with the anatomy and one who is a careful and deliberate operator.

It has even been said by some of our most prominent surgeons that it is a field to be explored by trained hands, and that no others should attempt it, and that it is good for the progress of surgery that there are still unexplored fields and operations with difficult technique.

Nevertheless, when we eliminate the dangers by a careful selection of cases suited to surgery, by the proper preparation of our patients before operation, by a suitable technique and proper aftertreatment, the removal of goiters, and especially the exophthalmic type, will be accompanied with as much success and as low a mortality as many of the operations now classed with the daily average types of surgery.

While we all realize that some, indeed a very small percentage of true cases of Graves' disease, will recover with or without any treatment whatsoever, we still are forced to acknowledge that surgery is the only permanent cure, in that it removes the organ producing the toxicosis and breaks the pathologic chain of this disease.

In the selection of our patients for operation we should realize that early operation, before complications have arisen, as in appendicitis and other surgical diseases, offers the best results.

Those cases whose pulse is not over 120 to 130, and which under careful preparatory treatment can be reduced to 100 or below, and whose arterial tension is not far from normal, will usually stand the operation well and give good results.

It is that class of cases where no preliminary treatment seems to be able to make such temporary reduction which seems to be especially dangerous. These usually have an irregular pulse, a degenerated heart muscle, low blood pressure in distinction to the majority, which have often a very much increased blood pressure; albumin in the urine, or enlargement and fatty degeneration of the liver.

Blood examinations, as so strongly advocated by the Kochers, have not given me much satisfaction or aided in determining the prognosis of any of my cases.

Those patients past thirty or forty years stand operation worse than those younger.

After a careful study of my operated cases I have noted that all patients in whom I was not able to reduce the pulse in preparatory treatment to below 110 have died, and I lost no patient in whom we were able to reduce below this number; this observation irrespective of the original condition of the pulse when patient entered the hospital. In other words, a patient entering the hospital with a pulse of 180 and reduced before operation to below 110 always recovered, and one entering the hospital with a pulse only 120-130 and not reduced to below 110 always died.

In the preparation of the patient for operation I have tried almost every remedy usually recom

mended to reduce the pulse and better the condition; but none has yielded such good results as absolute rest in bed and tincture of strophanthus. This latter drug is hard to obtain fresh and care must be used to get a reliable preparation. Epsom salts, so popular in the treatment of night-sweats in tuberculosis, seems also in exophthalmic goiter to act as a specific to neutralize the poisonous toxin, and is especially indicated in all cases except those with a profuse diarrhea. The calcium salts should always be administered for several days before operation as this lessens hemorrhage and seems to act especially upon the thyroid and parathyroid glands.

Aside from the proper selection and preparation of the case, the most important thing which concerns us is a rapid and safe technique, suitable to the average surgeon and not a variety of complicated methods.

While the Kochers have strongly recommended a preliminary ligation of the superior thyroid artery and vein in the worse cases, after an experience of twelve cases in which this was practiced, I have concluded that a rapid complete enucleation of the enlarged lobe can be done about as rapidly and with far better results. My mortality for those cases was more than double that of my other complete enucleations.

Some operators have even suggested the ligation of the inferior thyroid artery or several of the large veins to produce by this latter method a passive hyperemia. These procedures are extremely difficult to properly perform, and would probably cause as much shock as a complete and rapid enucleation.

The immense amount of attention given to the parathyroids has caused most surgeons to fear their injury in almost any operation in the neck. While we are all forced to acknowledge that tetany has been produced by the removal of the parathyroids in the dog, and has even followed operations in the human, it is also a strange fact that many who have done a very large number of thyroidectomies have never had a case of tetany to develop.

Is it that the technique of some has been at fault, and that the injury to or the cutting off of the blood supply to the parathyroids has been the cause? Or is it, as has been suggested, possibly due to other conditions quite independent of these structures in the neck?

Attention has been called by Kocher to the necessity of preserving the capsule of the gland, and yet, when this has been most carefully carried out, one or more parathyroid glands are occasionally found embedded in the structure of the tumor removed, and yet no harm has resulted.

The technique employed in my later cases has given such universal satisfaction in my own work and is so simple in execution that I believe it an improvement on older methods, and is especially well suited to the average surgeon, as it possesses

the two most important requisites, i. e., rapidity and safety.

