ bt .-"s = " ^ 2 1 ."l s r. i i o S X -^^ s J > 1 "C •— = § E. = .| i -^ PS o ' -f. '"3 o OJ ■-5 o 5 "33 1 ;2 "5 ■^ ^ IE £ 'ti -^ ol ii s HH ^ ^ ^ ;^ Sh 33 "i3 ^ t£ ^iili ac "3 o /2 cT bti b(j rS be if. Tc 'ii be a, X 1 i. ■y- S s c S O C 1 p aj bL J/. ;2 •J. :'; x" 5 = _ D t*^ 'x ¥■ ^.s'^ ^ i _ +3 ^ 1 3 53 O jiT if. Tc - ? X* X % X Tt i S "x . — ' 15 ti.^ — •" O 2 ^ 1 5 *x X 15 > .» £ i 1 ^ ei ij i. ■35 X g 2 = i^ ■s. ■^"i. X p. s = 5 ?^ i" X i s — S — >> ;^. '^"q-. s :^ ," ^"- "be - r*^ •Z^ o ^ ■^ -^ C .^ a_ 3 CC rH 1-H O -f^ ^ -" ^'r^ S " X "" - E ^ M =^ v: " 5^ 1^ X — IN iS f— 1 ^ r— ,^ -5 CC 15 "E X ~ i i; ^1 ^ ~ 31 :r = -_ ? >-.-e >-. •- i CHAPTER XII. EXOPHTHALMIC GOITRE AND ITS TREATMENT. (GRAVES'S DISEASE ; BASEDOW'S DISEASE.) Age — Sex — Pathology — Morbid anatomy — Characteristic appearance on section — Microscopical appearance — Absence of accumulated colloid — Secondary changes — Exophthalmos — Cause of — Enlargement of thymus - — .Symptoms and Diagnosis — " Formes fiuistes " — Treatment : Medical. Surgical — Operations upon the thp-oid — Extirpation — Results — ExotliATopexy — Operation upon vessels — Operation upon sjTnpathetic — Section — Resection — Unilateral — Bilateral — Results — Mortality — Prognosis without operation — Conclusions. A DETAILED description of the remarkable disease known as exophthalmic goitre would be out of place in a book which deals mainly with the surgical aspect of diseases of the thyroid gland. A short description only will be given here. The disease is found to occur in both sexes, but is far more common in women than in men. During the fifteen years 1884 to 1898, there were in the medical wards of St. Bartholomew's Hospital ninetv-six admis- sions for exophthalmic goitre. Of these eightv-eight were female \\liile only eight were male cases. True exophthalmic goitre is almost, if not cjuite, unknown before the period of pubertv and rarely begins after middle age. It is confined almost exclusively to the period of sexual activitv and is especially common in the earlier part of that period. Of the above-mentioned ninety-six cases, twelve were, on admission, between the ages of fifteen and twenty, forty-five were between twenty and thirty, twenty-six between thirty and forty, while only thirteen were over forty. Exophthalmic goitre does not occur as an endemic disease, and is not especially common in districts where ordinary goitre is endemic. Amons; a thousand cases of goitre seen by Dr. EXOPHTHALMIC GOITRE. 177 Savage in a goitrous district in the north of England, there was not a single case of Graves's disease. Dr. Montoya v Florez, Professor of Clinical Surgery at Medellin, Columbia, tells me that although endemic goitre is extremelv common in that country, he has never seen there a case of exophthalmic goitre. My own inquiries in many goitrous districts both in England Fig. 70. — A tjiiieal case of Exophthalmic Goitre ( Graves's Disease) in a yoiiug- nomau. (Seen in a meditMl ^^aril at St. Bartholomew's Hospital.) and abroad point in the same direction, and tend to show that exophthalmic goitre is rare in places where ordinary goitre is common, and certainly is often found to exist in places where ordinary goitre is unknown. Dr. Maude, on the other hand, whose writings on exophthalmic goitre are so well known, appears to think that there is some connection between the distribution of the two diseases. 178 THE THYROID GLAND. Pathology. — It must be confessed that the pathology of the disease is still obscure. The numerous theories that have been brought forward may be divided into three main classes, in which the cause of the malady is attributed to disease respect- ively of the central nervous system, the cervical sympathetic, and the thyroid gland. For a full discussion of the various theories reference must be made to works on medicine. With regard to the first two it is sufficient to say that they are unsupported by reliable post-mortem evidence. Slight changes in the brain and the sympathetic nerve have from time to time been described. In the great majority of cases, however, in which post-mortem examinations have been made, no definite lesion has been dis- covered in either of these structures. Neither an irritative nor a paralytic lesion of the sympathetic will account for the symptoms of the disease. These symptoms, moreover, are not those which we know to be the result of gross lesions of the sympathetic. The idea that the enlargement of the gland is due to vascular dilatation seems to lie at the root of the sympathetic theory. This idea has arisen, I am afraid, mainly from clinical examina- tion of the gland ; the actual investigations of morbid anatomy do not support it. Recent researches, especially those of Mobius, Greenfield and Murray point strongly, in my opinion, to the view that the primary source of the disease lies in the thyroid gland, in which alone definite and remarkable lesions are always found. The complex group of symptoms which characterise the disease are probably caused by an alteration of the internal secretion of this o-land.* The secretion appears to be altered in quantity and probably in quality also. This altered secretion, when circulating in the body, probably acts directly or indirectly, like many other poisons, upon the heart, upon the nervous system, and upon the nutrition of many tissues in the body. * How far this thjToid disease is dependent upon some unlcnown disease of the higher centres of the hrain is an interesting question which need not be discussed here. There is at least some evidence to show that violent emotions such as fright may be the immediate cause of the disease. (See an excellent paper by Dr. Raymond Cra\\'furd. " Graves's Disease : an emotional disorder," Kinrfs Coll. HoajK Eejn^., vol. iii. 1897.) EXOPHTHALMIC GOITRE. 179 Morbid Anatomy. — A museum specimen of a typical exoph- thalmic o-oitre is usually easily distino-uished from the other forms of goitre. Like the purely parenchymatous goitre, all parts of the gland are equally enlarged. The enlargement is rarely excessiye ; each lateral lobe seldom exceeds in dimensions those of a goose''s egg, and is often much smaller. The surface is smoother than that of a parenchymatous croitre. It is the cut surface of the gland, howeyer, that presents the most characteristic appearances. This shows a remarkably homogeneous, solid structure, yery unlike the yesicular appear- ance of a parenchy- matous goitre. Little or no colloid is yisible. The blood -yessels are usually smaller and less numerous than in a parenchymatous goitre of the corresponding size. This point is, I think, important, since it is often stated by those who appear not to haye inyestigated the matter for themseiyes that there is " great dilatation of the yessels.""* Microscopical examination of the thyroid shows marked ■' I quote liere the words of a well-knowu medical authority who -nTOte them in 1897. Pic. 71. Sketch of Tliyi-oid Gland and ueighboxu-ing- parts, fi-om an unmarried -svoman aged 19, tlie suljject of ExopMhalmic Goitre. The enlargement of tlie tli3-mus (the lower part of which has, however, been cut off) is characteristic. (St. Bart. Hosp. Mus. Xo. 2314T.> (Keduced J.) 180 THE THYROID GLAND. differences between the exophthalmic and the common paren- chymatous goitre. Instead of the vesicles distended Avith colloid secretion and lined with a single layer of cubical epithelium, which are seen in the ])arenchymatous goitre, we find in the exophthalmic variety a wholly different appearand'. The colloid is much reduced in quantity, and indeed is frequently almost entirclv absent. The vesicles are not distended and are not at all well marked. The epithelial lining has undergone a marked pro- liferation so that the place of the vesicle is frequently taken by an irregular mass of round cells with per- haps a trace of colloid. There is also a tendency for the epithelium to become columnar. The whole gland appears to be in a state of considerable physiological activity, but the secretion, instead of beino- accumulated in the vesicles, is not to be seen, having apparently passed into the lymphatics as soon as secreted. An extreme case presents considerable superficial resemblance to a round-celled sarcoma. The accompanying micro-photographs (Figs. 73 and 74) illustrate the appearance of parenchymatous and exophthalmic goitre respectively. The appearances above mentioned are those which are found in all severe cases, that is in all cases in which the disease itself has been the immediate cause of death. They are practically identical in all museum and post-mortem room specimens that I have had the opportunity of examining. There is no museum specimen with which I am acquainted which shows the "great dilatation of vessels'" to which allusion has been made.* * Excellent specimens of exophthalmic goitre may be seen in the following museums : Roy. Coll. Surg. 2891a ; Guy's Hosp. 99, 100, and 101 ; St. Bart. Fig. 72. — The prccediug, seen from Ijehiiid. A .suction ol tlie left lobe has beeu iii:ide, showiug- the homogeneous, solid stritctiu-e of the giand. (St. Bart. Hosp. Miis. Xo. 2314T.) (Keduced i.) EXOPHTHALMIC GOITRE. 181 If the examination be made of an exophthalmic goitre from a case in which death has occurred not wholly from the disease itself. 'j.'ar^y^^iitij' ^^'cj'c**. "o ^ = I £ .5 eS - •- :t ;z - ^ ; I I .ii : I— I "r " ~ 3 ft ii -S & = ^ § i ~ 1 1 = - — 5^ -^ ?;>:^'' --'pr "■'* c _ > _:£ 3 y £ — o '^ ^ ■^ Ip 1 > s 5 _ C O ii ~ — •- I s i ^£ ft = i- = ■? = 3 o g p ^ > ^ ^ :§ ^ i I c i ^1 "^ ^* ^ Ei ci; § '- " ^ 2 ,2 ^ .2 : g . X M 'S a £ Ho^p. 23US. T. and r : Chai-. Cross Hosp. 879a ; St. Marr s Hosp. 102.5 ;. Univ. Coll. Hosp. li58D: St. Thomas-s Hosp. li65A. Some^vhat less tj-pical ai'e Gurs Hosp. 102 and Westm. Hosp. 609. * Case of A. H., at. 15, described in £rit. Med. Journ. July 20, 1891. t Unpublislied. 182 THE THYROID GLAND. the appearances presented are similar but not so ]>ronounced. A good deal of colloid may be seen and many vesicles may still be easily recognisable. Opportunities for examining such specimens are occasionally afforded at the present time bv opera- tions for the removal of the goitre. Cysts and adenomata are rarelv met with in the goitre of Graves's disease, and this is probably one reason why this form of goitre seldom attains a very large size. A thyroid gland containing a pre-existing cyst or adenoma may, hoAvever, subsequently develop the characters of Graves's disease, and it is probably such cases that have led occasionally to the description of unilateral exophthalmic goitre. True and uncomplicated exophthalmic goitre, being a disease of the whole organ, is never unilateral. An exophthalmic goitre of long standing may develoj) secondary changes, such as fibi'osis, similar to those of paren- chymatous goitre. Examples of this, however, are rare. The exophthalmos is, I believe, due entirely to a local deposit of fat behind the eyeball. No reliable post-mortem evidence of its being due to any other cause has ever been brought forward. The absurd theory that it is due to vascular dilatation of the orbital vessels scarcely merits discussion. The vessels that supply the post ocular tissues (branches of the ophthalmic artery) supply also the conjunctiva and eyelids, both of which are easily examined by simple inspection. They do not show any increased vascularity in Graves's disease. On the other hand, increased orbital vascularity is a condition with which we are all familiar. It is often seen in cases of inflammation of the orbit and of tumour or thrombosis at the back of the orbit. In these cases, the proptosis which is often present, is accom- panied by suffusion of the conjunctiva, and often by swelling of the eyelids. This condition of affairs differs widely from that of Graves's disease, in which the visible parts of the orbit are not only not more vascular, but often positively paler or less vascular than in health. Why there should be, in this di-^ease, an increase of orbital fat, is a question that cannot at present be answered. But we do know, at any rate, that there is in Graves's disease a tendency to local deposition of fat in other parts of the body, such as the face and anterior abdominal wall. EXOPHTHALMIC GOITRE. 183 It is not unreasonable to assume that the same cause that leads to local deposil ion of fat in these regions may also cause it& deposition in the orbits. The theory that the exophthahnos is due to spasm of muscle is wholly insufficient to account for the amount of exophthalmos that is generally present in an ordinary case of Grayes's disease. A yery common, if not constant, accompaniment of the disease, is a great enlargement of the thymus gland, ^yhich forms a thick solid mass, sometimes weighing several ounces. This enlargement may be detected, during life, by careful per- cussion oyer the upper part of the sternum. The pathological significance of this undue persistence and enlargement of the thymus is unknown.* Symptoms and Diagnosis. — The three cardinal symptoms of Grayes's disease are : (1) Prominence of the eyeballs (exophthalmos). (2) Rapidity of the heart (tachycardia) with palpitation. (3) Enlargement of the thyroid gland (goitre). In most cases, howeyer, some or all of the following symptoms are also present. (4) Neryous symptoms, especially tremulousness and excit- ability ; often the patient shows a marked change of habits and tastes, and a condition resembling acute mania is by no means unknown. (5) Diarrhoea. (6) Glycosui'ia. (7) Pigmentation of the skin, usually of a patchy nature. (8) Local accumulation of subcutaneous fat, especially on the anterior abdominal wall, (9) Sweating, and consequent lessened electrical resistance of the skin. (10) Breathlessness. (11) Slight eleyation of temperature. The clinical picture presented by a patient in the advanced stages of the disease is usually quite characteristic, and there is * Good specimeus of thi^^ enlargement of the tliATQUS may be .^een in the following museums : St. Mary's Hosp. 1025 ; Univ. Coll. Hosp. 13.58D ; St. Thos. Hosp. 1-KJ5A : St. Bart. Hosp. 2314T and 2314r. 184 THE THYROID GLAND. i]o dirticulty in the diagnosis. {Sec Fig. 70.) In some cases, however, one or more of the three cardinal symptoms is absent, and then there may be much difficulty in the diagnosis. The enlargement of the thyroid may be so slight as scarcely to attract attention. Even when it is well marked there are no meann bij ic/iieh ice can dlst'ing'ui.sk it ic'itli eerta'intij from the simple parenchymatous enlargement. The gland usually presents a somewhat smoother and more rounded surface, and, occasionally, a feeling of firmness, of plumpness and solidity has seemed to me to afJbrd help in the diagnosis. Pulsation in the gland, and the presence of a bruit are not in themselves charac- teristic, since they are often found in parenchymatous goitres. A thrill is often felt. It is important to bear in mind that the increased pulsation of the thyroid vessels is not greater than that of the other vessels in the body. The exophthalmos is almost invariably bilateral and sym- metrical. Cases of unilateral exophthalmos due to Graves's disease are, however, said to occur ; but such cases have never come under my notice. Exophthalmos is by far the most characteristic symptom of the disease, although its presence is not absolutely essential for the diagnosis. When exophthalmos is absent the diagnosis is much more difficult. Ordinary parenchymatous goitre is fre- quently accompanied by cardio-vascular symptoms. Persistent frequency of pulse with goitre is sufficient to raise a strong suspicion of Graves"'s disease, and a careful examination should, in such cases, be made to see whether any of the other symptoms exist. It is in the early stages of the disease that the diagnosis is most important, especially from the surgical point of view. I have several times seen, and successfully operated upon, patients with goitre and rapidity of pulse, who had been considered, erroneously, to be suffering from Graves's disease. Probably, many of the reported cases of cure after operations for atypical Graves's disease (the ^o-CQS\&d^formeHf rusted of the French) have not Jbeen cases of Graves's disease at all. This may account for the cures. On the other- hand, it is important that the surgeon should not overlook the existence of this disease in its early stage. By doing so, he may make the serious mistake EXOPHTHALMIC GOITRE. 185 of undertaking to treat, by surgical means, a goitre which probably ought not to be interfered with. In the absence of exophthalmos, the persistently rapid pulse, the clammy, tremulous hand, and the fidgety, nervous manner of the patient afford, according to mv own experience, the best means of diagnosis. Dyspnoea is of course a common .symptom in both parenchy- matous and exophthalmic goitre. In the former disease, however, the dyspnoea is alwavs produced by direct pressure on the trachea, and is accompanied by stridor. In the latter, the dyspnoea appears to be due to cardio-vascular changes. An exophthalmic goitre only rarely produces an appreciable degree of pressure upon the trachea, and is consequently not usually accompanied by stridor. There are, however, rare cases in which an exophthalmic goitre does cause serious pressure upon the trachea and it may even become necessary to perform tracheotomy for the relief of the dyspnoea. At the meeting of the Pathological Society of London, held on INIarch 3, 1891, Mr. W. G. Spencer showed a specimen of exophthalmic goitre which had caused death by suffocation. The patient was a girl, aged 20, who had suffered for at least a year from the ordinary symptoms of exophthalmic goitre, namely, prominence of the eyeballs, rapidity of pulse, and thyroid swelling. Dyspnoea became so severe that tracheotomy had to be performed; this was attended with much difficulty; the trachea was opened above the isthmus, and an elastic tube four inches long had to be passed down the trachea beyond the obstructed portion before relief was afforded. In a few hours the dyspnoea returned, the patient was unable to expectorate through the tube, and death occurred, apparently by suffocation from the accumulation of mucus in the trachea and bronchi. The goitre, which is at present in the Westminster Hospital Museum,* was a large bilateral one, tolerably homogeneous in structure, but differing from most exophthalmic goitres in con- taining much fibrous tissue and numerous small cysts. None of these, however, are larger than small peas. The trachea was greatly flattened from side to side down to within an inch of * No. (309. 186 THE THYROID GLAND. the bifurcation. The presence of cysts and of much fibrous tissue, and a history of the goitre having been present for very manv years (" all her life," it was alleged), show that this case was not entirely typical. It is quite possible that this was really a case of ordinary parenchymatous goitre to which Graves's disease had recently been added. In the Lancet of February 7, 1891, Dr. Hugh Montgomerie reported " a case of exophthalmic goitre, ending fatally from sudden pressure on the trachea," in a woman of thirty-five. In this case also the goitre was unusually large, and the symptoms do not seem to have been very characteristic of Graves's disease. A low tracheotomy was performed, but without success. A post-mortem examination revealed extreme tracheal stenosis ; the goitre was not a symmetrical enlargement of the thyroid, showing that the case was not one of pure exophthalmic goitre. Treatment. Medical. — Numerous drugs have been recom- mended for the treatment of this most troublesome malady, but none of them can be considered to be thoroughly satisfactory. Most of them do not do more than alleviate symptoms, especially the palpitation. Something can be done by such hygienic measures as rest and change of surroundings. Removal to a higher altitude often causes considerable relief. Digitalis is often given to quiet the circulation and diminish palpitation. Belladonna appears to be useful sometimes ; it may have some effect in diminishing the thyroid secretion. Thyroid extract has also been given, but it seems clear that it not only does no good, but is positively harmful. This is only what might be expected if the disease is due to over-activity of the gland. Thymus feeding has also been tried, but with doubtful benefit; the undoubted connection between enlargement of the thymus and Graves's disease is, however, worth remembering in con- nection with this method of treatment. Ord and Hector Mackenzie, having made an extensive trial of thymus gland preparations in twenty cases, came to the conclusion that " no appreciable effect followed their administration.* Iodine and its preparations, so potent in the treatment of * Clifford Allbutt's " System of Medicine;' 1897, vol. iv., p. 507. EXOPHTHALMIC GOITRE. 187 parenchymatous goitre, are not only useless in Graves's disease, but usually aggravate the symptoms. Mobius speaks highly of the value of bromine preparations.* Iron is sometimes beneficial, and seems to be indicated in cases in which there is marked anaemia. The application of cold to the neck by means of Leiter s tubes appears to relieve the patient's distress in many cases, but does not exert anv curative* effect upon the disease. Treatment by electricity, both galvanic and faradic, has been strongly recommended, but does not seem to be of any more use than other remedies. A strong current may have some bene- ficial influence upon the patient's mental condition. The medical treatment of a case of exophthalmic goitre does not, however, come within the province of a surgeon, who is content to hand the case over to a physician. For further details of the medical treatment, about which volumes have been written, a Avork on medicine must be consulted. Surgical. — Although, in my opinion, the treatment of exoph- thalmic goitre belongs essentially to the physician and not to the surgeon, it is right that some account should here be given of the various forms of surgical treatment that have been from time to time adopted by surgeons. Especially in the last few years has surgical treatment been recommended and practised by some surgeons. The different forms of operative treatment that have been employed for exophthalmic goitre may be divided into the following groups : 1. Operations upon the thyroid gland itself. 2. Operations upon the thyroid vessels. 3. Operations upon the cervical sympathetic nerve. 4. Operations upon distant parts of the body. 1. Operations upon the Thyroid Gland. — Most of the oper- ations that have been practised for parenchymatous goitre have also been employed for exophthalmic goitre. Those, such as injection with iodine, which act by causing inflammation and obliteration of the vesicles, are not suitable, for the simple reason that in this disease we are not dealing with distended vesicles at all, but with a condition of epithelial proliferation. The absence of colloid in an exophthalmic goitre renders * Arcli.f. Esychiat., Berlin, 1898-9, xxxi., p. 923. 188 THE THYROID GLAND. division of the isthmus also a futile operation ; the shrinking of a parenchymatous goitre after division of the isthmus is due, as is shown elsewhere, to the draining away of the con- tents of the vesicles. In an exophthalmic goitre there is no accumulated colloid that can be drained awav. P'or a similar reason intraglandular enucleation, so excellent for the treatment of manv simple goitres, is not applicable here, because there are here no encapsuled tumours, and it is upon these alone that enucleation can be performed. In those atypical cases in which Graves's disease has been superadded to a pre- existing adenomatous or cystic goitre, enucleation of these tumours can, of course, be performed. Removal of a portion of the goitre bv the operation of "extirpation'' is feasible, and has been frequently performed. Much difference of opinion exists as to the value of this proceeding. Those who believe that Graves's disease is due primarily to an affection of the thyroid gland, and especially those who look upon the disease as being due to a hypersecretion of the thyroid epithelium, have naturally some a jjriori grounds for believing that removal of a portion of the gland might benefit the patient. Total extirpation of the gland has been performed, but it is agreed by all that this is neither necessary nor desirable, seeing that very serious results (cachexia strumipriva) follow this oper- ation, whether performed for exophthalmic or for any other kind of goitre. The operation that has most often been performed is removal of one half of the gland. It appears that good results have in some cases been obtained by this operation. On the other hand, it must be admitted that the operation is an extremely serious one. The mortality of unilateral extirpation for exophthalmic goitre is far higher than is that of the same operation when performed for simple goitre. Valuable information on this point has been afforded by Allen Starr,* who has collected from various sources 190 casesf of * " On the nature and treatment of exophtlialniic goitre with especial refer- ence to the thyi'oid theory of the disease and to the treatment by thyroidec- tomy," Med. News, Philadelphia, 1896, 68, p. -121. f All these operations were performed in or before 1895. These cases, how- ever, include a certain number of operations, such as ligature of the thyi'oid arteries, in which no part of the goitre was actually removed. EXOPHTHALMIC GOITRE. 189 operations upon exophthalmic goitre ; of these no less than 23 ended fatallv immediately after the operation. This mortality of 12 per cent, compares most unfavourablv with the mortality of 3^ per cent, afforded bv Reverdin"s statistics of extirpations of simple goitre. Sorgo"s statistics* embrace 174 operations performed in the years 1884-96. In two cases the result was not known. Of the remaining 172 patients, 27 (15'2 per cent.) were "much im- proyed," 62 (36 per cent.) were "distinctly improyed '" ; [that is, 89 (51 "2 per cent.) were improyed] -±8 (27'9 per cent.) were "cured,"" 11 (6"4 per cent.) were not improyed or were made worse; while 24 (13'9 per cent.) died soon after the operation. It is said that if the cases of so-called primary Grayes's disease are separated from those of secondary disease, the statistics are not materially altered. Mobius considers that in most cases " the operation will pro- bably result in comparatively rapid improyement, but that it is not without danger." With the latter part of this opinion I certainly feel disposed to agree. Even in the hands of the most experienced operators upon goitre, such as Kocher, the mortality is considerable. It would appear that Kocher has abandoned the operation of extirpation for exophthalmic goitre in favour of ligature of the thyroid vessels. It is not that the operation is in itself more difficult. But the patients are not good subjects for such an operation. They are especially liable to die from shock or from extreme rapidity of pulse. For these reasons I have myself never performed removal of an undoubtedly exophthalmic goitre and am of opinion that its performance should as a rule be restricted to those rare cases in which there is serious tracheal stenosis, threatening the life of the patient. Even in these cases it seems doubtful whether tracheotomy is not sometimes a safer proceeding. The operation of exothyropexij has been performed many times, especially in France. TTiis operation consists in cutting- down upon the gland, dislocating it through the wound and then leaving it exposed to the air. The effect of the operation is to cause a certain amount of shrinking of the gland. The * Quoted by Mobius. hjc cit. p. 922. 190 THE THYROID GLAND. risks of the proceeding and the extremely unsightly nature of the resulting deformity are, in the absence of any strong proof of its efficacy, sufficient to warrant its condemnation.* 2. Operations upon the Thyroid Vessels. — Ligature of the thyroid vessels has often been performed for exophthalmic goitre in the hope that cutting ofp the blood supply will cause the gland to shrink and produce less colloid secretion. Ligature of the superior thyroid vessels alone, which are usually much smaller than the inferior, is an easy operation, but does not cut off enough of the blood-supply to be of any real use. Ligature of the inferior thyroid vessels on one or both sides adds considerably to the difficulty and severity of the operation. I^igature of all four arteries probably entails a risk of the supervention of cachexia strumipriva. Ligature of both superior thvroids and of one inferior thyroid appears to be the best operation and is the one preferred by Kocher. This operator has performed ligature of the thyroid vessels for exophthalmic goitre over thirty times. 3. Operations upon the Cervical Sympathetic Nerve. — The operations that have hitherto been performed upon the cervical svmpathetic nerve include : (1) Simple section of the nerve (sympathicotomy or Jaboulay's operation). (2) Partial resection, the superior cervical ganglion being- resected, either alone or together with the nerve trunk. (3) Complete and bilateral resection of the whole nerve and all its ganglia. These operations appear to be founded partly upon the view that the primary seat of Graves's disease lies in the cervical svmpathetic nerves or ganglia, and partly upon the widespread but erroneous idea that the enlargement of the thyroid and the exophthalmos are due to the increased vascularity in the gland and in the orbit respectively. There is no doubt that there is a connection between exophthalmos and the sympathetic, but it is by no means clear that the exophthalmos of Graves's disease is dependent upon this nerve. The researches of Jessop upon the action of cocaine have shown that the instillation of cocaine into the eye produced * For further details of this operation see chap. xv. p. 244. EXOPHTHALMIC GOITRE. 