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. ON THE SURGERY OF BRONCHOCELE.

'; '^-'. '?/■''■ ■■ ■■ ' '■■■".

V ■ . ', By FRANCIS J. SHEPHMID, M.D, CM..

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Professor of Anatomy, and Lecturer on Operative Snrgery, Me frill Lnirersity ;
. - . ' Svrgeon to the Montreal General Hospital. ■ ' '

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ON THE SUUrjEllV OF UROXCHOCELE.*

15v FKANCrs J. SHEIMIKUD, J D., CM.,

J'rofaxsor of .\»nfoii>>/, 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

•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 <iravcs's

ON THE SURGERY OF JiliOXCHOCELE. 5

(liseuse. Now Kocher, in cases of Graves's or Basedow's
disease, ligates three arteries ; in one case, where four were
iigated, tetany developed. There was one death from
chloroform in the first 100, and none in the next 900. He
advises cocaine aneesthesia if there be much dyspnoea. The
surgical treatment of Graves's disease by excision of the
thyroid, partial or complete, has been practised considerably
of late, and many cases of cure have resulted. In some cases
where the whole gland has been removed myxcedema has
resulted, but has been cured by the administration of sheep's
thyroid. In some cases sudden death has occurred after
operation on the thyroid in Graves's disease.

Bronchoceles are of very many varieties. First, and most
common, are the cystic. The cysts may either contain fluid
or colloid material. The fluid may be all colours, from a
straw yellow to a dark brown — the latter colour probably
caused by blood extravasation, and containing cholesterin
crystals. The colloid cysts are almost colourless. These
solid, or semi-solid, thyroid tumours have a distinct fibrous
capsule, and are composed of vesicles filled with colloid
matter and lined with cubical epithelium. The cyst wall
is made up of several layers with atrophied gland tissue
between ; there is the evidence of the coming together of
vesicles by atrophy of the intervening wall.

Many of the fluid cysts have solid matter in masses at
the base ; not infrequently the cysts are multiple ; the most
favourable cases for operation are those in which we have
unilateral cysts.

Secondly, diffuse bronchocele. Where the enlargement of
the gland is diffuse no special growth can be made out, but
the gland is evenly enlarged. Such cases are also due to an
excess of colloid matter in the vesicles, and are not s j
favourable for operation as the cystic. It is customary ir.
these cases, first, to treat the patient by the administration
of thyroid extract gr. v thrice daily, and the good results are
often very surprising. I have now a patient under treatment
with a very large difli'use thyroid, where the neck has
diminished five inches in size the last three months. In some
cases the gland has diminished so much by this treatment

ON THE aVHUEHY OF URONCUOGELE.

that it lias become t'mictioiiless. If the luhninistration of
thyroid extract exercises no beneficial effect, then, if operation
be decided upon, only one half the gland should be removed.
After operation the other half frequently atrophies.

Thirdly, the vascular bronchoceles. These occur chiefly
in cases of Graves's disease, and are very formidable to treat
by excision.

The treatment of Graves's disease by operation has not
been very popular owing to the great danger of death from
causes unknown. A very high temperature often follows
thyroid excision, owing, it is thought, to excessive thyroid
absorption. Jaboulay {Lyon Medical, February 7th, IJSOT)
argues that since the prominent symptoms of exophthalmic
goitre are those of permanent excitation of the cervical
sympathetic, resection of that nerve trunk is the most
valuable method of treatment. He reports a second series
of three cases to support his contention. In these cases the
eyes retracted, the thyroid diminished in size, and the tumour
and tachycardia were immediately relieved. The operation
is an easy one, and the relief is immediate and lasting.
I have only operated in two cases of exophthalmic goitre,
and in both there was evidence of encysted solid growths.
In both cases there were marked tremor, tachycardia, and in
one exophthalmos, and in the other oedema of the lower
extremities. The removal of the excess of thyroid immedi-
ately relieved the patients, and their recovery was complete.
In many of the cases I have operated on there Avere nervous
symptoms, such as tachycardia, being easily startled, and
s3nnptoms of hysteria, which were all relieved by operation.
It is my opinion that there are degrees of Graves's disease
as of myxcedema; the thyroid being in evidence in the first
class they are not overlooked, though often the enlarged
thyroid is not given the credit for producing the nervous
symptoms. In the second class I believe many cases of
incipient or mild myxoedema are overlooked. In these cases
there is (h'owsiness and less mental acuteness than formerly,
and relief is afforded by the administration of thyroid extract.