The patient's head is elevated, with the body lying in the reverse Trendelenburg position, and a large sand pillow placed under the shoulders and neck. This position throws the chin upward and places the tissues of the neck on the stretch.

The skin is now grasped in the median line with two pair of Jacob's volsella forceps and traction is made upwards. With a large pair of blunt-pointed scissors, instead of a knife, the skin and platysma muscle are incised; then with constant upward traction the incision is continued around the neck as far as it is needed, which is usually to the edge of the external jugular veins on either side.

This method of elevating the skin by traction with the forceps has several important advantages over the method of cutting down on the structures with a knife. First, it is much safer, as we are not so liable to cut the veins and arteries lying below, for there seems to be a plain of cleavage between the platysma muscle and the deep fascia; and secondly, it is very rapid and allows the use of scissors which cause less hemorrhage of the smaller arteries when cut.

The two large flaps are not dissected up to above the hyoid bone and below to the sternum.

The ribbon muscles are freed in the middle line and the sterno-hyoid muscle of each side is doubled, clamped high up and cut, the forceps being left on

to act as retractors.

We next separate the broad and thin sternothyroid muscle from the gland capsule and divide on both sides.

The capsule is now opened and the tumor grasped with large three-pointed volsella forceps and traction is made in an upward and opposite direction. With gauze the capsule is wiped off the gland, having artery forceps to catch the capsule at several points.

As the arteries and veins appear they are doubled, clamped and cut high up on the tumor, so as to avoid injury to the recurrent laryngeal nerve or

etc. I next tie each artery and vein held in the forceps with catgut or celluloid yarn, as this latter is more rapid and less liable to slip than is catgut. A stab-wound is now made in the supra-sternal notch, and a large rubber tube and by its side a small piece of gauze introduced. This is much superior to the usual cigarette drain, as we have two different kinds of secretions to remove.

At this stage of the operation the cavity is repeatedly flushed out with normal saline, which removes all clots, gland secretion and allows us to see if all hemorrhage is completely checked.

The anesthetist now allows the patient to come out somewhat from under the anesthetic and with the straining and nausea we test our ligatures.

This is in the opinion of the writer one of the most valuable points in his technique, as on more than one occasion he has seen even the celluloid yarn give way and cause much hemorrhage. Catgut is exceedingly treacherous in neck surgery.

The ribbon muscles are now sutured and also united in the median line. If they are very thin and the patient is not standing the operation well, this latter step can be neglected and no harm result. Next the skin to which the platisma is attached is sutured with a subcuticular catgut suture.

The patient should be placed in a semi-sitting posture as soon as they come out from under the anesthetic. Saline, by rectum or otherwise, should also be given early.

In my very worst cases of exophthalmic goiter I do not entirely close the wound, but only one side, sutured with interrupted stitches, and the cavity from which the tumor was removed is packed with gauze to absorb all the glandular secretions. latter procedure is a great life-saver and has undoubtedly been of advantage in my work.

This

My anesthetic has always been plain ether, preceded by morphine and atropine, and from our success with it we see no reason to change. (For discussion see page 315.)

As early as possible the superior thyroid artery should be located and clamped, as this is the major portion of the arterial supply. The constant upward traction on the tumor causes the vessels to stand out clearly between the capsule and the tumor and also prevents venous hemorrhage. After the vessels have all been clamped and the tumor freed except at the isthmus, we place a very large forceps on this part and cut as near as possible the tumor V-shaped from the isthmus. Then we gradually loosen the clamp and ligate any bleeding vessels in the pedicle. Next the edges of the cut gland are whipped over with catgut and in this way the secretions as well as the hemorrhage are stopped. This latter method I have suggested as being much. superior to the usual method of cauterizing the stump with carbolic acid, Harrington's solution,

O

BY W. D. HAINES, M.D.,

CINCINNATI.