191 among other effects, exophthalmos and enlargement of the palpebral fissure. It has further been shown bv Jessop and by Edmunds that previous division of the cervical sympathetic prevented the occurrence of these phenomena. Jaboulay of Lyons appears to have been the first to apply these facts to the treatment of exophthalmic goitre in the human subject. His first operation was performed in February 1896, and his example was rapidly followed by others. The results being, however, not so good as had been anticipated, a further step was taken and in August 1896 Jonnesco of Bucharest excised the superior cervical sympathetic ganglion together with part of the main nerve trunk. This operation in its turn appearing to be insufficient, the total excision of the whole of the cervical sympathetic including its ganglia on both sides of the neck was introduced and is at the present time advocated by Jonnesco and others. Whether the theories upon which these sympathetic operations are based be right or wrong, it is well to inquire whether the results obtained by the operations are sufficiently good to justify their performance. Boissou, in his admirable thesis* on the subject, has collected twenty-seven cases of operations of one kind or another upon the sympathetic nerve for the cure of Graves's disease. These cases include nearly all the published and some hitherto unpublished cases, up to the date of July 1898. Full details of nearly all the cases are given in his essay. From these twenty-seven cases, four must be deducted since they prove nothing and are valueless for our purpose. Eight of the remaining cases are atypical (cas frustes) and should be put aside as inconclusive. Among the remaining fifteen cases there appear to have been two cases of cure, six of " marked improvement," three of slight improvement, one of failure and three of death. With regard to the eight atypical cases, one is reported to have been cured, two markedly improved, four slightly improved, while one was a failure. * •• Etude critique des iuterventious sur le sympathique cervical dans la maladie de Basedow," Paris, Henri Jouve, 1898. 192 THE THYROID GLAND. Among" the twentv-three cases there were thirteen partial sympathectomies (includino- the three reported cures and one death), seven total sympathectomies (with two deaths), and two sympathectomies (with no cures and no deaths). The two cases of cure are the following, both of which occurred in the practice of Jonnesco : * 1. A widow aged 30 had noticed for two months a swelling of the thyroid gland. On admission there was some exophthahnos and a pulse of 110-120. Graefe's sign was not present. There was some trembling of the upper limbs and the patient was in a nervous, excitable condition. On August 5, 1896, bilateral resection of the cervical sympathetic was performed, but the inferior ganglia were not removed. The wound healed by first intention and the patient left the hospital ten days after the operation. The imme- diate results of the operation do not appear to have been very striking. The jjulse remained at 120, but the exophthalmos dis- appeared. The trembling had also gone when the patient left the hospital. A month later the circumference of the neck had diminished from 37 to 35 centimetres. Fifteen months later the general condition was reported to be excellent ; there was no longer any goitre, exophthalmos, tachycardia, or trembling. The pulse rate was 74-80. 2. A girl aged l6 was admitted on account of goitre, exophthalmos, trembling, and a rapid pulse (110-120). On August 21, 189^, the whole cervical symj^athetic, except the inferior ganglion, Avas resected on both sides of the neck. The Avound healed by first intention and the patient left the hospital nineteen days after the operation. The exophthalmos diminished immediately, but the pulse remained at 110-120. When last seen, fifteen months after the operation, the exophthalmos and tachycardia had entirely dis- appeared, the pulse Avas regular, beating at 90, and the patient's general condition Avas excellent. The three fatal cases described by Boissou occurred in the practice of Jaboulay, Faure and Peugniez respectively .f 1. A woman aged 30 with exophthalmic goitre of tAvo years duration. Goitre, exophthalmos, tachycardia and trembling Avere all well marked. The pulse rate was 128-155. On Nov. 24, 1897, three centimetres of cervical sympathetic were resected on * Keported in Boissou's thesis above-mentioned, cases xi. andxii. pp. 148-1. ■')4. f Boissou, loc. c'tf., cases s. , xyiii. and xxAii. pp. 114, 175 and 206. EXOPHTHALMIC GOITRE. 193 each side of the neck. On one side the superior ganglion was removed, on the other it was not. After the operation the pulse rate was 120. On the following day the temperature rose to 104-5 and the pulse became bad. On the next day blood-stained expectoration and vascularity of the right conjunctiva were noticed. The exophthalmos diminished. In the next few days the pulse rate was 90-105, and the temperature about 101^. On the twelfth day after the operation the patient died. The post mortem showed congestion of the base of the right lung. 2. A woman aged 24, with all the usual symptoms very well marked. The whole of the right cervical sympathetic, including both superior and inferior ganglia, were removed and the operator had made the skin incision on the left side when the patient suddenly died. The post mortem threw no light on the cause of death, which seems to have been attributed to the chloro- form. 3. A woman aged 20 in whom exophthalmos, tachycardia and goiti'e were all marked. The symptoms had lasted about four years. Resection of the whole cervical sympathetic was performed, first on the left side then on the right, with an interval of twenty- three days between the two operations. After the first operation the exophthalmos of the corresponding side diminished considerably. The tachycardia, however, did not alter, the pulse remained at 144. After the second operation the pulse dropped to 128. Both wounds healed quickly, and the patient left the hospital apparently slightly improved. The improvement did not last very long, for on the day after her discharge from the hospital, twenty-four days after the second operation, she complained so much of feebleness and pain in the precordial region that she took to her bed and never again left it. Violent pain in the head and eyes, vomiting and extreme emaciation now became prominent symptoiTis. A week after leaving the hospital the exophthalmos was very marked, but the eyelids could still be closed. Soon the exophthalmos was so extreme that the patient became completely blind in both eyes, the left eyeball ulcerated and then collapsed, with discharge of the crystalline lens. Finally the patient died comatose on the fiftieth day after the operation. A careful study of the cases which are reported to have been "improved" does not seem to be at all convincing. Sometimes one symptom, sometimes another is said to have been alleviated. Sometimes the beneficial effect is said to have been noticed 194 THE THYROID GLAND. immediately after the operation, more often the ameHoration has occurred only after a lapse of weeks or months. The cases in which improvement is most likely to occur seem to be those atypical cases to which the tevxw formes Ji'ustes is applied by the French. In many of these cases, however, grave doubts exist as to the correctness of the diagnosis. For statistical purposes, it is best to omit such cases altogether from our con- sideration. Certainly it is not right to include them among the typical cases, the diagnosis of which shotdd be a matter of little or no difficulty, and from which alone conclusions of value can be deduced. 4. Operations upon Distant Parts of the Body. — Many years ago it was noticed that the removal of a polypus from the nose of a patient suffering from Graves's disease was followed by an amelioration of the symptoms of the latter disease. The same sequence of events has been noticed after operations on other parts of the bodv. Boissou * has collected no less than seventy- three cases of Graves's disease in which improvement or cure had followed an operation upon some distant part of the body such as the nasal fossae, the genito-urinary organs, abdomen, etc. I have myself, however, had no personal experience of such cases. Prognosis. — In considering the advisability of a surgical opera- tion for any disease, it is well to ask what would be the course of that disease if no operation at all were performed. Now, in the case of exophthalmic goitre the prognosis, if the disease be not treated by operation, is by no means wholly bad. Although in a few cases the disease ends speedily in death, yet such a termination is the exception rather than the rule. The careful inquiries that have been made by Williamson ,j" of Manchester, supplemented by those of Ord and Hector Mac- kenzie, have put us in possession of valuable information as to * 43 cases of Jouiu. 5 of Stocker, -t of Teilliaber, 3 of Van der Lenden, 3 of Fedei-n. 2 of Leflaive, 2 of Odeije, 2 of Bouilly, and those of Hack. Hoffmann, Fraenkel, Gottstein, Muschold, Picque, Turgis, Doleris, and Berger. quoted by Pierre Boissou in his " Etude critique des interventions sur le sympathique cervical dans la maladie de Basedow." Paris. 1898. p. 15. t "Eemarks on Prognosis in Exojjhthalniic goitre," hy E. T. Williamson, JBrlt. Med. Jum-n., Nov. 7, 1896, p. 1373. PLXOPHTHALMIC GOITRE. 190 the ultimate result of a large number of cases, none of which were treated by operation. Taking into consideration only those cases which ended either in death or recovery, or which had been under observation for at least five years, the figures of the two sets of observers * are as follows : EESULT IX FIFTY-SEVEX CASES. Or Fatal termination . . . Recovery complete . . . Recovery almost complete Improvement considerable Improvement slight In statu quo ... Alive, but exact condition not known ckenzie Williamson Tota 8 6 14 5 5 10 9 2 11 9 4 13 1 S 4 1 3 4 Conclusions. — Reviewing the whole subject of the operative treatment of exophthalmic goitre, it seems to me that it may reasonably be doubted whether surgical treatment is not on the whole worse than useless. For it must not be forgotten that in this disease there is naturally a strong tendency towards recovery. Many patients who do not recover completely, nevertheless improve greatly without operative treatment of any kind. None of the operations that have hitherto been practised upon the gland, the thyroid vessels or the sympathetic are free from risk. Actual proof that any of them really cure the disease is at present wanting. The sympathetic operation, although it may, and probably does to a slight extent, diminish the exophthalmos, does not usually cure it completely, and may be followed by very serious results, such as inflammation of the eye and even blindness. The larger operations upon the gland itself, such as extirpa- tion, are attended with so much danger as to make them un- desirable, unless it can be shown that the results are sufficiently good to justify the risks. At present this has not been done. Given in Clifford Allhutt's " System of Medicine," 1897, vol. iv, p. .501. lf)6 THK THYROID (xLAND. AVith regard to ligature of the thyroid vessels, it still seems to me doubtful whether this proceeding is followed by cure sufficiently often to justify its performance. There seems to be no doubt that if any of the above operations are undertaken by the surgeon, thev should be performed in most cases without general anaesthesia, and that they should be performed with as little disturbance as possible to the surrounding parts. CHAPTEK XIII. MALIGNANT DISEASE AND ITS TREATMENT* Aiiects both uormal and goitrous thyroid — Age — Sex — ^^'aiueties — Sar- coma and carcinoma — Eehitive frequencj" — Spuptoms and diagnosis — Infiltration of neighbouring parts — Skin rarely involved — Duration of the disease — Mode of death — Unusual forms of malignant disease — •• Malignant adenoma " — Papillif erous cyst — Treatment — Extirpation Difficulties and dangers — Often incomplete — Results of operations — Eecurrence — Statistics — Slowly growing forms — Palliative treatment — Partial removal — Simple incision — Tracheotomy — Difficulties — Danger of sepsis — Treatment of dysphagia and pain — Conclusions. Maxigxaxt disease of the thyroid gland is in this country a somewhat rare affection. It is fortunate that it is rare, since in the stage at which it is usually seen by operative surgeons it is seldom amenable to surgical treatment. The disease may occur in a gland that has previously been normal, but it is much more prone to affect one that has already been the seat of innocent goitre. This is doubtless the reason why the disease is much more commonly seen in localities where ordinary goitre is prevalent. E^"en in cases in which there is no history of pre-existing goitre it will often be found, upon examination after removal, that the tumour contains cysts, points of calcification, or some similar evidence of former disease. In several cases, however, which have come under my own notice, or which I have examined in museums, evidence of the previous existence of a goitre has been wholly absent. Age and Sex. — The disease is essentially one of advanced life, being rare below the age of forty. Out of thirty-four specimens of malignant disease in the London museums, in which the age * Most of tills chapter has akeady been published in the chapter on the th\Toid contributed b}- me to the recently f)ublished edition of Mr. Butlin"s •• Operative Surgerj' of Malignant Disease.'' 198 THE THYROID GLAND. of the patient is stated, I have fouml oulv three in which the age was below thirty-nine, and of these, one is a somewhat doubt- ful cono;enital sarcoma in an infant ; another is from a bov ao;ed three, and it is open to doubt whether the growth, described as a round-celled sarcoma, was not secondary to disease of the abdomen. The third specimen is in the Roval Free ]\Iuseum, and is from a patient of my own, aged 25, depicted in Fig. 77. Here and there in surgical literature are found cases in which the disease occurred in children or voung adults, but certainly in the great majority of cases the patients have attained at least the age of forty. Among fifty cases of undoubted malignant disease that have been published since 1884, I find onlv eight in which the age was below forty. In no less than twenty-four of these cases the age was fifty or more : of these, twelve had attained the age of sixty. As regards the frequency with \\hich the disease affects the two sexes there is not much difference. Some observers have found that males were affected rather more often than females. I\Iy own statistics show that of the fifty patients above-mentioned twenty-seven were women ; among thirty-nine specimens in the London museuiiis, seventeen are from male and twenty-two from female patients ; a very small number of cases overlap, and occur in both sets of figures. Bergeat says that of fifty-five cases seen at Tubingen between 1883 and 1894, twenty-three were men and tweutv-nine women, but the diagnosis was not in all cases verified. Varieties. — Both carcinoma and sarcoma occur in the thyroid o'land, the former beino; usually of the alveolar form with cubical cells, the latter either spindle- or round-celled. Various other rare varieties have occasionally been described but are not of sufficient importance to require further consideration here. It is exceedingly difficult to arrive at a definite conclusion as to the relative fi-equency of sarcoma and carcinoma. !Most writers have asserted that carcinoma is a good deal more common than sarcoma. Thus Kaufmann"' among fourteen cases examined microscopically by him in S\\itzerland, found that ^ ■• Die Struma Malisrna." Dciii-.^rh. Zeitsrh r.f. Chh-.. 187ii. xi. 4nl. MALIGNANT DISEASE AND ITS TREATMENT. 199 eleven Avere carcinoma and only three were sarcoma ; and subsequently he published six more cases all of Avhich were carcinoma. Orcel, in his excellent thesis,* gives details of sixteen cases of malignant disease observed at Lyons, a place where endemic goitre is frequently seen. Rejecting one of these, in which the proof of malignancy does not appear to be convincing and omitting five others which, although undoubtedly malignant, do not clearly indicate whether the disease was sarcoma or carcinoma, there remain ten cases ; of these five Avere sarcoma and five carcinoma. Of fifty-four specimens in London museums, twenty are sarcoma and thirteen are carcinoma, while of twenty-one, owing to want of proper microscopical examination, it is impossible to express a definite opinion. Among fifty undoubted cases found in literature published since 1884 (including Orceins ten cases) I find twenty-six sarcomata and twenty-four carcinomata. These last two sets of figures, however, probably do not represent the true proportions, since the rapidly growing form of sarcoma is a more striking affection than the ordinary form of carcinoma, and is, therefore, more likely to find its way into museums and into literature. In compiling the above statistics, I have felt obliged to reject a very large number of cases which in all probability were malignant, because the proof of this was wanting. Those cases only have been accepted as genuine in which such proof was clearly afforded either by accurate microscopical exami- nation or by evidence of local infiltration, or of secondary deposits. The difficulties which surround the whole subject are consider- able, since cases are frequently met with both in literature and in museums in which an obvious sarcoma is described as car- cinoma and vice versa. Instances are not unknown of simple adenoma being described as carcinoma, while obviously malig- nant infiltrating tumours have been pronounced to be adenomata. Even those who have had large experience in the microscopic examination of thyroid tumours will admit that it is often difficult to say where adenoma ends and carcinoma begins. * " Contribution a Tetude du cancer du corps thyroide," Lyons, 1889. 200 J'HK THYROID GLAND. .= c a . o = o .- MALIGNANT DISEASE AND ITS TREATMENT. 201 Chronic inflammation has before now been mistaken for sarcoma, as Tailhefer and Riedel have shown. Symptoms and Diagnosis. — CHnieally, it is very difficult to distinguish between sarcoma and carcinoma. In many cases it is not possible to do more than guess at the probable histological nature of the malignant growth. I shall, therefore, treat of them together, merely prefacing my remarks by saying that if the tumour has grown very rapidly, and is limited to one lobe of the gland, the disease is more likely to be sarcoma ; while if the affection, at a comparatively early stage, involves both lobes and pursues a somewhat slow course, it is not unlikely that it will prove to be carcinoma. Ex- ceptions to both these rules are, however, by no means uncommon. In its earliest stages, while the growth is still confined within the capsule of the gland, there are no means by which Ave can make a certain diagnosis of malignant disease. When, hozcever, in the thyroid gland of a person over forty, a tumour appears which is hard, which steadily and rapidly increases in size, and which is not of an inflammatory natiwe, the malignancy of such a tumour shoidd he strongly suspected. If, moreover, the surface of the tumour is irregular and bossy,* and if there is likewise dysphagia and pain in the neck, shooting up to the side of the head, or to the shoulders, then the diagnosis becomes almost a certainty. It is of the utmost importance that the diagnosis should, if possible, be made at an early period, since it is then alone that operative treatment can be adopted with a reasonable prospect of success. A little later, when the growth has penetrated the capsule, and begun to involve surrounding structures, various other signs appear which make the diag- nosis much less difficult. The vocal cord on the corresponding side often becomes paralysed, a condition rarely seen with innocent goitre. Involvement of the trachea, Avith pene- tration of its lumen by the growth, is very common, and is abundantly illustrated by specimens in museums. {See Figs. 78 and 80.) This penetration of the interior of the trachea is most common at a point about half an inch below the cricoid, and often takes * Figs. 75 aud 76 show well the bossv nature of a malignant tliyroid tumour. 202 THE THYROID GLAND. the form of a small prominent, sometimes even pedunculated, button of growth. It occurs both in sarcoma and carcinoma. Occasionally, a considerable length of the tracheal mucous mem- brane is involved, as in the specimen depicted in Fig. 80.* Involvement of the muscular wall of the pharynx is very I'lG. 77. — Spiiidk'-CL'llua Sarcoma of the left Lobe of the Tli.vroid. The position of the hiryus is sliowu by a slight swelling more than one inch to the right of the middle line. Trom a patient, aged 2-5, who had fli'st noticed the lump in his neck three months before the photograph was taken. The growth snrrotiiidcd the carotid artery and was too extensile to permit of any attempt at removal. Tracheotomy soon became necessary. {See Royal Free Hosp. Mns. Xo. xxii. 54.) common, but actual penetration of its mucous membrane is rare. There are but two specimens of this latter condition in the London museums. Kaufmann, in the cases collected by * From a specimen in the Mu^ieum of the Eoy. Coll. of Surg. No. 2907. For other specimens of penetration of trachea or larynx, see St. Bart. Hosp. Mus. No. 23190 ; St. Thos. Hosp. Mus. Nos. 1470A and 1472 ; Westm. Hosp. Mus. No. fil2. MALIGNANT DISEASE AND ITS TREATMENT. 203 him, found but one instance in which the mucous membrane was penetrated. Displacement, curving, twisting and flattening of the trachea, although common enough in cases of malignant disease of the thyroid are not more characteristic of malignant Tig. 78. — Spindle -cellod Sarcoma of the 'Diyi'oid, showing- the manner iu which the "TOfltli h;is extended behind tlie a«opli;igus and between it and the trachea, a. Larynx laid open from behind, b. Trachea surrounded and compressed by tumour, c. Remains of tliyroid tissue more or less healthy, d. Right lobe of thyroid infiltrated with sarcoma. E. Sarcoma extending- between tracliea and oesophagus (f). g and h. Riglit and left carotid arteries surrounded by gTowth. i. Aorta, k. Tracheotomy wound. (See Appendix, Case 113, p. 352, and Roy. Free Hosp. Mus. No. xxii. 55.) (8edu.ced ^.) than of innocent goitre ; indeed, the tendency of the former to infilti-ate, rather than to push aside, causes the displacement or deformity of the trachea to be less marked. On the outer side, the growth tends to become adherent to the carotid artery and internal jugular vein. The relation of -204 THE THYROID GLAND. the carotid to the tumour may afford valuable evidence of malignancy. An innocent goitre in its growth usually displaces the artery, outwards and backwards ; a malignant tumour tends to infiltrate, to overlap and surround it, without causing so much displacement. The artery can often be traced by its pulsation, running as far as the tumour, into the interior of which it seems to disappear. Paralysis of the sympathetic, shown by a contracted pupil and narrow palpebral fissure, is not uncommon. {See Fig; 81.) Fig. 79. — Microscopical section of a Careinoraa attacking- an old ooitre wliich has also nndergone mnch fibroid degeneration. ( x 130 diam.; Fixity of the tumour is an important and a very bad sign. It is well to bear in mind that a malignant tumour that has not become fixed to such immovable structures as the sternum, clavicle, vertebrae, or the larger muscles of the neck, may follow the movements of the larynx and trachea with tolerable freedom and yet may be hopelessly incorporated with the latter, or with the wall of the pharynx. Many a time has an operator, deceived by this apparently free mobility of the tumour, been led to undertake an operation for its removal, only to find, when too late, that the adhesions on the inner side were so extensive that complete removal was impossible. MALIGNANT DISEASE AND ITS TREATMENT. 205 Involvement of skin and of lymph glands afford but little help in the diagnosis. The skin is seldom involved, even in late stages, except in those cases in which the growth has been punc- tured or incised. Exceptionally, spontaneous ulceration of the skin takes place and may be the immediate cause of death, as in the following case : Harriet F ^aged 53, was admitted to the Royal Free Hospital under my care on March 2, 1899- Since childhood she had had a swelling in the neck, as lai'ge as a walnut. It had never caused her any trouble until November 1898, when it suddenly began to grow. It continued to increase steadily, but gave her no pain and caused little or no trouble in breathing or swallowing. The condition on admission is shown in Figs. 15 and 76. A large, hard, irregular, prominent tumour occupied the front of the neck and involved both lobes of the thyroid gland. The carotid could be felt indistinctly on the right side, not at all on the left. The diag- nosis of malignant disease was obvious, and owing to the fixity and extent of the tumour, operation for its removal was out of the question. On March 12, she returned to her home, being told to come up again if her breathing gave her trouble. In April she was seen again. She was much thinner and weaker, and the tumour had grown considerably, but there was very little dyspnoea. The skin over the tumour had recently ulcerated. The tumour grew to a very lai*ge size, the ulceration extended and was accompanied by very foul discharge. The patient gradually sank and died at home on July 7, 1 899^ of sepsis and exhaustion. Dyspnoea never became sufficiently bad to call for tracheotomy. The post mortem showed a spindle-celled sarcoma.* Out of some thirty cases that have come under my own notice during life, there was not a single one in which affection of glands afforded any material help in the diagnosis. By the time that enlargement of the glands can be detected, the nature of the disease is usually sufficiently obvious ; it must be remem- bered that the glands that first become affected are usually very deeply seated, at the root of the neck, or behind the sternum, where their detection is well nigh impossible. I have also been very much struck by the number of cases, especially * The tumour is uow iu the Royal Free Ho -p. Mus.'No. xxii. 53. 206 THK THYROID GLAND. of sarcoma, in museums, in literature, and in my own practice, in which affection of lymphatic olands was wholly absent, even in the latest stages of the disease. Expectoration of blood is an unusual symptom ; it generally occurs late and is of grave import, indicating probable penetration of the trachea, or, possibly, secondary growth in the lungs. Occasionally, it would seem to be a com- paratively early sign. In a case of carcinoma, recorded by Mr. Shattock, severe htie- moptysis occurred ten months before death, and seems to have been one of the first symptoms.* The course of malignant disease of the thyroid is usually very rapid. Rose, of Berlin, has estimated that theextreme limits of its duration are nine weeks and eighteen months, and in the main he is certainly correct. Many cases run their whole course within six months. One of the shortest cases that I have myself seen was that of a sarcomatous tumour in a gentleman, aged 68, under the care of Mr. Edgar Willett. When I first saw the patient, the tumour had been noticed only four weeks. It was already «o fixed as to be hopelessly irremovable. No operation of any kind was attempted ; the disease made rapid progress, speedily involved the lungs with secondary deposits, and death occurred within three months from the time of the first appearance of the tumour. The case depicted in Fig. 77 (p. 202) also ran a very rapid ■ * St. Thos. Hosp. Mu^. No. 1472. Fig. 80. — Vcvticiil Mediuu Section' tliroiii;ii Larynx, Trachea, Thyroid Gland, &c., showiu.o- malignant disease fungating' into the interior of the trachea in its upper two- thirds. (From a specimen in the Key. Coll. of Surg. Xo. 2907.) MALIGNANT DISEASE AND ITS TREATMENT. 207 course and is further remarkable for the unusual youth of the patient : Charles K , aged 25, was admitted into the Royal Free Hospital under my care in July 18, 1899:, on account of the tumour shown in the photograph. Three months previously he had first noticed a slight swelling on the left side of the neck. It gave him but little trouble and he paid no attention to it until a fortnight before admission, when it began to grow rapidly. Slight dyspnoea, dysphagia, and huskiness of voice were then noticed for the first time. On admission, a hard irregular tumour, some four inches in diameter, occupied the left side of the lower part of the neck, displacing the larynx and trachea far to the right. The left carotid artery was completely buried in the tumour and the left vocal cord was paralysed. The tumour, which was obviously malignant, was hopelessly irremovable. The patient became rapidly worse, dysp- noea, dysphagia, and pain in the left arm and shoulder became prominent symptoms. On July 28, an unusually severe attack of dyspnoea necessitated tracheotomy. This gave considerable relief for a few weeks, but the patient gradually succumbed and died on August 30, a little more than four months after the onset of tlae disease. The immediate cause of death was haemorrhage from the trachea. The post mortem showed a spindle-celled sarcoma of the left lobe, with extensive involvement of the trachea and pharynx. There were no secondary growths anywhere. On the other hand, there is no doubt that many cases last considerably longer than eighteen months. I have seen a ease in which the disease had already lasted more than two years, the tumour, having in that time, attained the dimensions of an emu's egg. This patient died four months later ; no operation was performed. In all these cases there had been, apparently, no pre- existing goitre, so that the onset of the malignant disease could be fairly accurately defined. In the more common cases in which malignancy is engrafted upon innocent goitre, it is often difficult to say at w hat date malignancy began, especially if the goitre is a large one. Such patients often first present them- selves for advice when the tumour has already penetrated the capsule and begun to cause urgent symptoms. I am inclined to think that in some few of these cases the malignant tumour 208 THE THYROID GLAND. may really have existed for several years, although in the great maiority of instances, the duration is probably a matter of months rather than of years. Death is usually caused both in sarcoma and in carcinoma by the extension of the primary growth to the air passages. The Fio. 81. — Spiadlc-celletl SarCOma of the Tliyroid, with Paralysis of the riglit syuapathetic nerve (shown hy tlie narrow palpebral fissure and contracted pupil). (From an ontiiatient seen at St. Bart. Hosp.) (See p. 213.) mechanical obstruction of the trachea thus produced may cause fatal dyspnoea. Ulceration into the trachea may set up septic processes in the tumour which rapidly lead to the death of the patient. Bronchitis or pneumonia, septic in origin, is fre- quently the immediate cause of death, especially if tracheotomy has been performed. Penetration of the numerous veins in and MALIGNANT DISEASE AND ITS TREATMENT. 