Fourthly, inalignant tumours. These may be either
cancerous or sarcomatous. Operation is difficult, and of

I \

ON THE SURGERY OE BRONCIWCELE. 7

only temporary benefit. When there is much surrt)unding
infiltration they should be left alone.

Fifthly, inflamed goitres. Wh(ni a goitre is acutely in-
flamed, Kocher advises extirpation. Incision and drainage
is the best treatment where pus is suspected.

Other forms of tumours, such as those produced by benign
growths, echinococcus, etc., are occasionally seen, and require
but little notice.

THE DANGERS OF OPERATION.

The great dangers of operation on the thyroid are
haemorrhage, wounding or injury of the recurrent laryngeal
nerve, and the after-ett'ects from total extirpation of the gland.

Formerly it was thought necessary by some to perform
tracheotomy before extirpating the thyroid, but it is n.)w
found that this is an unnecessary procedure, that it
complicates the operation and renders the risk of sepsis
greater. After removal of the goitre the dyspncea i;nmedi-
ately disappears, and the supposed danger from after-collapse
of the trachea is found to be chimerical. There is no doul)t
but that in these cases the suffocation can be best relieved
not by cracheotomy, but by removal of the bronchocele.
After a short demonstration of the surgical anatomy of the
thyroid, the lecturer described the various operations as
follows :

OPERATION.

There are three main methods of operating on the

thyroid : —

1. Extirpation, partial or complete.

2. Enucleation.

3. Ligature of the thyroid arteries.

Of the last method I have had no experience, so shall merel}
mention it.

1. Extirpation. — This operation is now undertaken with
much more confidence than formerly, and with small danger
of a fatal result. Complete extirpation, owing, as I have
before remarked, to the occurrence of cachexia strumipriva,
has been abandoned. Partial extirpation is performed in cases
of exophthalmic goitre and those diffuse forms of thyroid

ON THE SURGERY OF liRONCIIOCELE.

enlargement where administration of thyroid extract has
j)roved of no beneHt. In operating in these cases enncleation
should never be attempted, but the superior thyroid artery
and veins should first be ligatured, and then the inferior
thyroid artery compressed, and the tumour on one side
removed without opening its capsule. The inferior thyroid
branches should be ligatured quite near the thyroid to avoid
injury of the recurrent laryngeal nerve. In vascular cases
e 3cially, it is very important first to cut ofi' the blood
supply and avoid opening the capsule, for then the thin-
walled veins are torn, and furious and uncontrollable
luemorrhage results ; the veins are so friable that forceps
will not secure them, and it is possible to control the ha3mor-
rhage only by packing. The isthmus should be ligated, it
of large size, in sections, with strong catgut or silk. The
surgeon of experience will have no great difficulty in per-
forming this operation. A drain should be placed at the
lower end of incision for twenty-four hours and then removed
entirel}'.

2. Enitdeatvm. — In this country, at any rate, the most
frequent form of goitrous tumour is the cystic, solid or Huid.
These cysts may be single or multiple, unilateral or bilateral.
The unilateral single cysts are the most favourable for
operation. Thyroid extract is of no benefit in cystic cases.
In these enucleation is the proper mode of treatment. I
have now operated on nearly thirty cases by this method,
and have not yet had a death, and in all there was a
rapid cure.

The operation is undertaken for the relief of dyspnoea,
especially on exertion, dysphagia, and to relieve deformity.
Nervous symptoms, such as tachycardia, tremor, etc., .^••'^.
frequently noticed in these cases, especially where there has
been a sudden increase in the size of the tumour. All my
cases have, with one exception, been in women, chiefly for
the reason that women submit more readily to operation, and
nervous symptoms in them are, perhaps, more pronounced.
No doubt — in the province of Quebec at all events — goitre is
more comtuon in women than men. In every case in which
I have operated. benoHt to the general health has resulted.

ox THE SURGERY OB' BRONCIIOCELE.

and the patients looked and felt much better afterwards.
The operation is apparently a simple one, but occasional!}-,
when the cyst is adherent, the luemorrhage is tremendous
and most difficult to control: these are cases where external
applications have been used, or where there has been at one
time an inflanmiatory condition. This condition is com-
paratively rare, however. The sunplest cases for operation
are those where the cyst is single. This cyst may be in
cither lobe, the isthnuis, or in the pyramid or middle lobe.
Or the cysts may be multiple and involve all the lobes. Tlio
dilticulties increase with the increasing number of cysts.
When the cysts are on both sides I make two incisions, one
over each lobe. The great diliiculty of the operation is to
know when the proper cyst wall is reached; but after the
experience of a few cases, the operator soon gets to know it.