VER-ACTIVITY on the part of the thyroid, or inability on the part of the general system to utilize or eliminate the surplus, induces a condition to which many names have been given, the least objectionable and most expressive being hyperthyroidism. Although the symptoms were accurately described by Parry almost a century ago, and later elaborated by Graves, Basedow, Kocher, Horsley, Halstead and a host of others, lack of knowledge of the definite pathological changes taking place in the gland preceding and accompanying the systemic manifestations, has produced a con

*Read before the Ohio Valley Medical Association, Evansville, Ind., November 11-12, 1909.

fusing and almost hopeless entanglement in the nosology and treatment of the condition variously termed goiter, bronchocele, tracheocele, exophthalmic goiter, Basedow's disease and Graves' disease. Clinically, it has been known for years that we may have cases with great enlargement of the thyroid, which produce little or no deleterious effects upon the general economy; conversely, tremor, tachycardia, exophthalmos and skeletal muscular weakness have been observed in the absence of very marked thyroid enlargement. Explanation of these somewhat contradictory phenomena is found in the microscopic study of changes which have taken place or are taking place at the time the patient comes under observation. In the former, the large gland without symptoms, pathologic changes of a benign character are found, including cytolysis, disintegration of acini, colloid and cystic degeneration, which have destroyed large areas of glandular tissue, and, by increased intracapsular pressure from retained detritus, resulted in a species of lymph block which prevents the thyroid secretion, iodothyroglobulin, from entering the general circu

lation.

According to Wilson, there is an increase, not only in the number of intravesicular cells, but also in the number of vesicles, in thyroid glands which are overactive and producing symptoms. He further reports a very constant relation between laboratory findings and clinical symptoms. Germane to the foregoing are the deductions of Sajous, who, after an exhaustive review of the literature, presents the following conclusions:

1. What we term exophthalmic goiter is a syndrome ascribable (a) to overactivity of the adrenals, due primarily to excessive thyroid secretion in the blood; then, in the second stage, (b) to insufficiency of the adrenals-i.e., when the excessive thyroid secretion has induced their exhaustion or that of their centers.

2. All symptoms which have heretofore been directly or indirectly ascribed, in this disease, to the thyroid gland, should be attributed to excessive or insufficient activity of the adrenals.

The thyroid is developed from three separate rudiments, two lateral and a median, given off from the ventral wall of the pharynx opposite the second visceral arches. Remnants of the median diverticulum may be found in the adult in a cord-like ligament extending from the thyroid isthmus to the foramen cecum on the dorsum of the tongue.

The parathyroids are composed of reddish-yellow epithelial cells contained within a distinct capsule, and have an independent circulation (Evans). They are situated on the posterior surface of the thyroid capsule, and are about the size of a pea. They vary in number from five to eight, and are readily demonstrable. Although differing in embryologic origin and histologic conformation, they cannot be said to be disassociated functionally from the thyroid and certain other ductless glands, nota

In

bly the adrenals, thymus and pituitary bodies. deed, one physiological "fact," developed in the progress of physiology recently, which will perhaps survive the usual eighteen months' probation, declares as utter folly all attempts to assign one special function to each gland or organ; the lesser is contained in the greater, bearing in health a definite and complex inter-relationship to the whole economy.

Little is known of the function of the parathyroid bodies, but their complete removal is very constantly followed by muscular tetany and death. Beebe, by injecting a nucleo-proteid, kept animals alive after removal of the parathyroids, and Russell found uniform changes in the cortical brain cells of animals dead of tetany induced by the removal of the parathyroid bodies.

Many statements of a contradictory nature are found in the literature on the effects of total removal of the thyroid.

Gull, in 1874, described a condition clinically identical with myxedema, which followed removal of the entire gland. His observations were later confirmed by the Reverdins.

Kocher studied the changes following complete removal, and endorsed these clinical and laboratory findings, but gave it the name of cachexia strumiprevia. Other observers have denied the correctness of these deductions, and cite cases wherein total removal has been followed by no untoward effects.

It is highly probable that the latter observers were studying cases in which accessory thyroid lobes existed, and, while the gland within the capsule had been removed, sufficient glandular secretion to regulate oxidation was being supplied by accessory lobes overlooked at the time of operation.

Maurice Faure records a case in which exophthalmic goiter and myxedema coexisted for a period of two years, and in numerous cases myxedema has followed exophthalmic goiter, Baldwin, Gowan, L. Gautier, Joffroy, Achard and others, who erroneously conclude that excessive thyroid secretion. does not result in the production of exophthalmic goiter, nor lack of secretion end in myxedema.