209 around the tumour, especially in the case of sarcoma, frequently leads to the occurrence of secondary o-rowths in the luno-s. Secondary g-rowths in more distant yjscera may occur: the bones especially are liable to become the seat of secondary carcinoma- FiG. 82. — liU-ge, soft, aud very vasciilai- Malignant Tiiniour of the ThyroiJ. The patient died at home of suffocation a iew months later. (Seen at St. Bart. Hosp. in 1886.) tous growths. These secondary growths in bone have a remark- able tendency to reproduce the structure of the thyroid gland wdth its epithelial yesicles containing colloid matter. In some cases the resemblance between these secondary growths and the normal gland is singularly close. Sudden haemorrhage into the softened interior of the growth may be mentioned as an occasional cause of death. 210 THE THYROID GLAND. s ^ q a P4^ MALIGNANT DISEASE AND ITS TREATMENT. 211 It is well also to remember that in the later stages oedema of the glottis may supervene very rapidly, and be the immediate cause of death. A few words may be said about certain forms of malignant disease -whicli deviate from the ordinary type. Instead of being hard, the tumour may present itself in the form of a soft swelling which is then easily mistaken for a cyst or for an inflammatory swelling. There are cases in which the whole gland becomes the seat of a soft rapidly growing tumour. Such cases, when occurring in young subjects, may be mistaken for the common rapidly growing parenchymatous goitre of adolescents. Cases have been recorded by Boeckel and Tillaux, in which sarcomatous tumours have given rise to many of the symptoms of exophthalmic goitre, for which indeed they were mistaken. There are, moreover, forms of malignant tumour which must be classed among the carcinomata, although clinically their course is very different from that of the ordinary carcinoma. I refer to the so-called " malignant adenomata,"" and to the papuliferous cystic tumours. The former appear to occupy an intermediate position between innocent tumours and the more typical carcinomata. In general appearance these tumours may closely resemble the innocent adenomata, but differ from them in possessing a tendency to recur after removal, and to dis- seminate. From their rarity they are of comparatively little importance. Papuliferous cystic tumours, although rare, are of some importance. They grow slowly, and exhibit but a low degree of malignancy. They are, therefore, far more amenable to treatment by removal, even though they may have attained a large size. Mr. Barker has recorded* a very remarkable case of this kind, which is depicted in Figs. 83 and 84. The patient, whose age was fifty when the photographs were taken, lived no less than eighteen years after the first appearance of the tumour, and underwent in the last ten years of his life numerous operations for the removal, first of< the primary growth, and then of locally recurrent tumours. The tumours * Brit. Med. Jour//., June 21, 1890, and T/n/t.s. Path. Sue. Lond. 18'Ji;. xlvii p. 22.0. 212 THE THYROID GLAND. which were examined bv a committee of the Pathological Society were undoubtedly carcinomatous. Cases of a similar nature have been recorded by Berger, Wiilfler, Sulzer, and others. Treatment. — The only form of ti-eatment of malignant disease of the thyroid that offers any hope of cure consists in free removal of the whole of the disease, if this is possible. Opera- tions for the removal of a portion of a diseased thyroid may be divided into two main classes, that of extra-capsular eoctir- pat'ion and that of intra-glandular emicleation. In the case of malignant tumours, however, one only of these methods is suitable, namely, extirpation. An exception should perhaps be made for certain cases in which malignant disease attacks, and is limited to, an old adenoma with a well-marked fibrous capsule ; but as these cases are rare, and can scarcely be distin- guished from those of innocent adenoma, the exception is rather apparent than real. The ti-eatment of innocent thyroid tumours by enucleation is such a very satisfactory operation, and is so widely applicable to them, that attempts have from time to time been made to treat malio-nant growths in the same manner. This is, however, in my opinion, a grave error. Not only is the haemorrhage at times so profuse that the operation has to be abandoned on this account alone, but the removal is almost necessarily so incomplete, that speedy recurrence must be expected. The only way to remove a malignant thyroid tumour satis- factorily is to do a careful and deliberate dissection, and to avoid haemorrhage by tying the main vessels before they are cut. The operator should, at every stage of ttie operation, be able to see exactly Avhat he is doing. Otherwise he is liable either unnecessarily to w^ound important neighbouring structures or to leave behind portions of growth which might well have been taken away. An operation for the removal of a malignant thyroid tumour should, if possible, be a thorough one, and aim at the removal of the whole of the primary disease. When the disease is limited to the gland itself, this complete removal is possible. But, unfortunately, in the vast majority of cases in which MALIGNANT DISEASE AND ITS TREATMENT. 213 operations have hitherto been performed, this condition was not present. In most cases the growth is found at the time of operation to have penetrated the capsule, and to have involved the trachea, the pharynx, or the great vessels of the neck. In such circum- stances it has been thought advisable to resect portions of these structures, but such complications naturally add enormously to the danger of the operation. In most cases even after such resections, the whole of the disease will be found not to have been removed, and speedy recurrence takes place. The recur- rent tumour usually grows much more rapidly than the primary one. Two cases may here l)e cited : In the summer of 1887 I was asked by Mr. Howard Marsh to see a man aged 42 who had had for five years a hard lump in the right side of the neck. This had steadilj' increased in size, at first slowly, in the last few months more rapidly. A large, irregular, somewhat hard tumour occupied most of the anterior triangle of the neck ;'^ the sympathetic nerve of the same side was com- pletely paralysed. On account of this latter complication and of the probable involvement of the structures on the inner side of the tumour, I advised against any opei-ation. However, a few days later the patient consulted another surgeon who proceeded to remove the tumour, and subsequently published an excellent account of the case.f The operation was long and difficult, and in the account given, it was stated that the tumour was adherent to the larynx. It was not stated that the removal was considered to have been complete. The patient recovered sufficiently to leave the hospital, but in less than sixteen weeks from the date of the operation he returned with a recurrent tumour as large as an orange and ulcerated on the surface. The tumour was again re- moved, then tracheotomy was performed. Several other partial operations were subsequently performed ; sloughing took place, then secondary haemorrhao-e, necessitatina: ligature of the carotid. The patient died very soon after this operation, and just nine months from the date of the first removal. The growth was a spindle-celled sarcoma, and at the post-mortem examination no secondary growths could be discovered. * Fig. 81 sliows the condition at the time when 1 fil■^^t saw this patient. ■f 8t. TJiuntai.i! Husp. Eev.. 18SS-9, n. s. xviii. p. 233. 214 THE THYROID GLAND. The other case is one pubHshed by Cramer,* and also ilhis- trates incomplete removal at a rather later stage of the disease. A woman aged 46 had had for two years a small lump on the left side of the neck ; in the last nine months it had grown more rapidly ; hoarseness had then set in and lately she had had much pain. On admission there was no dyspnoea or dysphagia. The left lobe of the thyroid was as large as a goose's egg ; it was smooth, Imrd, and a little movable ; the skin was not affected. Malig- nancy was diagnosed and the tumour removed. Haemorrhage was but slight, but much difficulty was experienced in separating the tumour from the trachea and larynx. The wound healed up quickly and the paiient was on the point of leaving the hospital, when the wound suddenly re-opened and some secondary haemor- rhage took place. A few days later the wound was laid open again and the bleeding found to come from a nodule of growth. Severe hseinoptysis then took place. With the laryngoscope a mass of growth jjenetrating the trachea coidd be seen. Seven weeks after the original operation the larynx was split open and growth found on the left side extending from the middle of the thyroid cartilage to the fifth tracheal ring. A few days later total extirpation of the larynx was performed ; at first the patient seemed to do well, but in the second week recurrences began to be manifest at various places in the wound, pleurisy set in and eventually the patient died just fourteen weeks from the time of the first operation. I cite these two cases, because I believe them to be fair average examples of the difficulties that a surgeon must be prepared to encounter if he undertakes the removal of a malignant goitre when there is no longer any hope that the growth is still confined within the capsule of the gland. The operation for the removal of a malignant goitre in its early stage, that is before the capsule has been penetrated, should be performed in exactly the same manner as extracapsular extirpation of an innocent goitre. An incision of sufficient length is made, usually over the long axis of the tumour, the infrahyoid muscles are divided, and the capsule of the gland exposed. Wound of the capsule with its network of large * •• Beitrag. z. Kenntniss der Struma maligna. " .lrc7/. /. /,7///. Chi/:. Berlin 1887. xxxvi. p. 2.59. MALIGXAXT DISEASE AND ITS TREATMENT. 215 vessels should be carefully avoided. All the main vessels enter- ing or leaving the gland are tied with double ligatures, just outside the capsule, before being divided. After the superior th>Toid artery and the superior, lateral, and inferior thyroid veins have been treated in this manner, the tumoui" should, if possible, be lifted up, and the more deep-seated inferior thyroid arterv secured in the same A\"av. This artery may be tied before it reaches the recurrent larvngeal nerve, or its branches may be secured on the inner side of the nerve, just before they enter the gland. Great care must be taken to avoid wounding the nerve. The vessels at the upper and lower borders of the isthmus are secured with double ligatures, and the isthmus is then divided. The whole lobe is then freed from its remaining connections and removed. Ligatures are applied to any other bleeding points. After the tumour has been removed the cut surface of the isthmus should be examined to make sure that the whole of the growth has been satisfactorily taken away. If necessarv, some more of the isthmus may be removed. It may even be advisable to repeat the operation upon the other half of the gland. Total extirpation of the gland, however, is in my opinion, rarelv desirable, since if both lobes are involved in the disease, the growth has almost certainly already involved the trachea, and can no longer be satisfactorily removed. The simultaneous removal of both halves of the gland adds very much to the gravity of the operation. It should not, I think, be performed unless the operator feels confident that he can therebv make a complete removal of the whole disease, and that he cannot do this by any smaller operation. It may reasonably be doubted whether the larger operations, which include resection of organs outside the gland, are advisable. Irrigation of the wound ^^ ith antiseptic solutions should, if possible, be avoided. Aseptic rather than antiseptic treatment should be aimed at. It is scarcely necessary to add that during the whole operation the most strict asepsis should be main- tained. A drainage tube need seldom be kept in the wound for more than twenty-four hours. The removal of one half of the thyroid gland, if performed in the manner indicated, u]:)on a suitable case, is not more difficult lm6 the thyroid gland. than when performed for an innocent goitre. Upon this point Kocher, a\ hose experience of both classes of operations is very large, says " the prognosis (as regards the operation) in excision of sarcomatous or carcinomatous goitre, if performed at the right time, is not materially worse than that of innocent goitre.''^ Results of Operations for the Removal of Malignant Goitre. — In the first edition of Butlin's " Operative Surgery of Malignant Disease " published in 1887, statistical information is given in an analvsis of fiftv cases collected by Braun and Rotter. Thirty of the patients died from the effects of the operation at periods varying from a few hours to eight weeks. Of the remaining twentv there were two in \\'honi the operation was not completed. In four cases the further history was not known except for a very short period after the operation. " In ten cases there A\as recurrence, which was either fatal or promised rapidly to be so. Only in four instances was a favourable result obtained." Two of these patients died of disease of the lungs one year and two and a quarter years after the operation. One patient was known to be alive and well eleven months afterwards. The remaining patient was reported to be quite well nearly four years after the operation, but he too is now known to have died of recurrence not long after the date of this report. So that of the whole number there is not one that can be said to have been satis- factorily cured by the operation. Statistical information as regards the removal of innocent goitre has within the last few years accumulated rapidly and has shown a marked improvement in this branch of surgery. The gross mortality after partial extirpation (not enucleation) of the thyroid for all kinds of innocent goitre, except the exophthalmic variety, is Sh per cent., according to the most recent statistics of Reverdin (October 1898). This estimate is obtained from an analysis of 1212 cases reported to him bv a large number of surg-eons. Similarly satisfactorv improvement cannot however be claimed for the removal of malignant thyroid tumours. Some improvement has, however, taken place in the direction of earlier diagnosis and a lessened mortalitv from the operation itself. MALIGNANT DISEASE AND ITS TREATMENT. 217 Accurate statistical information with regard to the removal of malignant thyroid tumours is not easily obtained. Most of the operators who have published long series of operations for goitre have omitted from their statistics all the malignant cases. In a few instances, however, a series of consecutive cases has been published and these afford us valuable information. Such are the series published by Sulzer from the Canton Hospital at Munsterlingen (seven cases), by Bergeat from the Tiibingen Clinic (six cases), by Hochgesand from the Heidelberg Clinic (five cases), and the latest series, published by Kocher and his assistants, from the Berne Clinic (eighteen cases). Besides these I have collected from various sources thirteen isolated cases published by various authors,* since 1887. With the possible exception of some of the operations mentioned by Sulzer, the exact dates of many of which I do not know, all these operations have been performed since 1884. Many of them, including all of Kocher's series, are quite recent, having been performed withirj the last few years. Five of Hochgesand's cases I have excluded from my statistics because they were performed before 1884 and have already been included in Braun's statistics above mentioned. I have also excluded cases of papilliferous cyst, on account of its low degree of malignancy. The thirteen isolated cases include only those in which there was clear microscopical or other proof of malignancy. Of the total number of fortv-nine cases, there were seventeen in which death occurred as the result of the operation itself. This gives us a mortality of thirtv-four per cent., a distinct improvement upon the sixty per cent, of the earlier series. Kocher's figures alone, which show six deaths among eighteen patients, indicate a great improvement upon the results of his earlier operations. They may be taken as representing the best results that can be obtained at the present day when the opera- tion is undertaken by a surgeon who is especially experienced in this branch of surgery and who does not refuse to operate upon tumours that have already gone beyond the limits of the gland itself. It is the presence of severe complications that makes the * Cramer. Frank. Petrakides. Buschi. Berry. Jones and Battle, Lentz, Allen Davis. Stonliani. Ewald. Orcel. and Kuuuner. 218 THE THYROID (iLAXD. operation so fatal in itself and which causes its mortality to be so very much greater than that of operations for innocent goitre. Kocher's own remarks upon this subject are well worth quoting. Speaking in 1898 of the relatively high mortality in his series of eighteen cases, he says : "It is not the goitre operation in itself which leads to the fatal result, but the severe complications which the resection of neigh- bouring structures brings with it. In most cases it is necessary in removing a malignant goitre to excise at the same time portions of the trachea or oesophagus, or even the whole of these structures as far as they lie in the neck. Quite common in these operations are resections of the great vessels of the neck, most often the internal jugular vein, occasionally also the carotid. Important nerves too, such as the vagus and sympathetic, must in many cases be wounded or resected. When these severe complications are taken into account, the healing of the wound in two-thirds of all cases of malignant goitre may be considered to be a comparatively favourable result, since the end of such patients, if the}' do not undergo any operation, is usually preceded by great suffering and distress, either from dysphagia or extreme dyspnoea. It is to be wished that every doctor could be brought face to face with such patients in the later stages of their malady, so that he might thoroughly appreciate the necessity of an early diagnosis and timely operative interference. . . . Every goitre in an adult, and especially in an elderly person, that enlarges without obvious cause, should raise a suspicion of malignancv, even though it cause no pain or other trouble ; and if at the same time the goitre becomes harder and irregular, and symptoms of increasing distress set in, then the diagnosis becomes almost certain." AA'e may turn now to the ultimate results of the operation. From the thirty-two patients that recovered from the operation we must unfortunately deduct twelve cases of Kocher's, since Avith regard to them no information has yet. so far as I can learn, been published. We must also deduct six other cases of which there was no history for more than, at most, four months. ^Xe are left therefore with the comparatively small number of fourteen cases ; of these no less than eleven either died within a year or were known to have recurrence. Three only were known to have survived and to be free from recurrence for a MALIGNANT DISEASE AND ITS TREATMENT. 219 period of three years and two months, two years and seven months and eight months respectively — truly, not a very encourao-inor list. The three cases were : (1) A man from whom in May 1889 the left lobe of the thyroid was extirpated on account of round-celled sarcoma. When examined in July 1892^ this patient showed no signs whatever of recurrence and appeai-ed to be in fairly good health, although suffering to some extent from thyroidal atrophy, symptom^s of which had indeed been present before the operation. (Sulzer.) (2) A boy aged 10 in whom a " hyperplastic " goitre was supposed to have become sarcomatous ; there was slight dyspnoea. In July 1885, the tumour, which contained numerous cysts with hfemor- rhagic contents (surely an unusual form of malignant disease !), was removed by what seems to have been an atypical enucleation operation. In February 1888, there was no recurrence and he seems to have. been quite well. (Hochgesand.) (3) A woman aged 54 with a left-sided " malignant " goitre as large as a fist. There was much dyspnoea and dysphagia. In June 1887 the tumour was extii-pated, the oesophagus being opened in the course of the operation. Five weeks later oesophago- tomy was successfully performed for the closure of the fistulous opening that was present. The patient made a good recovery, and in February 1888 was reported to be in good health. (Hoch- gesand.) In neither of the two last cases is it stated that any micro- scopical examination of the tumour was made. The results of the operations in the two series of cases, those collected by Rotter and by myself, are shown in the following- tabular form. The two cases in which the opera- tion was not completed have been omitted from Rotter's series of fifty cases, and the whole of Kocher's cases from the second series. ^20 THE THYROID GLAND. Earlit'i- si-rics bt'l'on' l.SSi). Later series. Died of the operation ... ... iiO {(Y2 p.c.) ll(35p.c.) Further history unknown ... ... 4 6 Known to have had recurrence or to have died within a year ... 1 11 Known to have survived without re- currence for periods varying from eight months to two years and a half ... ... ... 3 2 Known to have sux'vived without re- recurrence for more than three years ... ... ... 1 1 Totals 48 31 The statistics given above show clearly that in the vast majority of eases the operation as usually performed does not result in a cure. It is much to be regretted that we have at present no reliable statistical information as to the results of operations undertaken in the early stages only, that is before the penetra- tion of the capsule has occurred. These are the cases in which we might reasonably hope that the operation Avould be of much benefit to the patient. Cases in which a long period of immunity has followed an operation undertaken at this early stage are occasionally seen. In the Philadelphia Annals of Surgery (1893, p. 554) is an account of a discussion which took place at the New York Surgical Society in May of that year on a case of malignant goitre. Dr. F. Kanmierer was reported to have then said that " of several total extirpations for malignant disease he recalled two in which the growth had not perforated the capsule. One Avas a very large cancerous thyroid and there was no recurrence after extirpation for four years, when recurrence did take place, and it ran a rapid and fatal course. In another case in which the diagnosis was established without doubt, the patient is still living without any recurrence seven or eight years after total extirpation." These remarks, if confirmed, seemed to me to be of such importance that I wrote to Dr. Kammerer asking for further information with which he very kindly supplied me. It appeared, then, that the fir.st case was one of Maas's, already men- MALIGNANT DISEASE AND ITS TREATMENT. 221 tinned among Rotter's cases. It is sad to think that the best case of all in this series should eventually have died of recurrence. It is some satisfaction, however, to know that a patient can live without recurrence for as much as four years after the removal of a goitre, the malignant nature of which is established without doubt. The other case that Kammerer had seen is still more impor- tant, as it shows that a patient may survive the operation for a period of not less than eleven years. It is that of a gentleman operated on by Kocher in or before the year 1885. The exact date of the operation I have unfortunately not succeeded in obtaining, but it appears to be quite certain that it was not later than 1885, and was probably somewhat earlier. In 1893 this patient was operated upon for the first recurrence by Dr. Lange of New York, under whose care he remained during the next three years. Tracheotomy was eventually performed and a long canula inserted. Extensive recurrences took place and the patient died in August 1896, having survived the first operation for a period of at least eleven years. Dr. Kammerer tells me that Kocher had stated that the tumour removed at the first operation was malignant. With regard to the nature of the recurrent tumour I have a report from Dr. Schwyzer, pathologist to the German Hospital, New York, who made the post-mortem examination, and who states that the tumour was a " tubular carcinoma with much interstitial connective tissue." The tumours known under the names of papuliferous cyst and papilliferous cystic adenoma form a class of malignant tumours that stand somewhat apart from the ordinary carcinoma and sarcoma. They are much less malignant. They grow slowly and exhibit much less tendency either to infiltrate locally or to dis- seminate. In these respects they are analogous to the papilliferous cystoma of the ovary, which they closely resemble. The patients are much less liable to speedy recurrence after operation. In Barker's case, already mentioned, the tumour had been growing for eight years before the first operation was performed. Death did not occur till ten years later still. Berger records the case of a woman aged twenty-six in whom a large tumour of this nature had been growins; for six vears. It was then removed with some difficulty owing to its intimate adhesions with the 222 THE THYROID (ILAND. internal jugular vein ; eight months later this patient was well and had had no recurrence, Wolfler cites from Billroth's practice the case of a woman aged twenty-three in whom the tumour at the time of operation occupied a large part of the neck. It had been growing for one year. Two years after the operation no recurrence had taken place. Palliative Treatment. — Although radical and curative treat- ment of malignant disease of the thyroid is in most cases im- ]iracticable, yet something can be done for these unfortunate patients bv palliative treatment. A partial removal of the disease will occasionally afford relief for a time, especially from the dyspnoea. As the operation is intended only to relieve symptoms, it should not be done until these symptoms are already sufficiently severe to cause consider- able distress. Partial and incomplete removal of the disease does nothing to check the progress of the disease itself and, if undertaken too soon, may easily make the patient worse than before. It should seldom be performed unless there is a reason- able prospect that the external wound will heal. It is chiefly useful when a mass of growth is pressing injuriously upon the trachea. Any incision into the growth is apt to lead to funga- tion into the wound, and if the latter become septic, a contin- gency often difficult to avoid, the operation may do more harm than good. The following case is one in which a partial extirpation aflTorded considerable temporary relief. Mrs. Fanny M , wf. 50, was admitted into the Royal Free Hospital under mj^ care on July 7, 1900, suffering ft-om dyspnoea, dysphagia, and a tumour of the thyroid gland. In September 1899 she had first noticed a swelling of the neck. This gi'adually increased in size and caused her a good deal of jjain in the shoulder and neck. In February 1900 she was admitted to King's College Hospital, and on March 1 underwent there an operation for the removal of the tumour. At this time the tumour was hard and irregular and involved both lobes of the gland. It moved with the larynx on deglutition. The growth was found to be a sarcoma. The wound healed quickly, the patient soon left the hospital and was much relieved by the operation. A week or two later recurrence was noticed in the neighbourhood of MALIGNANT DISEASE AND ITS TREATMENT. 223 the scar. For three months, however, she remained fairly well. Towards the middle of June dyspnoea and dysphagia again became yery troublesome, and for these symptoms she came under my care. At this time the thyroid gland was found to be much enlarged, each lobe being as large as a goose's egg. It was yery hard and much fixed. The tumour was yery deeply seated, lying largely behind the sternum. There was great dyspnoea with much stridor, and the patient was in great distress. The vocal cords however were still unaffected. On July li, a palliative operation was undertaken with the view of removing that portion of the tumour ' that lay behind the sternum, and that was evidently pressino- seriously upon the trachea. No hope was held out of performing a complete removal of the disease. A mass of growth as large as an apple and weighing four ounces was removed from the root of the neck and superior mediastinum. The operation presented no special difficulty and bleeding was not excessive. The trachea was found to be greatly compressed but not actually infiltrated. The growth on the left side was extensively adherent to the internal jugular vein, pharynx and CESophagus, and no attempt was made to remove this portion of it. As before, the wound healed by first intention, and on July 25, the patient returned to her home in the country, breathing freely and much relieved. In September the patient came up to see me again. She was breathing comfortably and her general condition was fairly good. She could swallow liquids without trouble, but not solids. Two months later however very severe attacks of dyspnoea occurred and she was re-admitted much exhausted from dyspnoea, pain and recurrence of growth. Tracheotomy Avas performed in November, a Koenig's canula being inserted. This gave her temporary relief. On November 12, 1900 she died rather suddenly, apparently from exhaustion from the disease and without having had any retlirn of dyspnoea. The post-mortem examination showed very extensive disease of both lobes. The groAvth extended downwards to the first ribs and apices of the lungs. Behind the trachea it formed a firm dense plate more than an inch thick, completely surrounding the oesophagus. (^See Fig. 78, p. 203, and case 113, p. 352.) There were no secondary growths. Microscopical examination shoAved spindle-celled sarcoma. A simple incision doAvn to or into a goitre that is the seat of irremovable malignant disease Avill occasionally relieve the dyspnoea. This is effected doubtless by causing shrinking of the non-malignant portions of the goitre. This operation has 224. THE THYROID GLAND. been practised for malignant disease more often in France than elsewhere.