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ON THE SURGERY OF BRONCHOCELE. '; '^-'. '?/■''■ ■■ ■■ ' '■■■". V ■ . ', By FRANCIS J. SHEPHMID, M.D, CM.. ,- . ^ • ■■ •■■■,.■ Professor of Anatomy, and Lecturer on Operative Snrgery, Me frill Lnirersity ; . - . ' Svrgeon to the Montreal General Hospital. ■ ' ' >!' ■ -V,. '>l -.s i V ■m-^ '1 i"^"' ''J ^;^->J' h ■ ■X . . ,,.'V/. ■.1, . • ... • •'('■ .,1 ».' ■i?> ''v.>^:: ■ \^=> .■'! -v' VA^f .■■-^^'''j ■(■?!■•; '^^v'i-X ■■.'';■'>■•. ■'.'''■;■ 'n "■' ;■ .V-V-; i:-%*,^'':.^,/v;^f^:.i>^^-^:.^i. .':•\v■^;:>^--• ■"--"';■ -^-v ■"■.'•': ■- ■'■J"' ri ..■;<,'./■■ -. ;• ■'■»'.-,, ^ ■■■•■■•■/ 'V-c-"-}-! j ■''■'•<•■ "■.•■■'■• t ' «n From "ThK I'UACTITrONKU " /«»• . I «//«.>/, anil Lecfvrer on Operative ^vrijcry, MediU rnireriiifi/ ; Sinyroii fo lite JfontrenI (ieneral Hospital. It is only twenty years since any scientific method for removal of the whole or a portion of the thyroid gland has been introduced. In reality, it was not until the universal adoption of antiseptic surgery that any success was obtained. Formerly, from thne to time, single cases of removal of the thyroid v/ere reported, and these were quite as often fatal as successful. It is true that only the larger thyroids, at this time, wore treated surgically, for it was only when the bronchocele became dangerous, interfering with respiration and deglutition, that surgical advice was sought and surgical interference recommended. In the cystic form, reliance was placed on tapping and injection with iodine, or the use of setons. In the solid forms potassium iodide internally, in larije doses, and the use of the biniodide of mercury ointment externally, were employed. Tappirig and injection with iodine were strongly advocated, and frequently practised with success, by the late Sir Morell Mackenzie {Lancet, May, 1872) ; but the danger of acute sepsis was so great that this mode of treatment was never popular with surgeons. Excision of the cysts was recommended by Celsus, (lalen, and many others, and was revived as a new treatment from time to time. Incision was practised from time immemorial. Professor ^\^ Warren (ireen, of Portland, Maine, in the later 'sixties, performed successfully several extirpati(»ns of very large thyroids, one of which was excessively vascular (^477*. Jour, Met!. Sr.., January, LSTl). His niethod was to make an * A Ifctnrt' dtlivci'i'd hi'l'ove the I'Dst-Chailiiuti- t'luss of MctJill rnivtisitv, June Tth, IH^»7. 2 ON THE SURUERY OF BRONCIIOCELE. incision directly over the tumour, (knvn to the fascia propria of the gland ; the thin fascia propria was then carefully divided on a director, the prominent veins being avoided, and then the tumour, regardless of even very great haemorrhage, was rapidly enucleated, and the posterior part, or pedicle where the arteries entered, ligated in sections, and the tumour removed. In one case of huge tumour, the operation was completed in twenty-two minutes. As was the custom in those days, the ligatures were left long and brought out at the lower end of the wound, and came away in about three weeks. Tn the three cases reported recovery took place, the wound healing rapidly by first intention at every point, except where the ligatures had been. At the conclusion of his achuirable paper. Professor Oreen says : " I prefer to submit these cases to the profession with very little comment. They ave the only ones in which I have ever performed the excision of bronchocele, and if they arc the last I shall not regret it. For, while their issue has been so fortunate, I am sure that no man could witness even, much less perform, those opera- tions and envy the man upon whose lot it fell to undertake them. Yet, under similar circumstances, I should not shrink from such responsibility, and this for the reason that the possibility of successful extirpation, even of the worst cases, is established : and I believe the operation, performed in the manner I have indicated, may claim quite as secure a place among legitimate deimierf^ resi^oiiK as amputation at the hip-joint." This explains well the position of surgeons of that day ; they regarded operation on the thyroid as a dernier ref^sort, and undertaken only to save life, never for the relief of deformity or discomfort. The late Professor Geo. E. Fenwick, of Montreal, stinndatcd by Professor Green's example, success- I'lilly removed an enormous cjstic bronchocele in 1872 {('(tn. Med. and Siiir/. Jour., vol. i., 187.^). According to P. Ih'uns, in a paper read before the German Surgical Congress of 180(), previous to 1877 only 150 cases of extirpation of the th)'r()id had been recorded, with a mortality of 21 per cent. During the five years following 1S77, 240 operations were reported, with a death- ox THE SURGERY OF Bh'OXCIIOCELE. 