The operation performed by me is as follows * : — The
neck having been thoroughly cleansed, an incision some three
or four inches long is made directly over the tumour. After
(;utting through the skin and fascia, the depressor muscles of
the thyroid cartilage are reached ; but these, if the tumour be
large, are so thin as hardly to be noticed. At this point we
frequently see a very large anterior jugular vein, which
should be divided between two ligatures. As soon as the
depressor muscles are cut through, the gland is reached; it
looks very much like muscle, and bleeds freely Avhen cut. A
small incision should be made through the gland tissue, and
at a greater or lesser distance the capsule of the tumour will
be seen ; it is recognised by its bluish-white colour, but it
re(piircs some experience to know when the proper layer is
reached, lieverdin says, truly enough, " Whenever you are
doubtful, you are not on the growth." When the capsule of
the tumour is reached the incision in the gland should l)e
enlarged and the tumour enucleated with the finger. Owing
to the hiemorrhage, which so freipiently occurs at this stage,
it is my custom to puncture the cyst and let out some of its
contents ; in this way tension is relaxed and the gland comes
out ol its bed, and as the cyst is delivered it is peeled off"
from ihc surrounding gland tissue, any larye vessels being

* Sn' lulirlo by llio writ' r in AkiihI.^ nf Sin-f/rri/, Sept.. IS!).").

ON THE SURGERY OF BRONCllOGELE.

tied, if torn, then and thore. The cyst is delivered liice an
ovarian tinnou]*. The danger of haimorrhage is reduced, and
the operation is thus made extra-cervical. In this way 1
have removed very large cysts, which extended below the
sternum and covered over the branches of the aorta, without
the slightest fear. When the gland is allowed to fall back,
and the situation of the cavity irom which the cyst has been
removed is seen, one is often amazed. In one case I could
see all the large vessels pulsating behind the thin wall of the
cavity, including innominate artery and transverse innominate
vein. In some cases the bed in which the cyst lies is lined
with huge tortuous veins, from which the cyst wall had been
peeled off.

If there are several cysts, one can be reached through the
bed of the other, and no fresh incision need be made in
the gland tissue; this saves loss of blood, and lessens the
danger of the operation. All bleeding points having been
secured, the cavity is packed with iodoform gauze, the end
of the strip being allowed to protrude from the lower angle
of the wound. I formerly used a drainage-tube, but
haemorrhage is not uncommon when reaction takes place,
and I have found that the only cases where this was alarm-
ing occurred when a drainage-tube had been used, or the
wound closed completely. In no case where gauze was
packed in was there any secondary haemorrhage. The skin
wound is sutured with horsehair and a sterilised gauze or
cotton-wool dressing applied. At the point where the gauze
protrudes a suture of silkworm-gut is introduced and left
untied. Next day the wound is dressed, the gauze removed,
and the opening closed with the silkworm-gut suture. I
never wash out the cavity, or use water at all to wash the
wound. A dry dressing is reapplied, and the patients arc
encouraged to get up and move about. By doing so I think
they get better more quickly. The stitches are removed on
the fifth or sixth day. Next day patient is discharged. My
cases average six days in hospital. The pulse is often rapid,
and the temperature may be high after operation ; but if the
wound looks normal I pay no attention to these symptoms,
and they seem to have no injurious ciie(;ts on convalescence.

ON THE SUIWERY OF BRONCHOCELE.

They may bo duo to disturbanco of tlio inland, and perhaps to
excess of absorption of thyroid matter (hn'injjf the operation.
Fiarge cysts are often more easily removed than small ones,
being often less adherent. If the cyst contents be solid I open
the cyst and turn as much of the contents out as possible,
and then treat the cyst wall as I have described above. In
most of the fluid cysts there are usually some solid masses
attached to the base. Healing in those cases is marvellously
rapid.