* Mr. Geortje Turner has recorded an interestino- case in which he had to perform tracheotomy for a malignant goitre. The operation caused almost complete disappearance of all swelling in the neck. So remarkable was this disappear- ance that the correctness of the diagnosis was questioned. But a subsequent recurrence of the growth placed its malignant nature beyond dispute. f Tracheotomy often affords the only means open to us of alleviating the dyspnoea from which these unfortunate patients suffer. As a rule it should be performed only when the dyspnoea has become a source of considerable distress to the patient. Occasionally it may be performed early, if there are any indica- tions that (edema of the glottis is likely to supervene. It should be remembered that this complication may occur without much warning and may rapidly prove fatal if not relieved by a timely tracheotomy. The difficulties of a tracheotomy may be considerable. If the growth is not large and does not displace or cover up the trachea, then the operation is generally easy to perform. The close proximity of the growth however is apt to cause enlarge- ments of the veins of the neck and this may render the operation difficult. The trachea may be so much displaced that the incision has to be made far away from the middle line. Thus in the case depicted in Fig. 77 I had to make the skin incision nearly an inch and a half to the right of the middle line. In another case in which, some years ago, I helped my friend Mr. Stanley Boyd at a tracheotomy for a sarcoma of the thyroid, the incision had to be made equally far out on the left side of the neck. It should be borne in mind that when the trachea is much displaced its relation to the carotid becomes seriously altered. In both these cases the trachea had been pushed outwards under the carotid artery. The tracheotomy was done just below the cricoid. Had it been done lower down the carotid would have been encountered, since it was found, when the patients eventually * See Adeiiot. " Liberation longitudinale de la traciiee coiiime traiteuieiit palliatif dans le cancer du corps thyroide," Axsoe. franc, de Cli'ir., Paris, 1896, X. p. 320. -j- Trun:-. CJln. S;u-., London. 1890. xxiii. p. 226. MALIGNANT DISEASE AND ITS TREATMENT. 22^ died, that it Jay directly in front of the trachea, more than an inch above the sternum. Frequently the tracheotomy has to be done directly through the growth if the latter covers the front of the trachea ; or, as in a recent case of my own, it may be necessary to remove some portion of the growth , ""~^^\ in order to reach the / trachea. Sometimes the f ' \ tracheotomy can be done V^ above the growth, rarely is it possible to do it below the tumour. The difficulty of finding the trachea, imbedded as it may be in a mass of hard growth and much distorted and flattened, is often very great. An ordinary trache- otomy tube is frequently not long enough to reach the trachea or to pass beyond the lowest point of constriction. The long flexible silver tube of Koenig I have found useful in such cases (see Fig. 85). If this is not at hand a flexible catheter may be used as a substitute. Tracheotomy does not usually prolong the patient's life for more than a few weeks at most, but it may add consider- ably to his comfort. If the growth has been incised, as it probably has been in the performance of the operation, then septic changes are apt to occur sooner or later in the tumour. Bronchitis, pneu- ., . . 1 ill Fig. 8 5. — Koenig's long- flexible monia or other septic pulmonary troubles tracheotomy tube, for tra- are frequently the immediatecause of death, ciieotomy in cases of maiig- In the case of some slow -growing malig- nant tumours the duration of life after the tracheotomy may be much longer, especially if it has been possible to avoid cutting into the growth itself. Sir Felix Semon has recorded a very remarkable case of a lady aged 52, upon whom he performed a low tracheotomy a few weeks after the first symp- toms of the disease had been .noticed. She survived the operation uant and other tuinoiu-s pressing- upon the trachea. 226 THE THYROID GLAND. more than two years. In this case, however, the amount of dysp- noea at the time of operation does not seem to have been very ^reat. The case was in other respects, too, a very unusual one.* If dysphagia be a marked symptom, as it often is, special means may have to be taken to feed the patient. This is best effected by means of an (esophageal tube. Gastrostomy even has been performed in such a case. Finally, morphia and other sedatives may have to be ad- ministered freely in the later stages of this most distressing and painful disease. Conclusions. — Theoperation for removal of the ordinary forms of malignant disease of the thyroid gland, unless performed at a very early stage of the disease, is attended by a high mortality from the operation itself. The danger lies chiefly in the involvement of important neighbouring structures, portions of which must often be cut away if the primary disease is to be thoroughly removed. The diagnosis of the earlier stages of the disease is not easy and it is especially difficult to say with certainty that the trachea and pharynx are not already involved. If the disease has not already penetrated the glandular capsule, the operation is not particularly difficult or dangerous, if the dissection is performed carefully and with due regard to the anatomical relations of the parts. Recurrence after operation is usually local and due to in- complete removal of the primary disease. In the later stages of the disease secondary deposits are likely to be found in the lungs and bones. There are certain forms of slow growing malignant disease such as the papilliferous cyst, in which the tendency to local and general malignancy is but slight and in which treatment by operation affords satisfactory results, even when the tumour has attained a very large size. In the majority of cases of malignant disease of the thyroid, the only treatment that can be adopted is but palliative, and consists chiefly in relieving the patient from dyspnoea, dysphagia and pain. * " A Case of Malignant Disease of the Thyroid Gland with ino-st unusual course,'' Med. Chir. Trails.. 1892-3, Ixxvi. p. 375. CHAPTER XIV. TREATMENT OF INNOCENT GOITRE— NON-OPERATIVE. General — Eemoval of cause — Medicinal — Iodine — Thyi-oid extract — Other di-ugs — Cases suitable for — Local — External applications — • Indian method. The non-operative measures that may be adopted for the treatment of innocent goitre mav be classified as follows : — (1) General; (2) Medicinal; (3) Local. (1) General. — It is obvious that if the cause of goitre be known, the patient should, as far as possible, be removed from its influence. This is especially important in the early stages of the parenchymatous form. Tumours of the gland, such as cysts or adenomata, although they may have originated in a gland that was the seat of parenchvmatous enlargement, are not likely to be influenced in their course by the removal of the original cause. Goitres in which other secondary changes, such as fibrosis and calcification, have occm-red, are naturally not amen- able to any such treatment. But in the case of early parenchvmatous goitres, care should be taken to remove, if possible, the cause of the disease. If the patient be living in a district where goitre abounds, it is well that he should, if possible, remove to a district where the disease is not prevalent.* When such removal is not convenient or possible, as is generally the case, then particular attention should be paid to the drinking-water, since this is, in the great majority of cases, the cause of the affection. So long as we are ignorant of the exact nature of the poison that produces goitre, it is difficult to sav definitely how the drinking-water should be * I have known several instances in which young girls had been sent to school in a goitrous district and had there developed the disease. Upon leaving the district the goitre disappeared spontaneously. 228 THE THYROID GLAND. treated, in order to render it innocuous from this point of view. It is well in most instances, however, to recommend that water suspected of being the cause of goitre should not be drunk without previous filtration and boiling.* As a general rule it may be stated that the younger the patient and the smaller the goitre, the more likely is a cure to be affected bv such measures as removal from the affected district or bv alteration of the drinking-water. {H) Medicinal. — Numerous medicinal remedies have been employed for the treatment of goitre. By far the most im- portant are iodine and its various preparations, and thyroid extract, thvroidin, and the other preparations of the thyroid gland itself. For parenchymatous goitre I usually recommend about five minims of the tincture of iodine together with four or five grains of iodide of potassium, the doses being gradually increased until the patient is taking three or four times as much. For the iodine treatment to be efficacious, it is desirable that the drug be administered in sufficiently large doses. Care should be taken, however, to diminish or stop the administration if svmptoms of iodism are produced or if the digestion be upset. If iodine in full doses does not produce a marked diminution in the size of the goitre in the course of two or three weeks, it is not likely that it will be of much use. The preparations of thyroid gland are also extremely useful in the treatment of parenchymatous goitre. I have sometimes found thvroid extract useful in cases that have not yielded to iodine and vice verm. As thyroid extract is a potent and sometimes even dangerous drug, it is Avell to be cautious in its adminis- tration and to begin with small doses. Arsenic, mercurv, strychnia, and various other drugs have been recommended, and have sometimes appeared to me to be of use. Medicinal treatment is most efficacious in the case of general enlargement of the gland, that is, of parenchymatous goitre. Upon encapsuled adenomata it has little or no influence, and for cysts it is equally useless. Many cases, however, of parenchy- matous goitre do not yield at all to medicinal treatment. The following case may be cited as an illustration of the use of iodine and thyroid extract in parenchymatous goitre : — * See Liistig and Carle's expennieiits, pp. 68. 69. TREATMENT OF INNOCENT GOITRE. 529 Alfred A , cet. l~ , came under my care at St. Bartholomew's Hospital in January IPOO^, on account of dyspnoea and enlargement of the thyroid gland. The thyroid swelling had been first noticed eighteen months previously and had been gradually increasing in size. It had caused difficulty in breathing, especially at night and on exertion. The patient was a deaf mute, somewhat mentally deficient, but not showing any signs of cretinism. He was found to have a large bilateral, nearly symmetrical, goitre. Each lateral lobe was as big as a goose's &g,g ; the right was slightly larger than the' left. The gland was moderately firm^ slightly nodular, and mo\ed freely with the larj-nx. There was a moderate amount of tracheal stridor. The diagnosis was parenchymatous goitre, with perhaps a few adenomata deeply buried in it. Tr. lodi Vi\\. and Pot. lod. gr.iv. were given three times a day with a tabloid of thyroid extract (gr.i^) every other day. The dose of each drug was increased every week. This treatment was begun earh' in January. By the end of the month the goitre had diminished to half its original size and was much softer. All dyspnoea had disappeared. The administi*ation of thyroid extract was noAv discontinued and the doses of the other drugs increased to 111^ xii. of Tr. lodi and gr.xi. of Potassium Iodide. By the end of February the general swelling of the gland had almost dis- appeared, but at the lower part of the right lobe a rounded firm tumour as large as a marble could be felt vei'y easily. This was evidently a cyst or an adenoma. As it caused no trouble no further treatment seemed necessary. (3) Local. — A common and often useful method of treating parenchymatous goitre consists in painting the neck with tinc- ture or liniment of iodine, or in rubbing the swelling with ointments of iodine or mercurv. It is possible that the mechanical pressure mav also do some good bv favouring the absorption of the accumulated colloid. \ iolent rubbing should, however, be avoided, as it is apt to damao-e the softened o-land and to lead to extravasation of blood within its substance. I have occasionally endeavoured to diminish the size of a soft parenchymatous goitre bv continuous gentle pressure applied by means of a broad elastic band, but without very satisfactory results. The Indian method consists in smearing the goitre thickly 230 THE THYROID GLAND. with biniodide of nieicurv oiiituicnt and then exposing the })atient's neck to the rays of a hot sun. The treatment is said to be very successful in India, but in this country, where the rays of the sun are less powerful, the beneficial effects are not so marked. I have been informed by surgeons who have employed this method in India that the patients are exposed to the sun for an hour or more, and that the ointment has to be well rubbed into the neck. The result is that the neck is terribly blistered, but the goitre* is frequently cured. I have tried to imitate this Indian process by making the patient sit for an hour or more at a time with the face covered and the neck exposed before a very hot fire. But I cannot say that I have met with much success. CHAPTER XV. TREATMENT BY TAPPING— INJECTION— INCISION— SETON— LIGATURE OF THYROID ARTERIES— EXOTHYROPEXY. Tapping : For cystic goitre — Occasionally cures — Risks of — HcBinor- rlaage. Injection : Of parenchymatous goitre — Directions — Risks — Fatal cases — Of cystic goitre — Directions — Risks — Results. Incision : Rarely desirable — Cases suitable for. Seton : Dangers of. Liga- ture of thyroid arteries ; Historical — Recent revival — Methods of operating. Exothyropexy : Historical — Objects of — Objections — Methods of operating — Results — Complications — Mortality. Tapping. — Like most other cystic tumours, those of the thyroid are frequently submitted to the operation of simple tapping with a trocar and canula. The object of this proceed- ing is, of course, to empty the cyst, and so to cause its collapse and cure. In many cases this result does really take place, and the cure may be permanent. Not uncommonly, however, a much less favourable result ensues. The cyst rapidly fills again, this time u.sually with blood, and the patient's condition may be worse than it was before, especially if the cyst be large. This remarkable tendency to intra-cystic haemorrhage on the part of thyroid cysts has already been mentioned in the chapter on cystic disease, and several cases have there been related in which serious and even fatal results have followed a simple tapping. The occurrence of serious harm may to some extent be obviated by keeping up a certain amount of gentle pressure upon the cyst during and after the tapping, so as to prevent the sudden diminution of intra-cystic tension. It must be borne in mind, however, that it is often difficult to apply satisfactory pressure to the soft yielding structures of the neck. For single cysts of small size in which the walls appear to be thin, the operation of tapping may be occasionally performed; but 232 THE THYROID GLAND. if the cvst be niultilocular, or if it have thick unvieldiiig walls which cannot collapse, or if the contents be solid, then tapjDing should not be attempted, as it is almost certain to fail. It is occasionally advisable to tap a thyroid tumour for diagnostic purposes, to see whether the contents be cystic or solid. For parenchymatous goitres, where no cysts of large size are present, a simple tapping is naturally of no use, since the viscid contents of the minute intercommunicating vesicles drain away verv slowlv. If, however, the canula be left 'm situ, for several davs after the operation, a considerable decrease in the size of the goitre may occasionally be observed. But this proceeding is obWously not without danger, as it is likely to set up suppura- tion. It should not be attempted Avithout due considei'ation of its risks. In any case in which tapping is performed the strictest attention should be paid to asepsis. Tapping of a goitre of any kind is a proceeding which, in my opinion, should rarely, if ever, be adopted. Injection. — The object Avhich is aimed at in the injection of a goitre is to cause sufficient inflammation to obliterate some of the minute vesicles of a parenchymatous goitre or the larger cysts of a cystic goitre. Possibly, also, there is some direct solvent action upon the colloid contents of the vesicles, which may promote absorption. It is obvious, therefore, that parenchymatous and cystic goitres are more amenable to ti'eatment by injection than are the harder and more solid forms. It has often been stated that "fibrous" goitres can be treated with advantage by injec- tion, but it may reasonably be doubted whether this is really the case. Truly fibrous goitres are by no means so common as is generally supposed. Many of the very hard goitres which I have often seen diagnosed as fibrous goitres proved eventually to be parenchy- matous or cystic-parenchymatous. The hardness in such cases is due to the tension of the fluid within the small vesicles, or to the solidification of the contents themselves. This is probably the true explanation of the benefit that has been supposed to result from injecting so-called fibrous goitres. TREATMENT BY INJECTION. 233 The matej-'ials that ha\e been used for injection are numerous. The one which occupies the foremost rank is undoubtedly iodine. This may be used either in the form of simple tincture or in combination with other drugs. Arsenical solutions, perchloride of iron, ergot, osmic acid, and iodoform have all been recommended, but probably not one of them is superior to iodine. Method of performing' Injection in Cases of Par- enchymatous Goitre. — The best directions that I haye seen for the performance of the injection of iodine into parenchy- matous goitres are those giyen by Sir Felix Semon, who has written as follows : 1. Select suitable cases only, i.e., cases in Ayhich the gland sub- stance is so thick that one may be fairly certain that the injection can be made into the parenchyma proper and in which, on the other hand^ the interstitial fibroid change has not progressed too far. 2. Inject eyery third day into the gland substance proper a quantity from twenty to thirty drops of an alcoholic iodine solution (one part of iodine in twelve parts of absolute alcohol) with a well- made and well-cleaned hypodermic and screw syringe. 3. Vary as much as possible the place of injection and never inject into the same neighbourhood on two consecutive occasions. ^. Avoid wounding superficial veins and injecting air. A piece of tape may be tied round the neck below the tumour so as to com- press the superficial veins. 5. Neither insert the point of the needle too timidly, when the injection fluid will very likely pass into the cellular tissue^ suppura- tion resulting ; nor too violently, when it may completely perforate the gland and the injected fluid may be thrown into other impor- tant tissues. It is a good plan to let the patient swallow when the needle has been inserted, before the injection is proceeded with, the body of the syringe being held quite loosely in the operator's hand ; if the point of the needle is in the gland substance the foremost point of the syringe will rise with the rising gland ; if it be in front of the gland no movement will ensue ; if it have per- forated the gland the hindermost part of the syringe will chiefly rise. 6. Never inject in such a direction that the point of the needle points directly towards the trachea or towards the great vessels and nerves of the neck. 7. Inject very slowly and watch especially the effect of the injection of the first few drops. Select the place of injection care- 234 THE THYROID GLAND. fully beforehand by palpation and steady the tumour with the left hand whilst making the injection. Previous freezing of the surface with anaesthetic ether* round the point selected for injection may l)e resorted to, but is not necessary. That the directions given above are excellent, there can, I think, be little doubt ; and any one who is about to treat a goitre by injection of iodine cannot do better than follow them. There can also be but little doubt that in a large number of cases, a successful result ensues, at any rate, for a time. There is, however, equally little doubt that very often the treatment is unsuccessful. A considerable number of cases have been recorded in which various complications, including death itself, have folloAved the operation. The injection may, and in most cases probably does, at first produce increased swelling of the gland. This may cause dyspnoea or aggravate that which is already present. The injec- tion may cause suppuration, which in its turn may lead to death. Obalinski relates the case of a man who had a large goitre ; a single injection of iodine caused suppuration, together with such increase in the size of the tumour that it was deemed necessary to remove part of it. The man died of pyaemia on the tenth dav. Liebrecht relates a case which occurred in the practice of Dr. Albert of Innsbriick; injections of iodine into the goitre led to suppuration and other severe symptoms ; the tumour was remoA-ed but the patient succumbed. Instances such as the above are numerous, and, were it necessary, many more might be cited here. In the above cases the evil results were due to inflammation and suppuration occurring in the neck. A considerable number of cases have, however, been recorded in which death ensued much more speedily, before suppuration had had time to manifest itself. Dr. Rose,+ formerly of Zurich, says that he himself knows of * This was written before tlie introduction of cocaine and eucaine as local anaesthetics ; at the present day these would be preferred. t '-Der Kropftod und die Eadicalcur der Kropfe," Archiv f. liUn. Chir. vol. xxii. TREATMENT BY INJECTION. 235 not less than six cases in which surgeons have lost healthy patients from injection of iodine into a goitre, death occurring either upon the operating table or within a few hours of the injection. Dr. Johannes Seitz,* in a monograph upon death from goitre, mentions the following cases : The first is that of a woman under the care of Dr. Schwalbe ; the injection of ten drops of tincture of iodine into a small goitre caused after a few minutes numbness and then paralysis of the left arm and leg, partial loss of speech, slight facial paralysis, general convid- sions and death at the end of twenty hours. No post-mortem examination was made. After this case Dr. Schwalbe gave up the use of iodine injections and employed alcohol instead. The next case is that of a young woman into whose goitre iodine had many times been injected ; after the last injection she took violent exercise for some hours ; the tumour then began to cause great pain ; the goitre became greatly swollen, and in three days the patient was dead. The third case occurred in the practice of Dr. K. St . The patient was a woman of 27, the goitre was as large as a small apple, moderately hard, and affecting the right lobe of the gland. A common Pravaz syringe of small size was three-quarters filled with tincture of iodine^ and the injection made in the ordinary manner. Immediately after the injection the patient complained of pain in the right eye. She then began to sway about in her chair, and quickly lost all power of speech. The right upper and lower eyelids became cedematous, and the right eye appeared to be pushed forwards. In the right half of the face appeared several blue spots, which increased in size until death occurred. In the first half-hour she was very restless, then became more quiet ; the breathing was quiet and regular, the pulse rather slow (48 to 50). The pupils were natural, and there was no facial paralysis. The patient remained in the above condition for about three hours ; then the pulse became much more rapid, and breathing became deeper and irregular Death occurred eight hours after the injection. f The post-mortem examination was unsatisfactory. In the vessels of the brain and its membranes no thrombosis or embolism was * •• Der Kropftod durch Stinimbtindlahmung," Langenbeck's Archlrf. Idin. Chir. xxix. 1. t Dr. K. St. alludes to another case which appears to have occurred at Berne and in which similar sj^mptoms occurred ; no particulars, however, are given. 236 THK THYROID GLAND. found ; on section the right side of the brain showed numerous bloody points ; the choroid plexus was of a darker colour than natural. Several ounces of serous fluid were found in the pleural and pericardial cavities. The goitre was chiefly ])arenchymatous, but contained also a small cyst, of the size of a hazel nut, in the posterior wall of which was a large vein^ into which it seemed possible that the iodine had been injected. Chemical examination of the contents of the cyst showed no iodine to be present. In 1884, Dr. Krieg * related to the Medical Society of Stuttgard, a case in which sudden death had followed the injec- tion of two drops of tincture of iodine into a goitre : The patient was a cretinous girl, aged fifteen. D^'spnoea had been present for many years, but had increased considerably in the last fortnight. Two drops of tincture of iodine were injected into the middle of the goitre and the syringe withdrawn. In less than a minute the dyspnoea becaine nciuch more severe, and the right side of the neck began to swell. The child became livid, lost con- sciousness, and in two minutes was dead. At the post-mortem examination it was found that the goitre consisted of a nodule as large as a hen's egg, involving the I'ight lobe of the thyroid gland. The injection had been made quite correctly into the centre of it. The small wound made by the syringe had led, however, to considerable haemorrhage into the tissues between the tumour and its capsule. The extravasated blood, pressing upon the already much narrowed trachea, and upon other surrounding structures, had been sufficient to cause death. The trachea opposite its second, third and fourth rings was so narrow that its walls were almost in contact. It was found, however, that this extreme narrowing was due, not merely to the pressure of the goitre, but also to the presence of a firm papillomatous fibrous tumour, which grew from the left wall of the trachea and filled up more than half its lumen. These cases show pretty clearly that injection of iodine into a parenchymatous or adenomatous goitre, is an operation by no means devoid of danger, even when performed carefully, and when only a small quantity of fluid is injected, as in Krieg's case. * ■■ Kotzliclier Tod durch purencliymatose Injection von lodtinctur in einen librosen Kropf . " Mediz. €uri-esj)on(l. Bl. d. Wiliiteinh. aer:tJ. Za/idrsve):,iitutt- gard, 1884, liv. pp. 145-149. TREATMENT BY INJFXTIOX. 237 Professor v. Mosetig-Moorhof * advocates the injection of a solution of iodoform for the treatment of soft parenchymatous goitres. Formerly he used tincture of iodine but this caused suppuration in one of his cases. He, therefore, gave up the use of it and used, instead, one of the following solutions : Iodoform .... 1 gramme "j [1 gramme Ether . . . . ') grammes .• or - 7 grammes Olive oil . . . - 9 grammes j [7 grammes. The solution should be freshly prepared, and is then of a light yellow colour and transparent. On exposure to light it is apt to become brown from liberation of free iodine, and should not then be used. It should therefore be kept in the dark when not required for use. v. Mosetig-Moorhof injects one gramme (15 minims) or more at a time, and usually makes from five to ten injections in each case. The reaction after each injection is usually very slight and does not prevent the patients from following their ordinar\' occupations. He has performed, altogether, some -100 injections upon seventy-nine patients, and says that he has always succeeded in reducing the size of the swelling. He has never had any bad result. He recommends this treatment only for soft parenchy- matous goitres, and not for the fibrous, cystic, or any other kind. Injection of Cystic Goitre. — For the injection of cystic goitre, iodine has been largely employed. It is open to the same objections that have been mentioned in connection with the injection of parenchymatous goitre. The use of perchloride of iron, instead of iodine, has been recommended for cystic goitre, and is often employed. The chief advantage of employ- ing perchloride of iron is that haemorrhage is more readily checked. The injection of perchloride of iron has been especially advocated in England bv Sir Morell Mackenzie, f and as his description of the method is the best with which I am acquainted, the directions that he gives may be quoted here : "The cyst is first punctm*ed and emptied with a trocar at its most dependent part, a drachm or two of the solution of perchloride * Wiejie?- Med. Presse, 1890, xsxi. p. 1. J Heatli's " Diet, of Sm"gery," Art. Diseases of Thyroid Gltxud. 