3 rate of 12 per cent. Tlie lessened mortality and greater number of operations were chieHy due to the introduction of a better technique, uiore certain methods of arresting bleeding, and the general adoption of the Listerian principles of antiseptic surgery ; for the former prevent deaths from secondary hajmorrhage, and the latter from wound infection. Rose, at the German Surgical Congress of 1H77, gave his experience of the radical cure of goitre by extirpation ; and, within a year or two, Billroth, Kocher, Socin, the two Keverdins, and others, improved the methods • of operation and still further reduced the mortality. But everything was not so bright as it seemed ; there was a dark side to the picture. The Messrs. Reverdin {Revue MM. de la Suisse Ronutude, 1888) followed the after course of their patients for several years, and found that in a certain proportion (about 20 per cent., if I remember aright) curious con- ditions existed, something like myxo^dema. There was first weakness and coldness at the limbs, then loss of appetite, slowness of speech, diminution of memory, and progressive amemia, accompanied in some cases by a peculiar u'dema most marked n the face. It was found that these symptoms occurred only when the thyroid was totally extirpated. The Messrs. Reverdin attributed this condition to a lesion of the vaso-motor nerves. In cases of total extirpation, when the patient remained healthy, the escape from the cachexia was probably due to the presence of supernimierary or para- thyroids. This report of the Reverdins did not attract the attention it deserved, and it was not until the following year, at the Twelfth German Surgical Congress, when Kocher read his conununication on Cachexia Strumipriva, that surgeons became alive to the importance of the symptoms produced by total extirpation of the gland. Kocher has since then given the disease produced by total extirpation of the thyroid the name of " cachexia thyreopriva." To prevent the occurrence of this disease many devices were advocated, such as intro- ducing sheep's thyroid into the peritoneal cavity, or under the pectoral muscles, etc.; but it was not until the importance of the internal administration of animal extracts was dis- covered that extract of thyroid was given for this disease and I: •1 ox THE SUIidER-Y OF BROXCUOCELE. inyxd'dotna. Dr. (1kis. Murray, of Xo\V(;asllo, Kni^laiid, was the first to use it for goitre. Now, however, total extirpation of the thyroid is rarely attempted except in malignant growths, and <\achexia thyreopriva is seldom seen. About 188»; Prof. WoelHer introduced the method of ligature of the four thyroid arteries for the cure of thyroid tumours, and his method was followed with more or less success: by other surgeons. Xow it is only practised in cases of exophthalmic goitre or very vascular goitres. Socin before this recom- mended enucleation of only the diseased portion of the gland, practised it with groat sucjcess, and reported fifty cases. It had been previousl)- adopted in 1840 by the Italian surgeon Porta, and then by .luillard, Rothman, and others. This operation, which I shall describe fully later on, consists in intra-glandular shelling out of the degenerated portions of the gland. The great advantages of this operation are the lessened danger of hiemorrhage and injury to ihe recurrent laryngeal nerve, also the absence of any fear of producing cachexia strumipriva. Yet another method of treating bron- choceles has been advocated by Mr. Sidney Jonr:^ {Lancet, November 28th, 1888) — namely, excision of the isthmus. In the case reported thei*e was a great deal of dyspnwa, which Avas relieved by the operation, and a month after, the large thyroid itself Avas scarcely perceptible. The late Sir (!. 1). (libb, formerly of Montreal, many years ago advocated divisi(Mi of the isthmus to relieve the severe dyspnwa which occurs in large bronchoccles. Leon quite recently has treated large bronchoccles successfully merely by open incision of the skin and exposing the gland to the air for some time, and then (ilosing the wound. Perhaps one of the most epoch- making papers was that read by Kocher, of Berne, at the rjerman Surgical Congress of 1895. He reported 1,000 operations for goitre. In his last 900 cases there was only one case of cachexia strumipriva ; in this case one half of the gland was removed and the other half atrophied. In 7 per cent, the recurrent, nerve was injured and the voice impaired. Of the 870 cases operated on for non-malignant :liseaso, only eleven died. Five desperate cases died as the immediate result of thf operation, anfl three died of