238 THE THYROID GLAND. of iron* is then injected, the canula with its plug and the iron solution being left in the cyst. After twenty-four hours the plug is removed, and the contents of the cyst withdrawn. If the fluid be then found to contain much blood, or if it be thin and sei'ous in appearance, a second injection must be made. In other words, while ha?morrhage must be carefully prevented, a slight inflamma- tion of the lining membrane of the cyst is essential. One injection is generally sufl5cient, but if the first injection fluid be too quickly removed, the process may have to be repeated three or four times at intervals of two or three days. When reaction has taken place and the discharge is free from blood, the canula with its plug must still be kept in the cyst. Poultices of linseed meal should be kept constantly applied for three or four weeks, sometimes longer. When suppuration is well set up the plug may be removed ; the canula, however, being allowed to remain until the secretions become limited in amount and thin in consistence. When the cyst is A^ery large it is best to try to reduce the quantity of fluid before injecting. This can often be done by drawing off a small amount, say two or three drachms, at intervals of a day or two on several occasions. No attempt must, however, be made to empty the sac entirely, for if this is done haemoi-rhage takes place from the lining membrane of the cyst into its cavity, which soon becomes full again. The duration of the treatment is from three weeks to four months, according to the size of the cyst, the usual time being six to eight weeks." Those who desire further information concernino- the details of Mackenzie's method of treating thyroid cysts will do well to read a paper by Mr. Mark Hovell on the treatment of cvstic goitre, "f I have never employed this method myself, as I consider it to be too dangerous. Suppuration appears to be a necessary part of the curative process, and having been once started, may be very difficult to control. It is veiy apt to lead to death from septic absorption. The dangers of suppurating goitre are, however, too well known to require further comment. Although there can be no doubt that this method does, in many cases, effect a cure, yet there is equally little doubt that it often fails. Either the patient is left with a fistula or the tumour returns after a while. A more or less permanent fistula * A watery 2.5 per cent, solution of perchloride of iron is used, t Lancet, 1888. p. 264. TREATMENT BY INXISIOX. 139 is especially likely to be produced if the walls of the cvst be firm and unyielding. Of this I have seen several distressing examples. (Fig. 86.) Another objection to injecting encapsuled thyroid tumours is that if the injection fails to cure, and enu- cleation becomes neces- sary, the latter opera- tion mav be rendered more difficult owing to the adhesions set up round the tumour. Some of the most troublesome enuclea- tions that I have had to perform have been in cases in which injec- tion had previously been perform ed . Never- theless, the method has its advantages. It is simple and requires no oTeat knowledge of aseptic surgery for its performance. ^lore- over, if successful, the scar that is left may be much smaller than that produced by any cutting operation. At the present day this method of treating thvroid cvsts is employed chiefly by those who are not familiar with the details of modern aseptic surgery, and upon those who. being exceed- ingly anxious to avoid a linear scar, are willing to incur a greater risk in order to attain this object. Incision. — Direct incision of a goitre is a method em])loyed chiefly in cases of cvsts and is of very limited applicability. The practice of incising thyroid cysts, and stitching their cut edges to those of the skin, is one which has now been almost entirely superseded by the much safer and more rapid method Fig. se. — A mau in whom a cystic yoitre had been tapi^ed aud injected some years previonsly (at another hospital ). A fistulous opening- had existed ever since the operation. (Seen at St. Bart. Hosp. in 1S86.1 040 THE THYROID GLAND. of enucleation. It is still, however, to be recommended for certain cases in which, from old or recent inflammation or other cause, the cyst is too adherent to surrounding parts to permit of enucleation. Some cases of suppurating goitre have to be treated, at any rate at first, by incision. Enucleation or extir- pation may have to be undertaken later. Incision of the isthmus as a means of treating parenchymatous goitre will be discussed separately in the next chapter. Seton. — A method of treatment of goitre formerly much in vogue, but now happilv becoming obsolete, is that of the intro- duction of a seton. A piece of silk or some similar material is passed right through the substance of the goitre and left in situ for days or weeks. Usually the goitre shrinks in size and may become permanently cured. This method is obviously open to two serious objections. First, there is considerable danger of transfixing some large vein and thus causing serious or fatal haemorrhage. Secondly, there is very serious risk of setting up septic inflam- mation in the goitre, and in the cellular tissue of the neck, and this, in its turn, is very likely to lead to pyaemia. A case, illustrating this latter danger, has been kindly com- municated to me by Dr. Bankart of Exeter : A young man had a goitre^ probably parenchymatous in nature, into which a seton was inserted on account of the dyspnoea from which he was suffering. Suppuration in the neck and mediastinum quickly ensued ; necrosis of several rings of the trachea took place and the patient died. In the museum of the Koyal College of Surgeons is a speci- men * of a thyroid cyst some three inches in diameter. " A seton introduced through the cyst by the surgeon in attend- ance caused diffuse inflammation, resulting in the death of the patient.'"' There is also a similar specimen in the museum of St. George's Hospital. f A seton is probably more efficacious in the case of a cystic goitre than in that of a parenchymatous one. In the former case, the fluid would be drained away by the side of the seton. * Xo. 2yu4. t Xo. 20a. LIGATURE OF THYROID ARTERIES. i>41 The method is, however, too dangerous to warrant its recom- mendation for anv kind of goitre. liig-ature of Thyroid Arteries, — This operation has been recommended and performed manv times in the hope that by cutting off the blood supply to the goitre, its size might be diminished. The operation is bv no means a new one. In 1814, Walther * of Landshut tied both superior thvroid arteries in a voung man, the subject of dvspuoea caused bv goitre. Four years later, Mr. Coates of Salisbury tied the left superior thyroid in a similar case. In a case of Sir William Blizard's, the operation was followed bv sloughing and death from secondary haemorrhage. McWhinnie,+ in his lectures upon goitre, delivered at the Roval College of Surgeons, mentioned a case in which ]Mr. Earle tied this artery, at St. Bartholomew's Hospital. i; Giinther has, according to Liebrecht, collected twenty-one cases of ligature of the superior th\Toid artery for the cure of goitre. In two cases a cure is said to have been the result ; in fourteen there was some improvement ; in two there was none, and in three death ensued. All, or nearly all, the preceding cases, occurred before the days of antiseptic surgery. In all of them it was the thvroid artery alone that was tied, on one or on both sides of the body. For manv years the operation was completely out of fashion,. and was ne\"er performed. Of late years, however, it has been revived by Wolfler and Billroth, who have recommended that not only the superior but also the inferior thyroid arteries should be tied. By this means the blood supply to the gland is cut off far more effectually than by ligature of the superior arteries alone, which are con- siderably smaller than the inferior. Ligature of the superior thvroid arteries was recommended * " Xeiie Heilart des Kropf es durcli die Unterhindiuig der oberen Schiag- adern," Salzbach. 1817. p. 2.5, quoted in Cooper's Diet, of Surgery. t Lancet 1861, ii. 30. J See also cases by Dowries at the Kashmir Hospital. Lanref. 1881. i. 4.58 ; temporary benefit is said to have occm-red. II •■ De Texcision du goitre parench}-mateux,'' 1883, 170. 24'2 THE THYROID GLAND. largely on the ground that it is a simple operation and tolerably easy to perform The same argument can hardly be urged in favour of ligature of the inferior thyroid arteries. From their deep situation, lying as they do upon the vertebral column at the back of the goitre, and from their close proximity to the sympathetic nerve, it is evident that the operation of tying them is one of much difficulty ; in fact it may be more difficult than that of removal of the goitre. \'ahiable information upon the subject of simultaneous ligature of both superior and inferior thyroid arteries, is to be found in two papers by Rydygier * of Ci'acow. He publishes sixteen cases in which he had performed the operation. In the first case, the two arteries were tied only on one side of the neck. In the others all four arteries were tied at one operation. He operated by Drobnik's method at the posterior border of the sterno- mastoid in all cases except the last two ; in these he used a horizontal incision in order that the scar might be less visible. All the wounds, with one exception, were treated without drainage. The results were good in all cases except two. One of these was that in which the arteries of the right side only had been tied ; only slight diminution occurred in the size of the goitre, which was a parenchymatous one. The other case was one in which one lobe only of the gland diminished in size and it was then discovered that the opposite lobe contained a cyst. This was subsequently enucleated and the patient made a good recovery. In one case only did troublesome haemorrhage occur. In this case the right superior thyroid artery gave way while the ligature was being placed upon it. Violent haemor- rhage took place, and could be controlled only by leaving pressure forceps in the wound for more than a week. The patient eventually made a good recovery, and the goitre dimin- ished in size. In several cases there was a slight rise in tempera- ture (in one case up to 102'), but this quickly subsided. Rydygier discusses the question whether it is enough to tie the arteries on one side of the neck only, and expresses himself strongly in favour of simultaneous ligature of all four arteries. Whether the operation can lead to the subsequent occurrence of cachexia strumipriva is a point which seems doubtful. . * OmtralUaftf. Chir., 1889, p. 2-1:1. LIGATURE OF THYROID ARTERIES. 243 The cases that appear to be most suitable for ligature of the thyroid arteries are early cases of parenchymatous enlargement and cases of exophthalmic goitre. With regard to the former, however, it seems to be better to treat them by medical means or, if operation is demanded, to do some more radical operation such as unilateral extirpation or resection, the results of which are extremely satisfactory. Ligature of the thyroid arteries for exophthalmic goitre has received the support of Kocher, who is, however, in favour of tying three only of the four arteries. It is obviously useless to treat cases of cystic, fibrous, or fibro-adenomatous goitre by ligature of the arteries. Ligature of the superior thyroid artery is best per- formed through an incision along the anterior border of the sterno-mastoid opposite the great cornu of the hyoid bone. The artery may be tied either near the tip of the great cornu of the hyoid or at the inner edge of the omo-hyoid muscle. The latter method is said to be the better when the goitre is large and the artery consequently much displaced. The apex of the upper horn of the gland is naturally a good guide to the vessel. Ligature of the inferior thyroid artery is much more difficult. This operation may be performed by one or other of three principal methods. (1) Internal to the sterno-mastoid (Velpeaa's method). An incision is made along the anterior border of this muscle. The veins passing from the thyroid gland to the internal jugular vein are tied and divided. The carotid sheath is drawn outwards away from the gland. The thyroid artery is then found at the inner border of the scalenus anticus muscle. The artery should be tied just where it changes its direction from the vertical to the horizontal. This operation is usually difficult. Many veins have to be tied. The artery is much overlapped by the goitre. The latter has to be lifted up out of its bed before the artery can be exposed. (2) Through the sterno-mastoid (Langenbeck's method, modi- fied by Wolfler). The incision is made over the sterno-mastoid. Its lower end is at the junction of the inner sixth of the clavicle with the remainder. The fibres of the muscle must be partially 244 THE THYROID GLAND. divided. Several large veins, including the external jugular, usual Iv require ligatui'e. Search is now made for the tendinous part of the onio-hyoid, an important guide to the artery. The tendon is drawn upwards or divided. The carotid sheath is drawn inwards, the phrenic ner\e outwards. The artery is then seen Iving at the inner edge of the scalenus anticus. If necessary this muscle must he drawn a little outwards. (3) Ej'tcrnal to the sterno-mastoid (Drobnik's method,* as practised bv Rydvgier). This appears to be the best method, at any rate for cases in which the gland is much enlarged. The incision is made at the posterior border of the sterno- mastoid. It begins at the clavicle or a little above it and is carried upwards to the point at which the external jugular vein crosses the posterior border of the sterno-mastoid, usually on a level with the lower border of the thyroid cartilage. The sterno-mastoid muscle and carotid sheath are drawn inwards and the arterv found as above. It is best tied immediately above the place where it is crossed by the omo-hyoid muscle. Rvdygier"*" has proposed a slight modification of Drobnik's original operation. He makes the skin incision not vertically, but horizontal Iv, a little above the clavicle. By this means the «car is rendered less visible. Exothyropexy. — ^This operation consists in cutting down upon the thvroid gland, dislocating it through the wound, and then leaving it exposed to the air. It has a twofold object, that of mechanically relieving the tracheal pressure and that of inducing atrophy of the exposed gland. First practised bv Jaboulay of Lyons in 1892, the operation has been performed much more often in France than in any other country. It is especially at Lyoiis that it is apparently in greatest favour. Our knowledge of it is due mainly to the experience of the surgeons of that town. In this country exo- thyropexy has not become popular, and it does not seem to me at all likely that it ever will. The best account of exothyropexy that has come under mv notice is that of Dr. Leon Berard, who in his excellent work on * Wien. nted. Wochenschr., 1887. p. (35. J Cent ralMatt fur Chirurgie. 188'J. p. 241. EXOTHYROPEXY. 245 goitre * has published many cases of exothyropexy ; nearly all of these occurred at Lyons in the practice of Poncet, Jaboulay, and their colleagues. The operation has been performed upon various kinds of goitre. It appears to have been performed most often upon, and to be most suitable for, the more solid and vascular forms of parenchymatous goitre and exophthalmic goitre. It is intended to obviate the risks of extirpation of such goitres. The proceeding has, however, risks of its own, and the objections to it are considerable and obvious. I have never mvself performed an exothyropexy, believing extirpation, if properlv performed, to be a safer, more satisfactory, and altogether better operation. The principal objections to exothvropexv are the mechanica , difficulties of effecting the dislocation in cases in which the goitre is deeply seated and causing much dyspnoea, the risk of venous haemorrhage and sepsis, the long time occupied bv the healing process, the liability to recurrence, and the verv con- siderable deformity which is necessarily produced bv the opera- tion. The cases in which it is most likely to be justifiable seem to me to be those of prominent and bilateral goitres of a paren- chymatous nature, in patients who are not suffering urgently from dyspnoea, and who do not object to the unsightly ap])ear- ance of the resultino- scar. It may perhaps be justifiable in certain unusual forms of prominent exophthalmic goitre of large size. It has also the advantages of being usually a short operation and one which requires very little of that exact knowledge of anatomy so essential for the successful performance of extiroa- tion. Method of Operating. — A median incision of suitable length is made in the middle line of the neck. This should extend downwards as far as the episternal notch. Any large superficial veins that may be encountered are clamped, cut, and tied. The incision is carried through the skin, fascia and layers of cellular 'tissue, until the capsule of the gland has been exposed. The wound is then enlarged with the fingers, which are insinuated gently between the surface of the goitre and the superficial tissues until the lateral borders of the goitre have been reached. * ■• Therapeutique chirurgicale du goitre." Paris. 1897. 2i6 THE THYROID GLAND. At this stage no instruments should be used for fear of tearing or cutting veins and other important structures. If, owing to the size of the goitre, the fixity of the structures over it, or any other reason, the edges of the goitre cannot easily be reached with the fingers, the operator must not hesitate to divide trans- versely the skin and muscles, so as to give more room. Each lateral lobe of the goitre has now to be dislocated forwards. This is effected by hooking one or more fingers round the external border of the lobe and then drawing it forwards. As a rule each lateral lobe must be dislocated separately, one after the other. Occasionally it is possible to dislocate both lobes simultaneously by Avidely opening the wound with the thumbs, while pressure is exerted upon the back of the lobes by fingers placed upon the skin at the sides of the neck. This proceeding, however, exposes the trachea to serious risk of dangerous or even fatal compression. The moment of affecting the dislocation, even of one lobe, is always a dangerous one, owing to the increased pressure exerted upon the trachea. The greatest care should be taken that the thyroid gland itself or the thyroid veins be not torn by the fingers. The fingers should be inserted at the sides of the gland, and not beneath its lower horn, where the veins are usually large and numerous. The fingers must never penetrate the thyroid capsule. The goitre having been dislocated, strips of sterilised gauze are now packed round the tumour in the cleft between the goitre and the edges of the skin wound. An antiseptic dressing is then placed over the whole of the exposed surface of the o-oitre. The strips of gauze which have been placed in the grooves between the goitre and the edges of the skin are intended to protect the mediastinum from infection by the fluids which exude abundantly at first from the exposed surface of the gland. These strips may be removed on the fourth day and need not be replaced. The skin is then allowed to unite with the goitre, and gradually re-covers it. Great care must be taken to keep the whole of the exposed surface aseptic during the process of cicatrisation. " Cutaneous cicatrisation is complete, on the average, by the end of six weeks or two months."* * Berard, op. rit. p. .321. EXOTHYROPEXY. 247 During the first few davs after the operation there is a copious exudation of serous fluid from the exposed surface of the gland. This exudation comes partly from torn lym- phatics, partly from the tui'gid veins compressed by the edges of the cutaneous wound, and consists also in part, no doubt, of the colloid secretion of the gland itself. After a day or two the veins on the surface of the tumour, which are at first swollen and prominent, become thrombosed. They then gi'adually become smaller, until at the end of about a week thev appear onlv as small brownish cords. It is worthy of note that Bcrard states that elevation of temperature is almost always ('' presque constamment ") present dui'ing the first eight or ten davs after exothvropexv. He explains this as "thvroid fever" due to absorption of secretion from the interior of the gland. In the course of several weeks after the operation the exposed gland gradually shrinks and recedes behind the skin. The latter encroaches upon the surface of the tumour, which becomes covered with a decreasins; area of g-ranulations, and finallv bv a scar. With regard to the ultimate appearance of the cicati"ix, Berard expresses himself as follows : " ^^^lat is usually foimd at the end of some months (after exothyropexy) is a decolorised disc, the dimensions of which vary from those of a two-franc piece (liV inch) to those of a five-franc piece (li inch), very smooth and shiny or else bossy, and which is adherent to the deeper parts of the neck, fixing them to the skin. Sometimes the appearance is still more ugly ; the little cysts which form during the shrinking of the tumour become adherent to the skin and project externally like true grafts of thyroid tissue, resembling gi'apes embedded in the skin." Berard gives an excellent photograph of a scar produced by an exothvropexv. It is certainly more ugly than any scar I have ever produced bv anv extirpation or enucleation operation. Complications of the Operation. — With regard to serious haemor- rhage, Berard is of opinion that with ordinary care it may usually be avoided, except in the case of very vascular goitres and of those which are very adherent to surrounding parts. He lays down a rule with regard to haemorrhao'e due to wound of capsular veins, namely that the lobe that bleeds should be 248 THH THYROID (iLAND. immediatcJv luxated externally. This tends to obviate dangerous bleeding into the cellular tissue of the neck. The haemorrhage moreover tends to stop spontaneously after dislocation has been effected. If bleeding still continue, it can more easily be arrested by pressure or ligature. If luxation of the lobe prove to be impossible, the bleeding must be arrested by leaving clamp forceps applied to the bleeding points. Secondary haemorrhage appears to be rare, occurring only when the wound has accidentally become infected. Painful dysphagia appears to be common during the first two or three days after bhe operation. In about one-third of the cases bronchitis appears to be troublesome. Complications due to the mechanical disturbance and dis- placement of the trachea appear to be not inicommon, although as a rule after exothyropexy the dyspnoea is relieved. In some cases of exothyropexy not onlv has the dyspnoea not been relieved but it has positively been aggravated. This will readily be believed by those who, like mvself, have had practical experience of the injurious effect of traction upon the trachea in the course of an ordinary operation of extirpation. If the dyspnoea be aggravated by exothyropexy it is recommended that the goitre be replaced, the surgeon contenting himself with the benefit that may follow mere division of the tissues m front of the goitre ; or tracheotomy may become necessary. This is, however, always a very serious complication of any operation upon a goitre, owing to the danger of setting up sepsis in the wounded cellular tissue of the neck. In at least one case, that of Jaboulay, removal of the manu- brium of the sternum has been performed to obtain access to a substernal goitre that was causing severe dyspnoea and that could not be reached by any other means. This is however a very serious complication and one that can be very rarely necessary. In some cases in which exothyropexy was found impracticable, owing to the impossibility of effecting the dislocation, the tumour has merely been laid bare by the operation. The wound has been packed with gauze. Shrinking of the goitre may follow this simple operation just as it may after a simple division of the isthmus. The possibility however of serious • EXOTHYROPEXY. 249 increase in the amount of dyspnoea due to inflammatory swelling must be borne in mind. Infection of the womid is obviously a serious danger and one which is not easy to avoid. Even Bei^ard, who is on the whole a warm advocate of exothyro- pexy, is obliged to admit that " it is very difficult to keep the dislocated e-oitre free from all infection." It is in the later stages of the healing process, when antiseptic precautions tend to become relaxed, that infection is apt to be produced. It may be followed by sloughing of the exposed gland and extension of the inflammatory process to the deeper parts of the neck and chest. MortalHij after Eocotliyropexy. — It is difficult to j udge of the true mortality after this operation. Berard has collected sixty- five cases of exothyropexy performed* chiefly upon parenchy- matous goitre but also upon several exophthalmic goitres. In four of these cases death resulted from pneumonia, septic infection with haemorrhage and acute Graves's disease (two cases) respectively. Among the sixty-one ciases that recovered were cases in which sloughing occurred, in which tracheotomy became necessary, or in which other operations such as extirpation or enucleation were subsequently performed. Many of the cases appear to have beneflted greatly by the operation, others seem to have been improved but little if at all. * By Poncet (15 cases), Jaboiilay (35), Pollossou (5), Blauc (3), Guillemot (3), Eocket, Albei'tin, Buchanan, and Hartmann (1 each). CHAPTER XVI. DIVISION OR RESECTION OF THE THYROID ISTHMUS. Early cases — "Atrophy" of lateral lobes — Explanation of — Dyspnoea not due to backward pressure of isthmus — Results of the operation — Reappearance of goitre — Conclusions. This operation is performed much more often in England than in other countries, and has been more highly praised by English than by Continental surgeons. Duncan Gibb appears to have been the first to advocate its performance. In the Lancet for 1875 he published two cases in which Mr. Holthouse, of the Westminster Hospital, had put into practice the operation suggested to him by his medical colleague. The first case was that of a cook, aged 29, who had had a goitre for about two years. Both lobes and the isthmus were affected. The amount of dyspnoea does not seem to have been great. On July 11, 1874, Mr. Holthouse exposed the thyroid isthmus, passed a ligature round each end of it, and removed the intervening portion. On July 17 the last ligature came away, and the woman subsequently made a good recovery. Four months later she was in oood health : the goitre was smaller and caused no trouble. The second case was that of a girl, aged 17, who had had a goitre for many years. The whole gland was enlarged, and caused dysphagia, dyspnoea, and cough. Some severe paroxysms of dyspnoea which had recently occurred made surgical inter- ference desirable. On December 15, 1874, an operation some- what similar to the last was performed by Mr. Holthouse. Instead, however, of dividing with the knife that portion of the gland that lay between the ligatures, he left it to slough away. After the operation the circumference of the neck DIVISION OR RESECTION OF THE ISTHMUS. 251 diminished from 14fh to 13J in. The patient recovered, apparently much reheved. For a period of nearly nine years the operation appears to have attracted very little notice, no cases having been published during that period. About the year 1883 M. Tillaux, of Paris, began to perform the operation, and soon afterwards Mr. Sydney Jones followed him and published some cases.* From this time onwards the operation has been practised extensively in this country. I have collected twenty cases from various sources published and unpublished. In eight at least of these the goitre diminished in size and the improvement lasted many months, in several cases more than a year. In four cases death occurred. In two at least of the cases the dyspnoea had been very severe ; in one of them death occurred during the operation. In one case the operation failed to relieve the dyspnoea, and removal of one lobe had to be performed. Mr. Jones has pointed out that the operation not only often gave relief from the dyspnoea, but that it caused a remarkable diminution in the size of the goitre, or, to use his own words, " an atrophy of the lateral lobes." That both these results — namely, relief from the dyspnoea and diminution in the size of the goitre, at any rate for a time —do usually follow the operation there can be no doubt, judging from the twenty cases before mentioned. Two questions may be discussed in connection with this operation : " What is the mode in which the relief from the dyspnoea is effected ? '' and " Is the diminution in the size of the goitre, and with it the relief from dyspnaea, permanent.''" It is frequently stated that as the isthmus is a band uniting the two lateral lobes, division of it will allow these lobes to separate from each other and so relieve the dyspnoea. This seems at first sight a plausible explanation, but it is, nevertheless, probably not usually the correct one. That this may be the result of the operation in some cases is not improbable. That it is so in all or nearly all cases cannot be admitted. I have seen the operation performed many times, and have frequently * Full details of Mr. Jones's cases will be found in the Lancet. 1883, ii. 900, and 1884, ii. 367. 252 THK THYROID GLAND. noticed that after the division has been effected the cut surfaces have not separated from each other at all. Sometimes, not only has the isthmus been divided but a considerable portion of it removed. What frequently happens, then, is that the lateral lobes, far from receding, actually come closer together to fill up the place of that portion of the gland that has been removed. Mr. C. A. Morton,* describing a case in which he operated for severe dyspnoea caused by a parenchymatous goitre, says that " after excision of more than an incb of the median part of the p-land the lateral lobes came tooether in the middle line." Then again, the relief from the dyspnoea frequently does not occur immediately, but only after the lapse of some hours or days. In several of the cases before mentioned no relief what- ever followed the operation. Thus, in an operation that I witnessed at Universitv College Hospital some years ago upon a boy with a large parenchymatous goitre causing considerable dyspnoea, a portion of the isthmus was removed. The cut surfaces on either side immediately came into contact, and the boy died of dyspnoea a few hours later. But relief from the dyspnoea should occur immediately after division if the constricting isthmus were the cause of the dyspnoea. Gibb, in his remarks upon the two cases published by himself, sa^s that his object was " to divide or remove that portion of the goitre which was in relation with the trachea itself, namely, the isthmus, before it had commenced to encircle the tube or had become too firmly adherent.'' Speaking of his first case, he says that he considered that " the cure of the attacks of dyspnoea was impossible without the removal of that portion of the tumour over the windpipe." It is clear, then, that he had fallen into the rather serious mistake of supposing that the cause of the dyspnoea lay in the direct pressure of the isthmus upon the front of the trachea. Hence that division or removal of the isthmus relieves the trachea from pressure. I venture to think that this view is wholly untenable. , * " The Causation and Treatment of Sudden Dyspncea in Goitre," Bristol Med. Ch'w. Jovr/i., 1896, p. 221. DIVISION OR RESECTION OF THE ISTHMUS. 253 The pressure of the goitre upon the trachea does not cause an antero-posterior but a lateral flattening of the trachea, as may be seen in Fig. 2. In this case the patient died from suffocation, and it will be seen that the trachea is greatlv flattened laterally like the scabbard of a sword, as Denime long ago explained. The trachea is never flattened antero-posteriorlv bv anv parenchymatous goitre or by any other form of general and uniform enlargement of the gland. AVhen the isthmus alone is involved without the lateral lobes, as bv the j^resence of a tumour within it, there mav be a slight amount of antero- posterior flattening; but such goitres never cause serious dyspnoea unless the tumour lies actually behind the sterniun, and even then the pressure is usuallv oblique rather than antero-posterior. The cause of the dvspnoea must be sought, not so much in the condition of the isthmus, as in that of the lateral lobes of the goitre. In suffocating parenchvmatous goitre, all parts of the gland are swollen and exert pressure upon everything in contact with them. That is, thev exert pressure not onlv upon the muscles and other structures outside of and around them, but also upon the trachea which lies between the two lateral lobes. Hence, it happens that mere division of the isthmus will not of itself free the trachea from the inward pressure of the lateral lobes. The effect of removal of the isthmus mav even be, as in the cases mentioned above, to cause the lateral lobes to come nearer to each other and so to increase the lateral flattening of the trachea. The real cause of the relief from the dyspnoea lies chiefly in the shrinking of the gland which follows the operation, and not in the mere mechanical separation of the two halves of the goitre. The next question is, " How is this shrinking caused 1 "" We must bear in mind that the enlargement of the gland in parenchvmatous goitre is very largely due to over-distension of the vesicles with secretion : therefore it is easy to miderstand that removal of that secretion will naturally cause diminution of the swelling. This is shown by the fact that the diminution 254 THE THYROID GLAND. does not occur at once but in the course of the few days fol lowing the operation. During this time the viscid colloid secretion has had time to ooze slowly aw^ay from the surface of the wound. Indeed, I have more than once, after operations upon parenchymatous goitre, seen this colloid secretion coming away from the gland. Thus in one case there formed in the neck, under the recently healed skin wound, a fluctuatino- swelling which was at first thought to be an abscess, but which, when opened, was found to contain a quantity of viscid colloid material that had evidently drained from the gland into the wound. Notes of a similar occurence will be found in a good many published cases. Ao-ain, the more fibrous the goitre the less the diminution in size that will take place. In a rare case of truly fibrous goitre on which division of the isthmus was performed some years ago at St. Bartholomew's Hospital by Sir Thomas Smith, little or no diminution in size followed the operation and the dyspnaea was not relieved. Lastly, as the wound in the gland heals, and the further escape of colloid material is thus stopped, the goitre often slowly reappears, if the conditions which originally produced it continue to act. The reappearance of the goitre is doubtless due to reaccumulation of its colloid contents. The following case, which came under my notice in St. Bar- tholomew's Hospital in 1886, affords a good illustration of this point. The patient was a girl, aged 17, with a bilateral parenchymatous goitre, causing such extreme dyspnoea that she was almost suffocated by it. Division of the isthmus was performed by Mr. Langton. Not the least relief followed and immediate tracheotomy became necessary. Within a week from the time of the operation the goitre had shrunk so much that scarcely any swelling of the neck was noticeable. Then as the wound in the gland healed, the goitre gradually re-enlarged mitil, at the end of some weeks, it had neai'ly regained its former size. As dyspnoea was found to occur whenever the tracheotomy opening was closed, it became necessary to do some further operation and the right half of the gland w-as removed. The same sequence of events now occurred in the remaining half of the goitre. At first it gradually diminished in size, and then, as DIVISION OR RESECTION OF THE ISTHMUS. 255 the wound healed, it gradually and slowly enlarged again. In most of my own cases of unilateral extirpation of parenchy- matous goitre, the operation has been followed by marked diminution in size, and then by re-enlargement, of the remaining half of the goitre. The exact manner in which the colloid of the vesicles passes from them to the cut surface of the gland is a point upon which it seems unwise to express a definite opinion. There is some evidence in support of the view of Boechat and others, that all the thyroid vesicles communicate with each other. If this be so, it follows that any incision into the gland will tend to drain all the vesicles. Possibly, however, the drainage is effected, not directly but indirectly, through the medium of the lymphatics. All these facts seem to point to the following conclusions : (i) That division of the thyroid isthmus usually relieves dyspnoea, not by mechanically allowing the two halves of the goitre to separate, but by draining the gland of its colloid secretion. (ii) That the relief aiForded may be permanent, but that fre- quently the goitre reappears when the wound has healed and the secretion is again pent up in the gland. (iii) That in many cases in which very urgent dyspncea is pre- sent, a mere division of the isthmus will not relieve the dyspnoea sufficiently quickly, and it becomes necessary to do some further operation, either tracheotomy or, better, removal of some con- siderable portion of the goitre. The operation is therefore not one which can now be recom- mended, except perhaps in certain exceptional cases. For parenchymatous goitre without dyspnoea it is not necessary, because such cases are better treated by medical means, such as the administration of iodine or thyroid extract. Cases of parenchymatous goitre in which dyspnoea is considerable and which do not yield to medical measures generally require re- moval of a considerable portion of one or other lateral lobe. The possible danger of trusting to a mere division of the isthmus has already been mentioned. When the dyspncea is very severe and urgent, division of the isthmus cannot be relied upon to give relief sufficiently quickly. In some few such cases how- ever, it may be advisable to divide the isthmus and then to 256 THE THYROID GLAND. watch carefully the effect of this before doing tracheotomy. But tracheotomy is scarcely ever desirable for parenchymatous goitre, except at the hands of those who do not feel able to perform the larger but nuich safer operation of aseptic uni- lateral extirpation. The dangers of an open wound such as that produced by division of the isthmus, or of the necessary septic \\ ound of a tracheotomy, are obviously greater than those of a properly performed aseptic extirpation of one lobe. An extensive resection of the isthmus may sometimes be preferable to unilateral extirpation, in some cases of parenchy- matous goitre in which the goitre is unusually prominent in the middle line. Such an operation is however usually more severe than a simple unilateral extirpation. For all cases of adenoma or cyst, division or resection of the isthmus is unsuitable, being; far inferior to enucleation. CHAPTER XVII. TREATMENT BY EXTIRPATION (THYROIDECTOMY). Difference between extirpation and enucleation — Partial extirpation — Preparation of patient — Question of general aufesthetic — Local anajs- thetic — Position of patient — Skin incision : oblique, vertical, transverse — Treatment of infi-a-hyoid muscles — Recognition of gland — Isolation of lobe — Ligature of thyroid vessels — Veins often thin and liable to tear — Treatment of inferior thyroid artery — Avoidance of recixrrent nerve — Treatment of isthmus — Arrest of haemorrhage — Cleansing of wound — Asepsis better than antisepsis — Suture of muscles, of skin — Question of drainage — Dressings — Use of sponge — Fixation of head and neck — Position of patient after operation — After-treatment — Convalescence. The removal of a goitre by a surgical operation may be performed by one or other of two widely different methods. These two operations are known by the names of extirpation and enucleation and it is highly important that the difference between them should be clearly borne in mind. By extirpation is meant the removal of the gland or some part of it (generally one half) by an operation conducted as far as possible outside the capsule. The principal vessels are all tied or clamped before they are cut. The operation is performed deliberately, step by step, by careful dissection. The wound being kept free from blood, the operator is enabled to see exactly what he is doing. He thus avoids wounding, on the one hand the plexus of veins which lie on the surface of the gland beneath its delicate investing capsule, on the other hand the important anatomical structures which lie in close proximity to the gland. Enucleation, on the other hand, consists in the shelling out of a tumour from the interior of the gland. The removal of the tumour is usually effected rapidly and no attempt is 258 THE THYROID GLAND. made to tie the vessels until after the tumour has been removed. The difference between the two operations is analogous to the difference between the removal of a breast as performed for carcinoma and the removal of a flbro-adenoma from that organ ; or to the difference between a hysterectomy and the enucleation of a fibro-myoma from the uterus. Each of these operations has several modifications which will be described later. Total Extirpation. — This operation is one which is not now to be recommended on account of the grave after-results which are known to follow if the patient be deprived of the whole thyroid gland. Moreover it is in my opinion never necessary, except possibly in some very exceptional cases of malignant disease involving both sides of the gland. The performance of total extirpation differs in no Avay from partial extirpation, except that both halves of the gland are removed. Partial Extirpation. — In the great majority of cases extirpation is performed upon one lateral lobe and it is this operation therefore that will be described in detail. In some cases extirpation of one lobe is followed by extirpation of a portion of the opposite lobe. The preliminary preparation of the patient includes the administration of a purgative on the day before the operation and the preparation of the skin of the neck. The skin of the whole of the front and sides of the neck must be thoroughly scrubbed with hot water and soap, and then washed with spirit, ether or turpentine to remove all greasy matter. An antiseptic dressing of carbolic acid lotion 1 in 30, or perchloride of mercury 1 in 2000 is then applied for several hours before the operation and is to be removed only when the operation is about to be commenced. Anaesthetic. — The question of the administration of an anaesthetic is an important one. If the patient has little or no dyspnoea or stridor, and if there is no history of paroxysms of dyspnoea, then there can be no objection to the administration of a general anaesthetic. But if, on the other hand, there seems to be any probability TREATMENT BY EXTIRPATION. 259 that serious dyspnoea may occur during the course of the operation, then it is certainly better to dispense altogether with a general anaesthetic and to do the operation under cocaine or eucaine. In cases where severe dyspnoea is actually present at the time of operation the use of a general ana?sthetic involves much danger. Many cases have been recorded in which sudden death from the anaesthetic has occurred in the course of the operation or even before the operation has actually begun. With the help of cocaine or eucaine the removal of a goitre may be effected with very little pain. Patients upon whom I have operated without the use of general anaesthesia have, after the operation, always assured me that the amount of pain felt by them was really quite trivial. Directly the tumour has been removed, and the danger of suffbcation is over, an anaesthetic may be given, if it be thought desirable, while the wound is being sewn up. I have been in the habit of offering an anaesthetic to the patient at this stage, but up to the present time in no case has the offer been accepted, the patient always saying that the pain was not sufficiently great to deinand it. Even if no anaesthetic of any kind, either local or general, be used, the pain of an operation for goitre is confined chiefly to the beginning and the end of the operation, when the skin is being incised or sewn up. The patients often complain also when traction is exerted upon the tumour or upon the deeper parts of the wound. In cases of severe dyspnoea there is a great advantage in the patient being conscious, since he can then immediately give warning if the operator be pressing unduly upon the narrow trachea. Patients suffering from suff'ocative goitre have on several occasions informed me that they dreaded the taking of an anaesthetic more than the actual operation and have felt relieved at being informed that the administration was neither necessary nor desirable. At the same time probably few patients will go so far as to declare, as one of Kocher's patients did, that it was a real pleasure to be operated upon ! By this he meant no doubt that the relief produced by the removal of a suffocating goitre was so great that the discomfort of the operation was as nothing to him. A minor advantage in dispensing with the use of an anaesthetic is that the patient is saved much of the retching and vomiting 260 THE THYROID GLAND. ihat fre(juently follow a prolonged operation performed under general ana?.sthesia. The rapid healing of the wound is thereby facilitated. If a general anaesthetic be employed it is well to give as small a quantity of it as possible, and to keep the patient only lightly under its influence. If cocaine be used, a solution containing not more than half a grain should be injected in several places in the line of the proposed incision. The use of cocaine in larger doses is apt to be followed by faintness or even by more dangerous symptoms. Eucaine may be used in much larger doses and has further the advantage that it can be sterilised by boiling. Both solutions decompose easily and should therefore be freshly prepared shortly before use. An injection of a quarter or a third of a grain of morphia about twenty minutes before the commencement of the operation is a useful adjunct to the use of the local anaesthetic. Position of the Patient. — Some surgeons prefer to have the patient in a half-sitting position. For myself, I prefer that he should be in the recumbent position, but with the shoulders well raised. The head should be extended as far as is compatible with safety, so as to draw the goitre as much as possible away from the thorax. Much extension of the head, however, may interfere seriously with the patient's respiration. It is well to ascertain, before the operation is begun, in what position the patient can breathe most comfortably, and then to get an assistant to hold the head firmly in that position throughout the operation. By these means the trachea, often greatly narrowed, is less likely to become kinked and occluded. Skin Incision. — Many different skin incisions have been practised. The choice depends largely upon the size and shape of the goitre. There are three chief varieties : (1) The oblique incision in the long axis of the tumour that is to be removed ; generally along the inner border of the sterno-mastoid muscle. This is the incision that should be adopted in most cases of extirpation and in those generally in which the operation is likely to be difficult or dangerous. It gives the operator plenty of room, and enables him to reach the upper horn of the gland without undue TREATMENT I3Y EXTIRPATION. 2{)1 262 THE THYROID GLAND. difficulty. The lower end of the incision should, in almost all cases, be carried down to the upper border of the sternum. If it be intended to operate upon both lobes of the thyroid, the incision should be made in a more slanting direction, the lower part of the incision being carried well across the middle line at a somewhat higher level than the top of the sternum. In some cases of bilateral extirpation the angular or Y-shaped incision, with the point of the angle opposite the cricoid cartilage, origin- ally recommended by Kocher, may be employed, but is seldom necessary. I have never yet found any difficulty in getting easy access to both lobes through a single incision, and have rarely employed the angular incision. Occasionally, when the tumour is very large, it is desirable to make an elliptical incision, so as to remove a large portion of skin. Thus in the patient from whom I removed the large goitre shown in Figs. 34-37 (pp. 78-80), an oblique incision was made across the front of the tumour and a second curved one along the right and lower borders. As a rule, however, no excision of skin is required, even in removing goitres of considerable size. The redundant skin soon contracts. {See Figs. 87, 103, and 111.) (2) The vei'tical incision may be used for goitres situated in or near the middle line of the neck, especially if they be small. It involves less interference with the infra-hyoid muscles, but, on the other hand, renders access to the region of the superior thyroid artery less easy. In some cases of deep-seated tumour beliind the sternum in which the operator is uncertain which half of the gland should be removed, the vertical incision may be employed for exploratory purposes, the incision being sub- sequently prolonged obliquely upwards to the right or left, as desired. It has the disadvantage that in young people the resulting scar is apt to become contracted and ugly. (3) The transverse incision a little above the upper border of the sternum gives the best results as regards the scar, but, on the other hand, it does not give the operator nearly so much room. It is consequently less easy to reach the upper horn of the gland unless the goitre is large and prominent. To obtain sufficient room, it is often necessary to divide very freely the infra-hyoid and even the sterno-mastoid huuscles. It is most suitable for TREATMENT BY EXTIRPATION. 263 CO X g g r 264 THE THYROID GLAND. prominent goitres, for small goitres low down in the neck, and for easy cases of enucleation in general. It is, in my opinion, not to be recommended, as a rule, to those operators who have had but little experience in removing goitres. If care be taken to place the incision in the line of one of the natural creases of the skin, the subsequent scar will be scarcely visible, and can, moreover, be easily concealed by the dress. In the case of ladies wlio wish to \\'ear low dresses the scar can be easilv hidden by a necklace or a band of velvet. After division of the j3latysma_and fascia, the superficial veins of the neck are exposed, and several of them will probably rcc[uire ligature. The oblique anterior^jugular vein will generally he found running along the inner border of the sterno-mastoid, and should be tied. Care should be taken in making the oblique skin incision not to split open this vein. At the lower end of the incision, just above the sternum, a transverse vein will generallv be found, requiring a double ligature. The infra-hyoid musclgs must now be dealt with. In the case of small goitres near the middle line, it may be possible to draw these muscles aside without dividing them. Care should be taken, whenever possible, to draw them outwards, not inwards, in order to avoid dividing the nerves Avhich enter their outer borders. If these nerves be divided the muscles atrophy, and afterwards cause an unsightly hollow in the neck. For the same reason, if the muscles have to be divided, as is usually the case, they should be cut near their upper ends, close to the hyoid bone, and then thrown dowuAvards and outwards. At the end of the operation they can then be replaced and sutured without nmch harm having been done to them. If the operation is likely to be a difficult or dangerous one, it is not worth while to spend time over a comparatively unimportant point like this ; in such cases the muscles may be divided wherever it seems most convenient to do so. When the transverse incision is used, the skin should be drawn upwards (or downwards) before the muscles are divided, so that the wounds in the skin and muscles do not correspond. Otherwise the muscles are likely to adhere to the cicatrix and cause a certain amount of deformity. The infrahyoid muscles are often very much thinned and spread out over the surface of the goitre. I have even seen them TREATMENT BY EXTIRPATION. 260 r— a O - ti = (D = r— I - r CL 266 THE THYROID GLAND. mistaken by an inexperienced operator for the proper capsule ~of"the goitre. Sometimes they lie in deep grooves on the surface of the gland, and must be carefully lifted out of these The surface of the thyroid gland has now been laid bare. It is covered by a layer of loose connective tissue lying immedi- ately outside the capsule of the _ gland. This layer is very yW Fig. 93. — The preceding- (Fig-. 91), three weeks after operaJou. Showing- small transverse scar low down in the neck. {See Appendix, Case 53, p. 346.) di stinct and easily recognised in all cases except those in which previous inflammation has matted the parts together.' Thjs is likely to be the case when the goitre has been subjected to i'AkJ injection, or if suppuration hes taken place in it. The capsule of the gland can usually be recognised without difficulty^by the network of large veins that ramify beneath it. _ The gland together with its capsule has now to be separated from the surrounding parts, f.nd m perfoiming this part of the TREATMENT BY EXTIRPATION. 267 operation the greatest care must be exercised not to wound, on the one hand the plexus of the vein Iving beneath the capsule, on the other hand the important structures lying in close contact with the gland. If the capsule and its veins be wounded the haemorrhage may be very difficult to control. If forceps be applied, the vessels or the glandular tissue are very apt to tear, and further haemorrhage takes place. Often the wounded gland oozes blood in an alarming and uncontrollable manner, the wound is obscured with blood and the subsequent steps of the operation become much more difficult. Even roncfh handlino; of the o-land mav lead to tearing of its thinned and dilated veins. The greatest care should therefore be taken to conduct the dissection with the utmost carefulness and delicacy. Should a vein be wounded accidentally, it may be possible to stop the hgemorrhage by means of a ligature carefully applied. But in cases in which a small puncture only has been made it is often better to get an assistant to put one finger on the bleeding point and to continue the dissection. The front of the gland is easily cleared and the muscles being held on one side bv retractors, search is made for the pi'incipal vessels, which must be tied just outside the points at which they penetrate the capsule. It is generallv best to begin bv clearing the upper horn and placing ligatures upon the superior thyroid artery and vein. But if severe and dangerous dvspnoea be present it mav be best to besin bv diseno-asins: the lower horn, so as to relieve the trachea from pressure. If the vessels are small thev mav be tied in a common ligature, but if thev are large they should be tied separatelv. It is often best to tie the arterv before the vein, so as to diminish the amount of blood in the gland. The artery will generallv be found without much difficulty at the inner border of the apex of the upper horn. It is desirable to tie it rather high so that the ligature may be above the origin of a large branch which is frequently found running from near the apex down the back of the gland. Sometimes when the g-oitre is large and extends nearlv to the lower jaw, there is considerable difficulty in obtaining access to the arterv, which lies at the bottom of a narrow space between 268 THE THYROID GLAND. the tumour and the jaw. This difficulty is increased if the head, on account of tlie dyspnoea, cannot be thrown well back- wards. Both veins and arteries are secured with double ligatures and the vessels then divided. The superior thyroid artery and vein having been secured, attention is next directed to the middle and accessory thyroid veins. The most common situation of these veins is shown in Fig. 7. They should be carefully isolated and tied with double ligatures before being divided ; they should be tied just where they leave the capsule of the gland. In dissecting towards the outer border of the goitre, care should be taken to avoid wounding the internal jugular vein, which is frequently expanded over the side of the tumour and may easily be wounded. It frequently lies in front of or even internal to the carotid artery and the pulsation of this vessel is consequently not a safe guide to the position of the vein. The branches of the inferior thyroid veins running downwards from the lower part of the goitre must now be dealt with in a similar manner. Here, again, there may be much difficulty in obtaining access to the veins if the goitre be a large one and extend down behind the sternum. The importance of raising the goitre so as to obtain as much room as possible is obvious. Care should be taken not to cut or tear any of these veins before they are tied, lest they should retract into the cellular tissue behind the sternum and there give rise to troublesome haemor- rhage. The goitre having been completely freed from its vascular connections above, below, and on the outer side, should now, if possible, be lifted up out of its bed and turned over towards the opposite side,* in order that the inferior thyroid artery and accompanying veins may be dealt with. If the fixity of the tumour be such that the latter cannot be lifted out of its bed, then the difficulty of tying the artery is * lu some cases, mid especially when the goitre is a pi-oiiiineiit one, tliis dislocation of the tumour out of the wound may be effected with advantage at a much earlier stage of the operation, before the superior thyroid vessels and inferior thyroid veins have been tied. In these cases the lateral thyroid veins must be tied before the dislocation is effected. The early dislocation of the tumour has the adA'antage of affording relief to the pressure on the trachea. TREATMENT BY EXTIRPATION. 269 much increased. Access to the artery is favoured ibv drawino- the sterno-mastoid muscle well outwards, or even by dividino- some of its fibres. Or it may be advisable to postpone ligature of the artery until the isthmus has been cut through, and the tumour thus rendered more movable. The inferior thyroid artery may be tied in one or other of two situations. The main trunk may be tied at the inner border of the scalenus anticus muscle, just at the point where it changes its direction from vertical to horizontal, curving inwards to enter the gland. Or the branches may be tied close to the gland itself. If the main artery be tied, care must be taken not to wound the sympathetic nerve which lies in very close relation to it. It is quite possible also to mistake the vertebral for the thyroid artery. The branches of the artery are more easily found, and should be tied inside the line of the recurrent laryngeal nerve. Which- ever method be adopted, the position of this nerve should be constantly be borne in mind lest it be accidentally cut or included in a ligature. It lies, most commonly, superficial to the artery, but may pass behind it. It may lie among the branches, some of these passing in front of and others behind the nerve. Some operators recommend that search be made for the nerve and that it be dissected out and held on one side. If the operator is doubtful about the position of the nerve, he may do well to follow this advice. It is better, however, to know exactly where the nerve should be and to avoid it without unduly exposing it. The wound must be kept as free as possible from blood while this stage of the dissection is being carried out. In removing the posterior border of the gland from the pharynx and other structures on its inner side, the anatomical arrangement of the fascia at the back of the gland (described on p. 7) must not be forgotten. In those cases especially in which the goitre sends a prolongation inwards behind the pharynx and oesophagus, the arrangement of the fascia is liable to deceive the operator, and to carry him, in his dissection, away from the surface of the gland. It is probably a want of due 270 THE THYROID (JLAND. appreciation of this important anatomical point that has led in some recorded cases to an unexpected wound of the pharynx or trachea. The next step in the operation is the division of the isthmus. The principal vessels lie along- its upper and lower borders and should be secured in these situations with double ligatures. Any veins visible upon the anterior surface may be clamped. The isthmus is then freely divided with knife or scissors. The few vessels that bleed from the cut surface of the isthmus must be picked up with forceps and tied. If the isthmus is small, it may be included in a single ligature, which is drawn tight as the glandular tissue is divided. This proceeding tends to prevent the escape of colloid into the wound. If the isthmus is very thick it may mechanically prevent the goitre from being turned over in the manner previously described. In such a case it may be impossible to reach the inferior thyroid artery satisfactorily, and the isthmus must then be divided at an earlier stage of the operation before search is made for the artery. I have never found the haemorrhage from the substance of the isthmus to be serious. The principal vessels lie upon the surface immediately beneath the capsule. After the isthmus has been divided, the few remaining connections of the tumour may be severed and the tumour removed. In dividing the band of connective tissue that unites the gland to the cricoid cartilage, care must again be taken to avoid Avounding the recurrent nerve which lies in close proximity. Indeed, at this, the final stage in the removal of the tumour, it is frequently a good plan to carry the knife a little outwards into the gland itself. By thus making the section a little outside the nerve and leaving a small portion of the gland and its capsule to protect it, the risk of wounding the nerve is still further obviated. The goitre having been removed, the treatment of the ex- tensive wound of the neck next demands attention. All haemorrhage must be scrupulously arrested. It is espe- cially on the inner surface of the wound that several small bleeding points may be found to require ligature. TREATMENT BY EXTIRPATION. 271 Any bits of blood-clot that may remain in the wound must be carefully removed by sponging. If perfect asepsis has been maintained throughout the opera- tion, as it should have been, the wound requires no further cleansing than is afforded by gentle sponging with sterile saline solution, or by laying against it a sponge that has been wrung out of weak sublimate solution. Irrigation of the wound with strong solutions of carbolic acid or perchloride of mercury should be avoided as being unnecessary and harmful. It is aseptic rather than antiseptic treatment that is desired in the removal of a goitre. In order to preserve asepsis during the course of the operation it is desirable that as little as possible of the wound should be exposed at any one time. While the operator is working at any one part of it his assistant should take care to cover the rest of it with layers of sterilised gauze. This not only keeps the wound clean but also checks haemorrhage from minute vessels. The dangers of sepsis in an extensive wound involving the cellular tissue of the neck are too well known to require further mention. If the infra-hyoid muscles have been divided, the cut ends are replaced and accurately united by fine buried sutures. A few points of suture may also be used to unite the cut edges of the platysma. It is generally advisable to drain the wound for twenty-four hours. This is best effected by laying in it a sterilised strip of gutta-percha tissue or gauze, or a drainage-tube. In cases in which the asepticity of the wound is doubtful, as in some cases of suppurating goitre, the safest course to pursue is to pack the whole wound with strips of gauze. For such cases it has been recommended to cover the whole internal surface of the wound with a layer of iodoform gauze and then to place inside this, strips of gauze wrung out of some antiseptic solution. The latter must be changed daily, but the former may be left in for many days until it becomes loose and can be removed without difficulty. The edges of the skin wound must be accurately united by fine sutures of silk or fishing gut. The wound is then covered with strips of antiseptic gauze 272 THE THYROID (iLAND. wrung out as dry as possible. Follow ing- the practice of Jiflliaiid and others, I usually place outside the first layer of gauze one or more marine sponges at the sides of the neck. These tend to keep the surfaces of the woiuid in contact and also help to keep the trachea in place. Outside the S'auze dressing a thick layer of cotton-wool must Fig. 94. — Bilateral Parenchymatous G-oitre. The riyi't lobf was C'xtirpatLMl on account of dyspna'ii. be placed. This should cover a large area, from the chin to the lower part of the sternum, and laterally as far as the shoulder on eithfer side. It is important that the bandages should be applied so as to lix the head, neck, and shoulders, and thus keep the wound as quiet as possible. It has been recommended that strips of plaster of Paris be applied to the sides of the head and neck toensure rest to these parts. I have never adopted this plan. TREATMENT BY KXTIRPATIOX. 273 I make a point, however, of always impressing upon the patient before the operation the gTeat importance of keeping the head and neck as still as possible for the first two davs after the operation. After the effects of the anaesthetic have passed off', unless collapse contraindicate this position, the patient should lie in Fig. 95. — The precediiii;- « Fig-. 94), six days after operation. ( .SY-." ApiK-udix, Case 111, p. 3-52, and Eoyal Free Hosp. Mus. Xo. xxii. 21.; a semi-recumbent position, the head and shoulders being well propped up \\ ith pillows. ]Most patients after an operation for goitre are much more comfortable in this position than Avhen kept lying down. A sandbag on either >.ide of the head helps to steady it and keep it in position. The after-treatment of the case is u.sually simple. For several hours after the operation no food should be given ; then milk. .s 274 THE THYROID GLAND. beef-tea, and other fluids may be given for a day or two, vmtil the patient can swallow solid food without difficulty. Deglutition is usually somewhat painful for the first day or two. It is occasionally advisable, in bad cases, to feed a patient partly or wholly by the rectum for a few days. My patients are almost always allowed to get up on the second or third day after the operation, but occasionally bad cases are kept in bed a little longer than this. The drainage-tube is always removed at the end of twenty- four hours, except in the few cases in which primary union is not to be expected. The stitches should be removed on the third or fourth day after the operation. By the end of a week the patient is usually completely well and able to return home. CHAPTER XVIII. MODIFICATIONS OF EXTIRPATION—RESECTION— RESECTION-EXTIRPATION— AMPUTATION. Mikulicz's resection— Description — Results — Kocher's resection- extirpation — Comjjai-ison of the two operations — Advantages over other operations — Amputation. Resection. — Mikulicz of Cracow has given the name of re- section to an operation which is particularly suitable for cases of parenchymatous goitre. The object of it is to remove the chief part of one or both lobes and to avoid any risk of wounding the recurrent nerves. At the same time enough thyroid tissue is left behind to carry on the functions of the gland. The following is Mikulicz's description of the operation as he performed it upon a boy of sixteen who had a large bilateral goitre causing much dyspnoea : * "I began the operation," he says, "intending to perform the ordinary one of removal of the left lobe, and hoping to be able to leave the right intact. In the course of the operation, however, it became evident that the right lobe lay partly behind the sternum, and would, if left, prove a source of danger to the patient. So in- stead of doing the usual extirpation, I resected this lobe in the following manner. First of all it was isolated as far as possible in the usual way with blunt instruments. The smaller blood vessels were tied with double catgut ligatures. I then tied the superior thyroid artery and vein in the ordinary manner at the summit of the lobe ; also the superficial vessels passing to the lower part of the gland. I now, by means of short snips of the scissors, freed that portion of the tumour which was adherent to the front and side of the trachea, but took care not to go too far back, so as not to come into collision with the recurrent laryngeal nerve. * " Ueber die Resektion des Kropfes nebst Bemerkungen ueber die Folgezu- stande der Totalexstirpation der Schilddi-lise," Centralhlatt f. C'hir., Dec. 19. 1885. ^276 THF. THYROID (ILAND. Eventually the whole tumour was attached only to the angle between the trachea and oesophagus, where it covered the recurrent nerve and inferior thyroid artery. This attached portion, the hilus of the gland, I treated like the short thick pedicle of an ovarian tumour. I had already on previous occasions convinced myself that the parenchyma of the gland was extraordinarily tolerant of mechanical injury, and this knowledge led me without scruple to put a row of ligaturfes upon the gland substance itself. While my assistant with his fingers compressed the vessels entering the hilus, I split the pedicle lengthwise with blunt scissors into several por- tions, seized each of these in a strong pair of pressure forceps and placed catgut ligatures in each of the clefts so formed. Then the goitrous mass was cut off with scissors, leaving a pedicle of 5—10 mm. (i-|^ inch) in length. The forceps squeezed out nearly all the glandular tissue, leaving in their grasp little but connective tissue. The result was that the catgut ligatures could easily and safely be placed round the separated portions of the pedicle. Not a drop of blood came away from the cut surfaces ; only here and there in the intervals was a little oozing ; this slight haemorrhage was easily stopped by the application of a few ligatures. The remainder of the gland had now shrunk to a lump about as large as a chestnut, which lay in the angle between the trachea and oesophagus. Neither recurrent nerve nor inferior thyroid artery came into view' on this side." The wound healed by first intention and the patient was dis- charged ten days after the operation. Breathing was easy, the voice was weak but clear and the vocal cords were intact. Four months later the patient was seen again ; there was not the slightest trouble in breathing and the voice had regained its strength ; the neck was slender and presented no sign of swelling. At the time of the last report seven months after the operation, the condition of the patient was in every respect satisfactory. Results of Mikulicz's Resection. — Trzebicky * has pub- lished details of twenty -three cases of Mikulicz's resection per- formed by Mikulicz or himself. The patients were nearly all young subjects, fifteen of the number being under twenty-five years of age. In all cases dyspnoea was present, in many it was very severe. * " Weitere Erfahrimoeu iiber die Resection des Kropfes naeli Miknlic-z." Langenbeck's Arch. f. Id'in. Chlr., 1888, vol. xxxvii. p. 49S. RESECTION. 277 111 the first five cases, one lobe of the gland was completely removed, then the other was resected. Nine times resection of one lobe only was performed, nine times both lobes were simultaneously resected. The only fatal case occurred among those in which both lobes were resected. The patient was a girl aged 16 ; after resection of the right lobe and during the separation of the left lobe an attack of severe dyspnoea occurred Avhich necessitated the per- formance of tracheotomy ; the operation was hurriedly concluded and the wound packed with iodoform gauze. Two hours later severe recurrent haemorrhage took place from the right side of the wound, the bleeding could not be controlled and the patient died. At the post mortem, it was found that the ligature had slipped from the superior thyroid artery. Of the remaining twenty-two cases, in one tracheotomy had to be performed ; this necessarily prevented primary union in the wound, which nevertheless healed by second intention without any trouble. Twenty-one times the wound was closed and drained ; in only one of these did the wound fail to heal by primary union ; this was a case in which artificial respiration had to bt performed several times in the course of the operation. Perfect asepsis could not be maintained and in consequence, suppuration, with necrosis of the stump, took place, and recovery was delayed for about ten weeks. In the remaining twenty cases, with the exception of two in which a little superficial suppuration occurred, healing by first intention was perfect. In three cases, the otherwise normal convalescence was complicated by an attack of slight inflamma- tion of the luiiffs which however exerted no deleterious effect upon the healing of the wound. As regards the vocal cords in the twenty-two cured cases, they were intact both before and after the operation. In nine cases there was either marked or slight paralysis of the cords before operation ; in four of these the paralysis remained after operation ; in two cases it dis- appeared immediately after the operation, in two other cases, only after the lapse of a few months. In no case did the operation produce any deleterious effect upon the voice, or injury to a previously healthy vocal cord. As regards after-results, in three cases no information could 278 THE THYROID GLAND. be obtained. The others were known to be in excellent health, in eight cases two to three and three-quarter years after the operation, in five cases one to two years, and in six cases six months to a year afterwards. The dyspnoea in all cases disappeared almost immediately after the operation and, so far as is known, did not return. In one case, an attack of suffocative dvspnoea occurred immediately after the operation. In no case was there any report of a return of the goitre in that part of the gland which was left behind, although many of the cases were examined personally, and in many others information upon this point was obtained from the local doctor. In no case did any impairment of general health (cachexia strumipriva or tetany) follow the operation. Of the fourteen patients on whom the operation was performed on both sides, twelve are known to have remained in good health. Resection -extirpation. — This name has been given by Kocher * to an operation similar to that of ^Mikulicz. As the name implies, the operation is a combination of two operations. Kocher first isolates the lateral lobe of the gland as in extirpa- tion, tying the superior and inferior thyroid arteries and their corresponding veins. Then the isthmus is cut through at its thinnest part. The vessels at the upper and lower borders are tied. Then a section is made through the gland from before back-wards, beginning near the junction of the isthmus and lateral lobe and ending on the posterior surface of the gland outside the line of the recurrent laryngeal nerve. It should be borne in mind that the nerve is sometimes drawn out of its normal groove between the trachea and oeso- phagus and is stretched over the posterior surface of the gland. Care should therefore be taken, in making the section through the posterior surface of the gland, to keep well away fi'om the nerve lest it be accidentally wounded. Kocher lavs stress on the importance of making the section on the inner side of the upper horn well above the level of the cricoid cartilage, so as to avoid any possibility of wounding it. TTie whole of the mass external to the line of section is then removed and any bleeding vessels are tied. * Correspynd enzhJatt f. schicel:. Aer:tp. Rasle. 1889. p. 38. RESECTION-EXTIRPATION. 279 During the whole operation the isolated thyroid lobe lies in the operator''s left hand so that even if the main arteries have not previously been tied, the bleeding can be controlled by digital compression, and ligatures are then required only for the cut surface of the stump. Comparing Mikulicz's with Kocher''s operation, it will be seen that both agree in leaving intact that portion of the gland that lies nearest to the recurrent nerve. But the latter surgeon avoids separating the gland from the surface of the trachea and especially refrains from tying up masses of thyroid tissue, a practice which he, quite rightly I think, strongly condemns. He says that not only does this practice tend to prevent that primary union which is all important, but that the application of the ligatures is apt to endanger the safety of the nerve. Such an accident may occur even when the greatest care is taken. With reference to this point Kocher says that formerly, when he had had less experience in removing goitres, he had sometimes, when attempting to remove one, been obliged on account of bleeding or dyspnoea to ligature the pedicle in one or more masses, in order to cut short the operation. But he had noticed tolerably often that hoarseness, from paralysis of the vocal cord, was produced at the moment of applying the ligature. The chief advantages of resection and resection-extirpation are : (1) That they enable the operator to remove, when necessaiy, both lobes of a goitre and yet to leave behind sufficient gland tissue to carry on the function of the organ. (2) By leaving intact that portion of the gland which covers Ihe recurrent nerve, they lessen the risk of injuring that :5tructure,i The operation of resection-extirpation is the one which I myself now usually adopt when removing a parenchymatous goitre. I find it to be a very satisfactory operation. Amputation. — This is a term used for an operation the indications for which are rarelv present. It consists in simply cutting off, with knife or scissors, the projecting portion of the goitre. It is suitable only in some few cases in which the tumour forms a prominent more or less pedunculated mass. CHAPTER XIX. TREATMENT BY INTRA-GLANDULAR ENUCLEATION AND ITS MODIFICATIONS. Intraglandular enucleation: Historx — (':i;^es siutubU' for — Description of operation — Hiarenchyinateux," Samuel Keser, Paris, 1887. INTRA-GLANDULAR IINUCLEATION. 281 subject prominently before our notice by publishing an excellent series of cases.* In the last few years the operation has been practised exten- FiG. 9G. — Showing n Transverse Sear low down iu the ueck, one month after enncleiition of a left cystic adenoma as large as a duck's eg'g'. The tumour had caused considerable dyspnoea. (,S'ee Appendix. Case 54, p. 346.) sively by very many surgeons and its excellence thoroughly proved. The operation of enucleation depends for its feasibility upon the following facts : Many goitres consist, not of an enlargement of one or both lobes of the thyroid gland, but of a circumscribed timiour lying in more or less healthy gland tissue. Sometimes the tumour is a cyst, unilocular or multilocular ; sometimes it is solid, of an * •• Eight Cases of Thyroid Cysts and Adenomata treated by Euueleation," Trans. Clin. >S:if. vol. xxiii. p. .51. 282 THE THYROID GLAND. adenomatous nature, like the corresponding tumours which are found in the breast and other glandular organs. Of whatever nature, the tumour is surrounded by a well- marked capsule composed of connective-tissue, and of thyroid tissue altered and atrophied by pressure. It is owing to the existence of this capsule that enucleation can be performed, the tumour alone being shelled out without interference with the remainder of the gland. The nature of the capsule surrounding the goitrous tumour varies according to the size and position of the tumour. If the latter be small and deeply seated, it is surrounded by what is obviously, to the naked eye, thyroid tissue. If, on the other hand, the tumour be large and project much, it will probably be covered on its superficial aspect by what appears, at first sight, to be merely connective tissue, but which is really a thin layer of thyroid tissue. Whether thick or thin, then, the capsule of the tumour is composed everyAvhere of thyroid tissue, the presence of which can easily be demonstrated by means of the microscope. (^ It is very important that the distinction between the con- nective tissue capsule of the gland and the glandular capsule of the tumour proper, should be carefully borne in mind. ) The earlier stages of the operation, that is down to the exposure of the thyroid gland, are the same as in extirpation already described. An incision is now made through the capsule of the gland and through the gland itself, until the surface of the tumour has been reached. Any large vessels that may be seen on the surface of the gland may be clamped before this incision is made, or they may, perhaps, to some extent be avoided by placing the incision in a part where the vessels are least conspicuous. As a rule, the incision should be made directly over the most prominent part of the tumour without much attention to the vessels. If the capsule of the tumour be very thin and transparent, as is often the case, it may be closely adherent to the capsule of the gland and the two may appear to form but a single layer, which may be closely adherent to the tumour itself. As it is very important that the surface of the tumour be distinctly INTRA-GLANDULAR ENUCLEATION. 28^ recognised, it is sometimes advisable to begin the incision somewhat higher up, where the glandular layer is thicker and more easily distinguished by its reddish colour from the subjacent tumour. The tumour itself is most easily recognised bv its colour, which is almost invariably different from that of the healthy gland. ■'i^s.mw Fig. 97. — Eiglit lobe of the tliyroiil. removed bv extlrpatiou, on account of dyspnoea, from a womau aged 25. It contains a Cystic Adenoma, which miglit, with advaiitage, Iiave been removed by enucleation. (Case 11.* See Eoyal Free Hosp. Mus. Xo. xxii. 4i.) (Xattiral size.) It is generally of a dark blueish hue from the presence of blood-stained fluid within it ; it is frequently of a light yellowish colour", especially if the tumour be old and have thick walls. It is only in the case of soft, very vascular, solid adenomata that the colour of the tumour at all resembles that of the healthy gland. Published in the Brit. Mp(1. Jovrn.. Julv 1900. J84. THE THYROID GLAND. The operator must cut boldly through the gland until the surface of the tumour has been clearly defined. He must be careful, however, not to cut into the tumour itself, and thus miss the proper layer between tumour and gland, in which alone enucleation can be properly performed. As soon as the tumour has been reached, the knife is laid aside and the tumour shelled out of its bed with finders or with a blunt instrument, such as a goitre scoop {see Fig. 98). In the Fig. 98. — Goitre SCOCps, usud chiefly for tlic enucleation of cysts and adenomata. A. KoclierV. b. Tlie >:ame. sliL^htlv modified. absence of a better instrument, the handle of a scalpel or a closed pair of curved, blunt pointed .scissors, will do very well for the enucleation. Some operators think it desirable to remove the tumour in an unbroken condition. I attach, however, but little importance to this. If the tumour is soft and contains fluid, as is very often the case, it is very liable to be ruptured during the removal. In the case of a tumour which is suspected to contain fluid, I often begin by plunging a knife or some blunt instru- ment into the interior to let out this fluid. Throuoh the INTRA-GLANDULAR ENUCLEATION. 285 O -^ PI (B .; •iH > 'o ^ o3 = O ~ o ^ pi H § 286 THE THYROID GLAND. opening thus made I put the left forefinger and thus grasping the wall of the tumour between the finger and thumb, draw it forwards and effect the rest of the eimcleation by peeling the gland away from the tumour with a pair of dissecting forceps held in the right hand. Or the wall of the tumour may be grasped with broad forceps instead of with the finger and thumb. In many cases of soft solid tumours and in some cysts, the ^\"all is so thin that it tears readily when traction is made upon it. In these cases it is best to place several pairs of forceps on the cut edges, so as not to exert too much traction upon any one point. The preliminary evacuation of the contents of the tumour, by diminishing its size, often enables the operator to draw the tumour well forwards out of the wound through a comparatively small incision. I have often, by adopting this manoeuvre, succeeded in removing large cystic and even solid tumours through skin incisions considerably shorter than the diameter of the tumour itself. It must be remembered, however, that inter- ference with the interior of the tumour often causes smart haemorrhage, and that no attempt can be made to control this hannorrhage until the tumour has been removed. Before attempting to enucleate a tumour through a small incision, the operator should feel certain that the tumour will permit of rapid and easy enucleation ; otherwise he may get into serious trouble wdth the haemorrhage. In performing the enucleation, whether by finger, scoop, or forceps, the operator must be careful to keep always close to the external surface of the tumour, and not to let the point of his instrument wander through the gland tissue into the tissues outside the gland. This is easily done if the gland be much atrophied and form only a thin layer over the tumour. Directly the tumour has been removed attention must be directed to the haemorrhage, which is often profuse during the few moments occupied by the actual enucleation. A sponge should be placed in the cavity formerly occupied by the tumour and the whole cavitv drawn forwards, either by means of the forceps previously placed on the cut edges, oi' by forceps applied to the inner surface of the posterior wall. It is often a good INTRA-GLANDULAR ENUCLEATION. 287 o ^ a ^ CO \^ a o „ rt -^ o " ' ci O o _J^" _^ ^ H ■^ s cS 8 ^ cS Sc^ 8 r-i a 2 \^ a A o I—* i g ci r^ o « =! a ^ r^ .^ a ^ C5 ^ a S -3 RESULTS OF OPERATIONS. 341 upon one or both lobes of the goitre, pallor and general weak- ness have been noticed, which have seemed to be greater than those which usually follow operations of similar magnitude upon most other parts of the body. These svmptoms, which were probably due to temporary interference with the functions of Fig. 121. — The precediut;- (Fig. 119;, several mouths alter extirpation of tlie whole ol the riglit lobe and most of the left lobe. The iuli-a-hyoid muscles were not sutured, and the Sear is consequently deeply depressed and ugly. (See Appendix, Case 41, p. 344.) the gland, have invariably been transient and have given rise to no anxiety or alarm. They have rarely lasted more than two or three months. They have usually been treated by iron, strychnia, and other general tonics. In the great majoritv of cases, the general health of the patient has been improved by the operation. Palpitation, lassitude, and other symptoms that have frequently been .'i42 THE THYROID GLAND. prominent before the operation, have in most instances either greatly diminished, or completely disappeared, after the removal of the goitre. These beneficial effects following the removal of a local disease are to be explained, I believe, chiefly by the removal of local pressure. The freedom from dvspnoea enables the patient to take far more exercise than before, and thus improves the general health. Healing of the Wound. — In 104 of my 126 cases, the wounds healed by primary union throughout. In ten cases the wounds healed almost by primary union, but a small sinus, generally in the track of a drain, remained open for a few days. In seven cases a sinus resulted which remained open for periods varying from several weeks to several months (in one case nearly a year). In all these latter cases the supj^uration was of a very mild type and, except for a short time after the operations, the patients were able to go about and pursue their ordinary avocations during the slow healing of the sinus. Of profuse and really dangerous suppuration I have no case to record. A permanent fistula, such as is seen sometimes after injection and of which Fig. 86 is an example, is a condition that has never occurred after any of my operations. The Sear. — As has already been mentioned in chap. xvii. the nature of the scar depends to a considerable extent upon the direction in which the skin incision has been made. Trans- verse wounds healing by primary union almost in\'ariably leave fine linear scars often scarcely noticeable when the redness has passed off. Such scars are shown in Figs. 96 and 116. Vertical and oblique scars in young people, even when the ^vounds have healed bv primary union, have a considerably tendency to widen and become unsightly. (.SV^ Fig. 117.) They sometimes become thick, prominent and ugly, assuming a keloid nature. In elderly people, on the other hand, this tendency is very slightly marked. {See Figs. 105 and 118.) Wounds that heal by granulation naturally leave worse scars than those that heal by primary union. APPENDIX. ONE HUNDRED CONSECUTIVE* CASES OF REMOVAL OF GOITRE BY OPERATION (EXTIEPATIOX AND EXUCLEATIOX) PERFORMED BY THE AUTHOR 8IXCE FEBRUARY 1894. SUMMARY OF THE FOLLOWING TABLE. CASES. EKIES. DEATHS. Extirpations Bilateral . 5 5 Unilateral .... 21 20 1 Extirpation on one side combined with enucleation on the other 1 ] Enucleations Bilateral 3 3 Unilateral .... 70 70 100 99 * One other case, of a large, fixed and hopelessly irremovable, malignant goitre, in which a portion of the tumonr was removed merely to allow of access to the trachea for the purposes of an immediate and urgent tracheotomy, has not been included in the list. ( 34.4. ) ONE HUNDRED CONSECUTIVE CASES OF REMOVAL OF Performed by the Author between No. Date of Opera- tion. Name. Chief Reason for Operation. Operation. Nature of Goitre. 1 1894 27* March 17 Barkland C. (male) 15 Dyspnoea, dysphagia Extirpation, ■whole of right, one third of left ParenchjTiiatous ; 8 oz. R. 28 March 27 James H. 21 Dyspnoea Extirpation, right lobe and isthmus Parenchpnatous ; 6 oz. R. 29 July 1 Mr. R. B. 30 Deformity Enucleation Prominent cyst size of golf ball in front of larynx R. 30 July 20 Mary H. 39 Severe dyspnoea Extirpation, right Parenchymatous «ith cystic adenomata ; 4i x 3 in. : 8 oz. : partly sulisternal R. 31 Oct. 13 Constance K. 10 Dyspnoea Extirpation, right and part of left Parenchymatous; 4-}x2iin. ; weight of right 4 oz' R. 32 Nov. 3 Kate M. 20 Dyspnoea, dysphagia " Parenchymatous ; 4i x 3i in. ; Vih oz. ; partly substernal R. 33 Dec. 5 1895 Ellen S. 15 Dyspnoea " ParenehjTuatous ; extending into thorax R. 34 March 7 Ellen N. 43 Severe dyspncea Extirpation, right and isthmus Parenchymatous ; 4 x 5 in. ; 7 oz. R. 35 March 31 3Iiss S. 25 Deformity Enucleation Cystic adenoma (one-third solid) ; 2i in. in diaineter R. 36 May 18 Margaret 15 Dyspnoea Extirpation, left Parenchyruatous ; very large goitre (Figs. 22, 23) R. 37 Sept. 20 IMi-s. B. 41 Dyspnoea Extirpation, left and part of right Parenchymatous; i{ oz. R. 38 Dec. 16 1896 Hannah D. 50 Malignancy Extirpation, left and isthmus, and small part of right 2 X IJx 1 in. ; pale non-encap- suled timiour, surrounded hy thick layer of healthy thyroid gland ; microscopically malignant R. 39 feb. 1 Mrs. W. 38 Deformity ; slight dyspnoea Enucleation, left Cystic adenoma size of walnut R. 40 Feb. 29 Clara S. 16 Dyspnoea, dysphagia Enucleation, right Cystic adenoma ; li in. in dia- meter ; partly substernal R. 41 March 8 :Miss H. 43 Dyspnoea Extirpation, right and most of left ParenchjTuatous ; llf oz. ; partly substernal (Figs. 119, 120) R. 42 May 28 Sarah P. 25 Deformity, dis- ■ placement of trachea Enucleation, right Cystic adenoma, one-third solid ; size of hen's egg R. 43 Oct. 3 1897 Kate C. 26 Dyspnoea " Cystic adenoma, two-thirds solid ; 2i oz. R. 44 March 27 Lilla W. 14 Slight dyspnoea » Cystic adenoma size of orange R. 45 May 17 Mrs. J. 37 Severe dyspnoea " Solid adenoma ; 3x2} in. ; largely substernal R. 46 May 22 Francis L. 18 Slight dyspnoea ; tracheal stenosis Extirpation, right Parenchj-matous ; lOA oz. D. Cases 1 to 26 have already been published in the Brithh Medical Journal, June 1891 and July 1900. ( 345 ) GOITRE BY OPERATION (EXTIRPATION AND ENUCLEATION). Fehniaiy 1894 and Januaiy 1901. Drainage ; primary union Drainage ; primary union except in track of tube Drainage ; primary union No drainage ; primary union Drainage ; primary union except in track of tube ; sinus healed in fortniglit ; considerable collapse ; temporary paresis of sympathetic Drainage ; primary union No drainage ; primary union Drainage ; primary union Drain age ; mild suppuration ; sinus for 8 months ; operation prolonged and very severe ; in- frahyoid muscles not sutured ; slight syrnptoms of cachexia strumipriva for some weeks Drainage ; primary union Drainage ; operation long (nearly 2 hours), but presented no unusual difficulty ; profuse recurrent haemorrhage 4 hours after opera- tion ; wound opened up by house- surgeon ; death 15 hours latei' SO C ftOJ 100.2° 100.2° (?) 99.8° 100.4° 100.0° 104.0° 100.2° 100.0° 101.4° 98.8° (?) 99.2° 100.2° 99.4° 101.4° 101.8° a X (?) (?) Oblique Median Oblique Median Trans- verse Oblique a Dyspna3a Dyspniea Low situation ; slight dyspnoea Dyspnoea ; deformity Dyspna-a Dyspna'a Deformity Occasional dyspnoea Deformity Deformity and dyspnoea Dyspnoea and leakage from previous tapping Deformity Enucleation, left Enucleation, right and left Enucleation Enucleation, left Enucleation, right Nature of Goitre. Extirpation, right Enucleation, right Enucleation, left Enucleation, right and left E.xtirpation, left Enucleation, pyramid Enucleation, right Extirpation through right posterior triangle Enucleation, left Enucleation, right and isthmus Solid adenoma, size of hen's egg ; partly substernal Two adenomata. R. solid, size of walnut. L. four-fifths fluid, size of orange Cystic adenoma, size of chest- nut; very deeply seated and at the back of the gland Four adenomata, largest solid and size of walnut and sul)- sternal ; very deeply seated Five adenomata ; all solid ; largest, size of tangerine orange Solid adenoma ; 3 oz. Solid adenoma, size of cocoa- nut ; 16 oz. (Figs. 55, 56) Cystic adenoma, size of hen's Cystic adenoma, size of egg ; partly substernal Parenchymatous ; dh oz. Cystic adenoma, size of hen's Solid adenoma, size of turkey's egg Two adenomata ; left lobe; size of cocoanut and chestnut respectively ; 16 and 2 oz. Small solid adenomata ; deeply seated Parenchymatous, with adeno- mata ; 11 oz. Cystic adenoma of pyiamid, size of walnut (Fig. 31) Cyst, size of hen's egg Cystic adenoma, size of hen's egg Parenchymatous, with adeno mata ; about 5 oz. Large cystic adenoma with thick fibrous and calcified wall, size of large orange Solid adenoma, size of orange ( 351 ) GOITRE BY OPERATION (EXTIRPATION AND ENUCLEATION). February 1894 and Januarij 1901. No drainage ; primary union No drainage ; secondary union ; slight suppuration ; wound opened up on 11th day ; sinus healed after 14 weeks Drainage ; secondary union ; slight suppuration ; wound par- tially opened up on 6th day ; pa- tient went home on 21st day ; sinus persisted for 8 months ; was twice laid open, then healed Drainage ; primary union No drainage ; primary union Drainage ; primary union ; was riding a bicycle on 7th day after operation No drainage ; primary union Drainage ; primary union No drainage ; primary union 100.6° 99.6° 100.6° 100.8° 99.4° 99.4° 99° 99° 99.6° 100.2° 99.6° 99.4° 99.4° 99.8° L,.p3 o o to o £" '^ &ss s <^ Oblique Trans- verse Oblique Trans- verse Trans- verse (Fig. 57) Trans- verse Oblique Trans- verse (Fig. 116) Oblique Trans- verse Mor- phia and co- caine Chloro- form Oblique Trans- verse Oblique Trans- verse Vertical, in posterior triangle Oblique Trans- verse Latest Report (and Source of). Mor- phine and co- caine Chloro- form Jan. 1901. — Quite well (personal observation) Ditto Jan. 1901.— Quite well (letter) Jan. 1901. — Quite well (personal observation) Jan. 1901. — Quite well ; remaining adenomata have undergone some enlargement but caused no trouble (personal observation) .Jan. 1901. — Quite well (personal observation) Ditto Jan. 1901 —Quite well (letter) Ditto April 1900.— Quite well (personal observation) Jan. 1901. — Quite well (personal observation) Jan. 1901.— Quite well (Dr. Maund, Newmarket) Jan. 1901.— Quite well; left vocal cord in cadaveric position but voice natural (personal observation) Jan. 1901.— Quite well (letter) Jan. 1901.— Quite well (personal observation) Ditto Jan. 1901.— Quite well (letter) Ditto Jan. 1901. — Has been very much better for the operation (Dr. Evill, Barnet) Nov. 1900.— Quite well as regards neck but is suffering from thoracic aneurism (letter) Jan. 1901.— Quite well (letter) t Temperature taken every four hours. ( 352 ) ONE HUNDRED CONSECUTIVE CASES OF REMOVAL OF Performed hy the Author between No. Date of Opera- tion. Name. < Chief Reason for Operation. Operation. Nature of Goitre. 105 June 3 Ann C. 69 Dyspncea Enucleation (re- section enuclea- tion), isthmus and right Old calcified adenoma, size of an orange (Figs. 43, 44) K. 106 June 7 Eliza van I. 39 Dyspnoea Enucleation, left Cystic adenoma, one-tenth solid ; size of hen's egg ; deeply seated E. 107 June 12 Caroline T. 43 Dyspnoea " Cystic adenoma, size of small orange ; oue-ciuarter solid ; deeply seated E. 108 June 23 Jane "VV. 23 Dyspnoea Enucleation, right Cystic adenoma, size of walnut : two-thirds solid ; deeply seated E. 109 June 23 Emily H. 30 Defoi-mity Enucleation, left Solid adenoma, size of a small oi-ange (Figs. 114, 115) E. 110 June 28 Mary L. 17 Dyspncea Enucleation, right E.xtirpation. Cystic adenoma E. 111 July 5 Fanny F. 64 Dyspncea Parenchymatous ; 10 oz. E. right (Fig. 94) 112 Julys Sarah M. 55 Dyspnoea " Parenchymatous, with much fibrous tissue ; 16 oz. (Figs. 49, 50, 51) E. 113 July 14 Fanny M. 50 Severe dyspnoea ; malignancy Partial extirpa- tion, left and middle Spindle-celled sarcoma ; tum- our removed size of apple ; 4 oz. E. 114 July 16 Mrs. G. 39 ; Dyspnoea Enucleation, left Cystic adenoma, size of orange ; two-thirds solid E. 115 Sept. 7 Ellen H. 37 Dyspncea Enucleation, right Three cystic adenomata, lar- gest size of walnut E. 116 Sept. 8 Elizabeth E. 17 Dyspnoea » Two solid adenomata, largest substernal ; size of goose's egg E. 117 Sept. 15 Elizabeth C. 36 Dyspnoea " Solid adenoma, size of goose's egg E. 118 Oct. 17 Miss A. 36 Deformity ; palpitation Enucleation, left Cystic adenoma, size of hen's egg ; mainly solid ; much fibrous tissue E. 119 Oct. 20 Eliza H. 52 Bulk, weight, and deformity Extirpation, right and middle Old parenchj-matous goitre ; weight of tumour after re- moval, 49 ozs. (Figs. 34, 35, 36) E. 120 Oct. 25 Mi-s. L. 39 Bulk, weight, and deformity Enucleation, right Cystic adenoma, size of large orange E. 121 KoY. 3 Grace B. 35 Dyspnoea Enucleation Cystic adenoma, size of hen's E. 122 Nov. 10 Ellen L. 33 Dyspncea and and ansmia Enucleation, left egg Solid adenoma, size of a turkey's egg E. 123 Nov. 10 Jemima S. 43 Dyspnoea Enucleation, right Solid adenoma, with much fib- rous tissue ; size of orange ; very adherent E. 124 Nov. 10 Albert D. 18 Deformity; dis- comfort; slight dyspnoea Dyspnoea ; Cystic adenoma, size of small orange ; mainly fluid E. 125 Nov. 26 Miss S. 32 Enucleation, left Cystic adenoma, with hsemor- E. discomfort hage ; four-fifths solid ; size of a lemon 126 Dec. 8 Gertrude A. 29 Dyspncea Enucleation, right Solid adenoma, size of duck's egg ; contained also a cyst size of cheiTy E. ( 353 ) GOITRE BY OPERATION (EXTIRPATION AND ENLX'LEATION). February 1894 and Janiumj 1901. Brainage ; primary union No drainage ; primary union Drainage ; piimaiy union Xo drainage ; pruuary union Drainage ; primary union If o drainage ; primary union Drainage ; secondaiy union ; slight suppuration for about a fortnight; left hospital on 17th day after operation : wound almost healed Drainage ; primary union Jfo drainage ; primaiy union Drainage ; primary imion 2s o drainage ; primary imion 99.6= 99.8- 99.2° 99.4= 100= 100.0° 100.8° 100.8= 99.4= 100.8° No drainage; primary union 100.4= i Drainage ; primary union ini.G' 101.4= 101.4° 99.8= 100.8° S s Si; I Trans- verse Mor- phia and eu- Oblique came Chloro- form Trans- Trans- verse " Oblique (Fig. 95) Trans- verse Oblique „ ■ Trans- verse Oblique >' Trans- verse (T- shaped) Trans- verse Oblique (ellipti- cal) (Fig. 37) Trans- " verse Oblique „ Trans- vei-se " Latest Report (and Source of). .Jan. 1901. — Quite well (personal observation) Ditto .Jan. 1901.— Quite well (Dr. Tol- putt, Kettering) .Jan. 1901. — Quite well (personal obserN'ation) Ditto Ditto Dec. 1900.— Quite well (letter) •Jan. 1901.— Quite well (Dr. Mar- shall, Bex-hill) Kov. 1900. — Ee-admitted for trach- eotomy and died soon afterwards with extensive recurrence (Fig. 78) Nov. 1900. — Quite well (personal observation) •Jan. 1901.— WeU : still several small adenomata in both lobes ; respiration easy .Tan. 1901.— Ee-admitted -svith a small sinus which soon healed ; othenvise well (personal obsen'ation) Quite well on lea^'ing hospital on 9th day : quite well when last seen several weeks later (Dr. Ban-on, Ascot) Dec. 19C0. — Quite well (personal observation) Jan. 1901. — Quite well (Dr. Image Buiy St. Edmunds) Dec. 1900.— Quite well (letter) Jan. 1901.— Quite well (Dr. Eob- ertson, &ospoi-t) Jan. 1901.— Quite well (Dr. Raglan Tliomas, Exeter) .Jan. 1901.— Quite well (Dr. Mar- shall, Bexliill) Jan. 1901.— Quite well (pei-sonal obsei-vation) Jan. 1901.— Quite well (Dr. Stack, Bristol) Jan. 1901.— Quite well (letter) t Temperature taken every four hours. INDEX. Abscess of thyroid, 130-45 Accessory thyroid vein, 268 thyroids, anatomy, 12-13 compensating hypertrophy, 15 Acute goitre, 48 Adenomata,transitiou into cysts, 154-5 Adenomatous goitre, colour of, 283 cystic, 42-3 enucleation of, 280 et seq. ; — versus extirpation, 337 evidement of, 294 fatal case of removal of, 311 foetal, 39-42 malignant, diagnosis from innocent, 98, 199, 211, 221 results of operations on, 221-2 Air and sunshine, supposed effect on goitre, 53-5 Amputation of goitre, 279 Amyloid goitre, 48 Anassthetic, use of, in thyroid opera- tion, 257-60, 295-7 Aneurism, diagnosis from thyroid tumour, 92-96 Animals, cretinism in, 67 goitre in, 67 symptoms following removal of thyroid in, 320 Antisepsis — versus asepsis, in thyroid operations, 215-16, 270-1 Arteries, carotid, relation — to thyroid, 5 — to thy- roid tumour, 87-9, 92, 140, 204 — to trachea, in malignant goitre, 224 resection of, 218 inferior thyroid, ligature of, danger to sympathetic in, 302 history of operation 241- 3 Arteries, inferior thyroid, ligature of, in, extirpation, 268-9 in, resection-extirpation, 278 method, 243-4 recurrent haemorrhage from, 305 relation to thyroid, 5, 9 superior thyroid, ligature of, history of operation, 241-3 in extirpation, 267-8 in resection, 275 in resection-extirpation, 278 method, 243 relation to thyroid, 8-9 relation to enlarged thyroid, 89, 92 thyroidea ima, 9 Aseptic treatment, value of, in thyroid operations, 215-16, 270-1, 304 Asphyxia, due to congenital goitre, 15, 19 " Asthma, simulating goitre, 106 Atmosphere, relation to goitre, 51-2 Atrophy of thyroid, in cretinism, 26, 30 in myxoedema, 21-2 senile, 20-1 Atrophy of tracheal wall, 114-16 Austria, goitriferous waters in, 65-6 Basedow's disease {See Exophthal- mic Goitre) Bedfordshire, goitre in, 51, 58 Belladonna, use of, in Graves"s disease 186 Blood, expectoration of, in malignant goitre, 206 hsematozoa in goitrous, 69 Blood-vessels [Sec under Arteries and Veins) Bloodless enucleation, 292-3 Bohemia, goitre in, 65 Bone, growths secondary to malignant goitre in, 209 356 INDEX. Brachial plexus (.SV( under Nerves) Brain, relation to exojphtbalmic goitre, 178 Brecknockshire, goitre in, 63 Bromine, use of, in Giaves's disease, 187 Bronchitis, causing death f;fter thvroid ojoera- tion?, 208, 225, 334 complicating exothyropexy, 248 dyspnci'a from, 120 goitre i-imulating, 106 Bronchocele (/Vfc Goitre) Buckinghamshire, goitre in, 51 Cachexia strumipriva avoided by compensating hyper- trophy of thyroid, 15, 31, 324-5 due to absence of thyroid, 14, 188, 320, 324 due to ligature of thyroid vessels, 190 history of, 318-22 Horsley's experiments, 320 relation to myxedema, 320 symptoms, 323-4 temporary, 326-7 treatment, 327 Cachexia thyreopriva, 318 Calcareous rocks, distribution of goitre on, 55-6, 58-63, 64 Cambrian rocks, distribution of goitre on, 63, 64 Cancer, condition of thyroid in, 35 Carboniferous rocks, distribution of goitre on, 62-4 Carcinoma (.SVe Malignant Disease of Thyroid) Cardiac nerves, injury of, in thyroid operation, 315 Carotid artery (See under Arteries) Cellulitis, complicating thyroid operations, 307 Cervical lymphatics, abscess of, simulating goitre, 75 inflammation of, simulating thy- roiditis, 134 Cervical plexus {8cc under Nerves) sympathetic (Sec under Nerves) Chalk districts, goitre in, 58 Chloroform, fatkl cases of thyroid operation under, 296 Cholera, causing thyroiditis, 131 Chronic inflammation of thyroid, 136-7 simulating sarcoma, 199 Climate, influence on goitre, 50-2 Coal measures, goitre on, 62, 64 Cocaine, effect of injection into eye, 190-1 Cocaine, use of, in thyroid operations, 259-60 dose, 260 Colloid goitre, 46-7 Colloid secretion, 12 abnormal accumulation, 122, 152-3 absence of, in exophthalmic goitre, 180, 187-8 in myxcedema, 21-3 absorption of, 314-15 character of, in cystic disease, 161-2, 167, 169, 172-5 in exo{.hthalmic goitre, 178 diminution of, 253-5 in senile atrophy, 20 relation to fat formation, 35 Congenital goitre, cases of, 15-16 in animals, 17-18 treatment, 18-19 sarcoma, 198 Cough, in tracheal obstruction, 102, 132 Cretaceous formation and goitre, 56, 58-9 Cretinism, atrophy of thyroid in, 26, 30 cause of, 14, 320 connection with cachexia strumi- priva, 320 endemic goitre, 24, 26, 29-30 myxcedema, 23-4, 320 enlarged thyroid in, 25-6, 30 fatty tumours of, 27-8 in animals, 67 sporadic {See Sporadic Cretinism) treatment, 30 Cricoid cartilage, division of, in extir- pating goitre, 270 Crystalline rocks, goitriferous waters in, 66 Cysts, simulating thyroid enlargement, 73, 75 thyroid of, adenoma [Sec that name) classification, 156-7 colour, 283 description, 37-8 developmenr, 154-5 diagnosis from malignant goitre, 210 hEemorrhagic, 46, 123 hydatid (See Hydatid Cysts) intra cystic growths, 164 h^morrliRge, 158-60 origin of, 152-6 position of, 82-3, 84-5, 91 papilliferous {See Papuliferous Cysts) structure, 160-4 IN13EX. 357 Cysts, thyroid of, suppurating {!'^-f that name) treatment, by extirpation, comj)lications, 213-14, 218 danger of recurrence, 2 1 3-1 -! , 219-21 method, 21.5-16 mortality statistics, 216-21 prognosis, 216 palliative, incision, 223-4 partial extirpation, 222-3 tracheotomy. 224-6 varieties of. 210-12 relative frequency of sarcoma and carcinoma. 198-9 Manubrium of the sternum, complica- tion iu substernal goitre, 248 Median goitre. 112-13 Mediastinitic, 133, 209 Menstruation, enlargement of thyroid during. 32 Mercurv oiLtment, use of in goitre, 229-30 Micro-organisms, in goitre-producing water, 65-6 Middle thyroid vein (.See under Veins) Middlesex, goitre in, 58 Mikulicz's resection {Sc Resec- tion) Millstone grit, 62, 64 Molasse, geological structure and goitre, 56, 66 Morphia, use of, in operation on thyroid, 260 Mountainous districts, goitre in, 51-3 Mountains, geological structure and goitre, 55-6 Murmur in thyroid tumour, 93-5 Muscles (.SV-e also Infra-hyoid, Scalenus anticus, and Sterno- mastoid) relation to thyroid, 5, 6, 8 to enlarged thyroid, 85-7 Muscular exertion, relation to goitre, 69, 70 Myxcedema, atrophy of thyroid in, 21 cause of, 14, 320 occasional enlargement of thyroid, 22 relation to cachexia strumipriva, 320 cretinism. 23-4, 320 fat formation, 35 treatment of, 22-3 Nerves. brachial plexus, involved in thy- roiditis, 132 pressure of goitre on, 101 cardiac, injury of, in thyroid opera- tion, 315 cervical plexus, involved in thy- roiditis, 132 pressure of goitre on, 101 cervical sympathetic. fatal svraptoms following divi- sion", 313, 315 involved in thvroid tumour. 99-101 operations on, in exophthalmic goitre, 190-4 relation to exophthalmic goitre, 178 wound of, in extirpation, 302 involved io chronic inflammation, 13S, 140 of thyroid gland, 11 recurrent laryngeal. compression by scar. 316, 338 danger to. in extirpation, 300-1 dangerto, in removal of hydatid, 171 dvspnoea, due to irritation of, '116-18. 295-6 INDEX. 361 Nerves, recurrent, effect of injury, 337-9 in relation to ligature of in- ferior thyroid artery, 269, 270 involved in chronic inflamma- tion, 138, 140 involved in thyroiditis, 132 protection of, in resection, 275-6 protection of, in resection- extirpation, 275-6 relation to thyroid, 5-6, 8 thyroid tumour, 97-9 vagus, 302 Nervous symptoms, in Graves' dis- ease, 183, 185 Norfolk, goitre in, 58 Northamptonshire, goitre in, 54, 60 Northumberland, goitre in, 63 Norvi'ay, scarcity of goitre in. 52-3, reason of, 55 Nottinghamshire, goitre in, 61 (Edema, of face and arm, from goitre. 97 of glottis, causing death in malignant goitre, 210 dyspnoea due to, 119 in thyroiditis, 133 ffisophagus, infiltration in chronic inflamma- tion, 140 injury in thvroid ooeration, 171, 304 partial excision in thyroid opera- tion, 218 pressure from goitre, 102-4 ; from inflamed thyroid, 132, 134 relation to tbyroid, 6, 7 ; import- ance of in extirpation, 269-70 thyroid fistula opening into, 137 Oolite rock, distribution of goitre on, 59-60, 65 Operative myxedema {See Cachexia strumipriva) Palaeozoic formation and goitre. 56, 61-3 Papuliferous cysts, description, 164, 211-12 treatment, 221-2. Parathyroids, 13 Parenchymatous goitre, cause of enlargement of gland in, 36, 253-4 consistency, 96 description, 36-7 dyspnoia from, 109, 122-3, 126-7 rapid enlargement of, 117, 122-3 Parenchymatous goitre, shape of compressed trachea in, 109 symptoms and diagnosis (.See goi- tre, diag. ) diagnosis from exophthalmic, 179-80, 184 diagnosis from malignant dis- ease, 210 diagnosis from thyroiditis, 134 symptoms of death following re- moval, 312-13, 316 treatment {See Goitre, Treatment of) Perchloride of iron, injection in cystic goitre, 237-9 Permian rocks, goitre in reeion of, 61-2 Pharynx, injury to, in removal of goitre, 304 involvement of muscular wall, 202 penetration in thyroiditis, 133-4 penetration by malisrnant growth, 202-3 pressure of goitre on, 103-4 pre-sure of inflamed thvroid on, 132 relation to thyroid, 6,7; import- ance of, in extirpation. 269-70 Phthisis, condition of thyroid in, 35 Pleura, injury in thvroid operation, 303 Pneumonia, following tracheotomy. 225 Post-tertiary formations, absence of goitre on, 56 Potash salts, relation to goitre, 68 Pregnancv, relation to thvroid, 32-4, 123 Puberty, relation to thyroid, 34 ; to fatal dyspncea, 122-3 Puerperal fever, thyroiditis in, 131 Pulsation of thyroid tumour, 92-6 Pulse, rapid, following thyroid opera- tion, causes of, 314-16 danger of, fatal cases, 310-14 Pyaemia, causing thyroiditis, 131 Pyramid of Lalouette, 3-4 tumour of, 84 Eaixfall, influence on goitre, 51 Eecurrent laryngeal nerve {See under Nerves) Kesection, advantages, 279 description, 275-6 enucleation, 288-92 extirpation, advantages, 279 compared with resection, 279 description, 278-9 results, 276-8 362 INDEX. Restlessness following thyroid opera- tion, causes of, 314-16 danger, .110-14 Rheumatic thyroiditis, 130-1 Salzburg, goitriferous waters at. 65-6 Sandstone districts, goitre in, 55-6, 61, 63 Sarcoma {Sir Malignant Disease) Scalenus anticus muscle, in relation to ligature of thyroid artery, 269 Scar, after thyroid operation, 262-3, 342 Scotland, scarcity of goitre in, 52 Sepsis, danger of and treatment, 307-10 Seton method of treating goitre, 240-1 Sexual excitement, relation to thy- roid, 34 Silurian rocks, goitre on, 63, 64 Skin, condition in cachexia strumipriva. 323 in Graves's disease, 183 incision of, in extirpation, 260-4 involvement of, by malignant goitre, 205 spontaneous ulceration. 140-2. 305 Soda, salicylate, use in thyroiditis, 135 Sodium salts, relation to goitre, 67, 68 Somersetshire, goitre in, 16, 59-60, 63, 95 Sporadic cretinism, distinguished from endemic, 27-9 due to absence of thyroid, 24, 25 Sporadic goitre, use of term, 48 Staffordshire, goitre in, 63 Sterno-mastoid muscle, in relation to extirpation of goitre, 260, 262 to ligature of inferior thyroid artery, 243-4, 269 relation to thyroid tumour, 86-7 Sternum, relation to thyroid tumour, 8, 88-92, 113 Submaxillary, tumour of, simulating goitre, S3 Substernal goitre, diagnosis from aneurism, 93 position of, 89-91 relation to fatal dyspnoea, 124-5 Suffocating goitre, 48 Suffolk, goitre in, 58 Sunshine and air, supposed eft'ect on goitre, 53-5 Superior thyroid {See under Arteries and Veins) Suppurating cyst, asphyxia due to rupture of, 119 penetration into trachea and pharynx, 133-4 treatment, 135 Suppuration, due to injection, 234. 2 iS into trachea after thvroid opera- tion, 309-10 Surrey, goitre in, 58, 59 Suspensory ligament of thyroid, 8 Sussex, goitre in, 58, 59 Switzerland, distribution of goitre in. 15, 51-4, 91 /(. geological structure and goitre, 55-6 goitriferous waters in, 64-7 Sympathetic nerve (.See Cervical sym. under Nerves) Sympathicotomy, 190 Syncope, in goitre operation, 48, " 148-51 Tapping of cystic goitre, 231-2 Temperature, after extirpation and enucleation {See Appendix) in Graves's disease, 183 rise after exothyropexy, 247 Tertiary rocks, goitre in region of, 56, 57-8, 64 Tetany, complicating thyroid opera- tion, 316-17 Thymus, administration of preparations, 186 enlargement in Graves's disease, 183 Thyroid gland, absence of, effect on, 24, 25, 317- 318, 320, 324 absorption from pressure of hydatid, 166 administration of extract, 23, 30, 186. 228-9, 327 atrophy, 20-30 blood-vessels, 8-10 ligature of. 190, 267-9 congenital diseases, 15-19 malformations, 14-15 cystic disease {See Cysts) disease of {See Goitre) extirpation, 257-70 {See also this name) hypertrophy, 31-5, 166 inflammation, 130-45 influence of menstruation, 32 pregnancy, 33-4 INDEX. 363 Thyroid gland, influence of puberty, 34 sexual excitement, 34 innervation, 11 isthmus, 1-2 lobes of, 1, 3-4 lymphatics, 11 operations on, for exophthalmic goitre, 187-90 relations, 5-8 structure, 11 syphilitic disease of, 148-50 tubercle, 146-8 variations in human, 34-5 weight of, congenitally diseased, 16 normal, 1 relative weight in old age, 20 Thyroidea ima, 9 Thyroidectomy [See Extirpation) Trachea, adhesion of thyroid abscess to, 138 altered relation to carotid, in malignant goitre, 224 collapse of, in removal of goitre, 304 complication in exothyropexy, 248 compression, causing dyspnoea from goitre, 16, 97, 102, 107-16, 120, 253 due to hydatids, 167, 172, 174 displacement, 82, 101-2, 113, 203 infiltration, 139-40 injury to, in removal of goitre, 218, 302-3 mucous membrane involved by malignant goitre, 201-2 penetration by thyroid abscess, 133-4 malignant growth, 118-19, 201-3, 208 pressure of enlarged thyroid, 72-3, 74, 76-7, 132, 203 relation to thyroid, 6, 7 rupture of hydatid into, 167, 172 Tracheal diseases simulating goitre, 73-5 Tracheal wall, changes in, due to goitre, 113-16 Tracheotomy, danger of, during thyroid opera- tions, 298 in exophthalmic goitre, 198 malignant goitre, 224-6 Tracheotomy, danger in, parenchy- matous goitre, 256 Tracheotomy, danger in, primary chronic inflammation, 145 Traumatic inflammation, 131-7 Triassic formation and goitre, 56, 61, 66 Tuberculous goitre, 48, 146-8 Tumours, of thyroid {See Goitre, varieties) simulating goitre, 73, 76-8, 83 Typhoid fever, thyroiditis complica- ting, 130 UmLATEEAL goitre, relation to fatal dyspnoea, 124 Urticaria, in hydatid cyst, 168-9 Vagus, wound of, in extirpation, 302 Valleys, prevalence of goitre in, 53-5 Variola, causing thyroiditis, 131 Vascular goitre, 47-8 Veins, accessory thyroid, 268 inferior accessory thvroid, 10 thyroid, 10, 278 internal jugular, relation to thyroid tumoui', 88-9, 96-7, 140, 204 resection in goitre operation, 218 ligature of, in extirpation, 264, 267-8, 275, 278 middle thyroid, 10, 268 recurrent haemorrhage from, 305 superior accessory thyroid, 10 thyroid, 10, 267-8, 275, 278 thyroidea ima, 10 Vocal cords, effect of resection of goitre on, 277 paralysis of, after thyroid operation, 337-9 cause of late, 316 due to goitre, 97, 98, 201 Wales, goitre in, 52, 62, 63-4, 94 Warwickshire, goitre in, 60-1 Water, microscopical examination of goitriferous, 65-6 supply, influence on goitre, 55, 57, 62, 64-9 Wealden area, goitre in, 59, 65 YOEEDALE rocks, 62, 64 Yorkshire, goitre in, 15, 16, 34, 58, 59, 60, 61, 62 INDEX OF NAMES Albeks, 172 Albert, 2.34, 316 Albevtin, 249 Aldriuh-Blake, 84 Alibert, 80, 81 Atkinson, 16 Bach, 19 Baillagev, 50, 67 Bankai'D, 240 Barker, 212, 221 Barlow, 131 Batten, 97 Battle, 142 Battle and Jones, 217 Baumann, 130 Baumgarten, 148 Beach, 24 Berard, 244, 246, 247, 249, 302, 303, 304 Bergeat, 198, 217 Berger, 194, 212, 221 Berry, E. E., 68 BidweJ], 146 Billroth, 78, 222, 241, 280, 302, 216 Birch-Hirschfeld, 150 Bircher, 50, 52, 56, 66, 67, 68 Blanc, 249 Blizard, 241 Bock, 165 Boechat, 255 Boeckel, 210 Boissou, 191, 192 Bose, 292-3 Bouchardat, 67 Bouilly, 194 Bowlby, 73, 88, 91, 124, 138, 139, 311 Boyd, 170, 175, 224, 298, 306 Bramwell. 127, 302 Braun, 216, 217 Bruns, 115, 147, 148, 299, 322 Bryant, 129 Buchanan, 249 Burckhardt, 280 Buschi, 217 Butlin, 84, 85, 159, 216 Cakle, 68 Carver. 93 Chavier, 170, 175 Chiari, 146 Cloquet, 150 Coates, 241 Cock, 166, 175 Colby, 15 Comte, 160 Cordua, 145 Corley, 305 Cramer, 214, 217 Crawfurd, 178 Crisp, 17 Cruveilhier, 131 Curling, 24, 27 Dalrymple, 94 Dardel, 165 Davies, 51 Davis, 217 De Ranee, 57 Demme, 15, 108, 149 Dewes and Heidenreich. 12-; Dixon, 165 Dolerio, 194 Downes, 241 Drobnik, 242, 244 Duquet, 165 Eaele, 241 Edmunds, 13, 191 Edwards, 127 Eminson, 15, 83 Ewald, 217 Fagge, 24, 25 Eaure, 192 INDEX OF NAMES. 36c Federn, 194 Fergusson, 93 Ferrant, 173 Florez (Dr. M. Y.), 177 Fraenkel, 151, 19i Francis, 93 Frank, 217 Furnivall, 73 Fiirst, 149 Gallozzi, 167, 173 G-aucher, 106, 129 Genevet. 19 Gibb, 250, 252 Gibbs, 127 Gooch, 172 Gottstein, 191 Grasset, 69 Gray, 93 Greenfield, 178 Guillemot, 249 Gull, 320 Gtinther, 241 Gurlt, 165 Guthrie, 131 Hack, 194 Hanau, 26 Hartmann, 249 Heidenreich. 133 Heidenreich and Dewes. 123 Henle, 165, 174 Hicquet, 317 Hirsch, 67 Hochgesand. 217 Hoffmann, 194 Holthouse, 250 Horsley. 317, 320 Hovell, 238 Hurry, 128 Husson, 106 Jaboulay, 192, 244, 245, 248, 249 Jeannel, 144 Jenks, 32, 34 Jessop. 190-1, 332 Jobert, 172 Jones, 251 Jones and Battle, 217 Jonnesco, 191, 192 Jouin, 194 Julliard, 272, 280, 292, 296 Kammeeee. 220, 221 Kappeler. 330 Karpetchenco, 167, 175 Kauffman, 103, 198, 203 Keser, 80, 162, 280 Klebs, 65 Koch, 103, 161 Kocher, 109, 132, 135, 159, 189, 190, 216, 217, 218, 219, 221, 262. 278-9, 288, 291, 292, 293, 317, 318-20, 324, 327 Kohn, 74, 131, 133, 134 Kottmann, 91, 280 Krieg, 132. 236 Kronlein, 115, 334 Kummer, 217 Kiittner, 151 Laennec, 165 Lange, 221 Langeubeck, 165, 243-4 Langton, 254 Lannelongue, 167, 16S, 169, 170, 175 Larrey, 73 Laura, 131 Lavaran, 69 Lebert, 131, 133 Lediard, 16 Leflaire, 194 Lentz, 217 Liebrechb, 109, 234, 241, 302, 303, 304, 316, 329 Lieutaud, 172 Liouville, 131 Lockwood, 149 Liicke, 89 Lugenbiibl, IS , Lustig, 68 Maas, 220 MacClelland, 55 McDougall, 127 Mackenzie, Hector, 186, 194 Mackenzie, Morell, 73, 237-8 McWhinnie, 89, 92, 241 Madelung, 18 Maidlow, 15 Malgaigne, 19 Marchant, 173 Marsh, 98. 100, 213 Marshall, 3, 4, 6, 7 Maschka, 129 Mason, 51 Maude, 177 Maumene. 67 Meinert, 173 Mikulicz, 170, 174, 275- ) Mobius, 178, 187, 189 Molliere, 130 Montgomerie, 186 Morean, 137 Morris, 325 Morton, 252 Mosetig-Moorhof, 237 Moxon and Wilks, 175 366 indj:x of names. MuUer, 115, 280 Murray, 178 Muschold, 194 Naumann, 172 Nelaton, 92, 94, 172 Newman, 128 Nicholls, 129 Nivet, /lO. 52, (57 Nussbaum, 303 Obalinski, 234 Odeije, 194 Orce], 199, 217 Ord, 186, 194, 320 Ormsby, 15 Oser, 174 Osier, 78, 123-4 Paget, 119, 133 • Parker, 309 Paul, 312, 314, 315 PaxtOD, 129 Pean, 174 Pearson, 150 Perry, 147 Petrakides, 217 Peugniez, 192 Peyrot, 170, 173 Picque, 194 Pitts, 128 Pollosson, 19, 249 Poncet, 245, 249, 303 Porta, 280 Potter, 159, 160 QUINLAN, 147 Kapp, 172 Kaynaud, 94 Eeece, 76, 159 Eehn, 127 Keimers, 148 Reverdin, A., 119, 189, 216, 316. 323, 334 Eeverdin, A. and J. L., 318-20 Eeverdin, J. L., 165, 329-31 Eey, 128 Eioe, 60 Eiedel, 138, 143, 144, 145, 199 Eobinson, 24 Eocket, 249 Eodocanachi, 311, 314, 315 RoUeston, 147 Ecse, 108, 113-14, 116, 206, 234 Eotter, 216, 219, 221 Eous, 304 Rullier, 172 Rydygier, 242, 244, 302 St. Lager, 50, 65, 67 Sainsbury, 106 Salzbach. 131 Salzer, 174 Samuel, 127 Savage, 177 Savory, 126, 309 Schiff, 320 Schimmelbusch, 19 Sclmitzler, 128 Schoenborn, 316 Schramm, 317 Schwalbe, 235 Schwyzer, 221 Seitz, 117-18, 128, 235 Semon, 118, 139, 225, 233-4, 320 Shattock, 206 Shaw, 92 Sick, 320-2 Smith, 95, 103, 138, 139, 254 Socin, 80, 280, 292 Sorgo, 189 Spencer, 185 Starr, 188 Stocker, 194 Stokes, 325 Stonham. 217 Sulzer, 212, 217 Symonds, C, 150, 280 Symonds. H. P., 127 Szumann, 317 Tailheper, 138, 144, 145, 199 Tait, 34 Taylor, C. H., 129 Taylor, E., 34 Teilhaber, 194 Thomas, 94 Tillaux, 210, 251 Trzebickv, 276 Turgis, 194 Turner, 224 Van der Lenden, 194 Velpeau, 243 Vincent, 119, 133 Vitrac, 168, 175 Voelcker, 147 Von Bergmann, 170, 174 Von Zoege-3Ianteuffel, 170, 174 Wagner, 320 Walther, 131, 241 Webster, 16 INDEX OF NAMES. 367 Weiss, 316 Wolfenden, 74 Wermann, 151 Wolfler. 21, 74. 78, 91, 212; 222, 241, Wilks and Moxon, 175 243 Willcox, 126 Wolper, 174 WiUett, 206 Woodward, 57 Williamson, 194 Winslow, lOS Zesas, 181, 320 Printed in- Bai.laxtvne, Hanson g' Co London e~ Edinburgh RC655 Berry B45 Diseases of thp +v ^ tne thyroid gland and their- surgical treatment.