Recent biochemic and pathologic studies have conclusively shown that retrograde changes in the thyroid are of a benign nature in so far as the overproduction of iodothyrin, thyreoglobulin, etc., are concerned, and the above citations are but examples of over-correction through retrograde metamorphosis, leaving the patient in the same condition as if the thyroid had been removed-i.e., devoid of secretion. A decided advance in the pathology and management of goiter was gained when we realized that simple goiter in the majority of instances will, if not checked by medicine or surgery, run the entire gamut of hyperthyroidism.

At present writing we may deduce the following rules for guidance in operating upon the thyroid gland: (a) Total removal is followed by myxedema;

(b) removal of all the parathyroids is followed by tetany.

Carral, the wizard of vascular surgery, has obtained relief experimentally in induced hyperthyroidism by diminishing the caliber of the vessels supplying the thyroid, and has seen the effects of hypothyroidism disappear like magic after vasodilatation following nerve section. He has also increased the blood supply to the thyroid in reversing the current, by anastomosing the common carotid with one of the thyroid veins, and providing for return of venous blood by suturing the superior thyroid arteries to the internal jugular.

Luska estimated the amount of blood carried to the thyroid as being equal in volume to that conveyed to the brain by one carotid and vertebral artery. Mayo has, by preliminary ligation of both superior thyroids in acute goiter cases, preparatory to doing a two-stage operation, obtained results which precluded the necessity for further operation upon the gland. We have had but little experience with this type of operation, but our results have been encouraging, in that the thyroid diminished in size, and there followed a marked abatement of symptoms, but no case was permanently cured.

We commend ligation of the superior thyroids in moderately enlarged hyperactive glands for the following reasons: Ligation is less serious than thyroidectomy, is never followed by hyperthyroidism, and, if complete relief does not obtain, the patient will be in better condition for the heavier operation of removal of the gland at some future time.

American surgeons are coming to recognize more and more each year the inestimable value of preliminary preparation and post-operative treatment in all major operations. In no other class of surgical risks does careful preparation count for more than in the one under consideration. A week or ten days spent in bed with an ice-cap over the heart, 2-gram doses of belladonna, and exclusion of visitors, combined with proper supervision of personal habits of the patient, constitute our preliminary preparations. We sometimes give morphia and atropia hypodermically a few minutes before sending the patient to the ether room. It checks some of the excessive bronchial secretions and allays ner

vousness.

Local anesthesia may act very well in a certain phlegmatic type of patient, with whom the personality of the surgeon counts for more than the use of drugs. Personally, we prefer and employ general anesthesia in all goiter operations-ether given by the drop method.

The reverse Trendelenburg position will lessen the amount of hemorrhage, and a flat sand bag beneath the shoulders will render the region of the thyroid accessible and facilitate celerity in operating.

After transverse division of the skin over the most prominent part of the enlarged gland, a flap should be reflected one-half inch or more, in order that the platysma may be divided on a different

enter.

level to that of the skin. By separating the platysma and retracting the sternohyoid and sternothyroid muscles, the capsule of the gland, which in a degree resembles peritoneum, is exposed to view. The capsule may be divided on the anterior surface of the gland for the entire distance between the points where the superior and inferior thyroid arteries Trabeculæ extending from the glandular substance to the capsule usually give way readily on gently sweeping the finger between the gland and capsule. However, in some instances detachment of the capsule will be better accomplished by wrapping a piece of gauze around the finger, stretching the capsule and gently breaking the connections by gauze dissection. Extreme gentleness in this manipulation will avoid laceration of surface veins, which may give rise to troublesome hemorrhage, delay operation, or prove fatal to the patient. The arrangement of the arterial supply of the thyroid is easily the most beautiful in the body. The superior vessels, branches of the external carotid, enter the capsule over the apex of either lobe. The inferior, from the thyroid axis, enters the lower pole of either lobe in close relation with the recurrent laryngeal nerve. There is a free anastomosis between the four vessels and the thyroidea ima (latter not constantly present). Venous blood is returned through the superior and middle thyroid veins to the internal jugular, and by way of the inferior thyroid to the innominate vein. Nerves supplying the thyroid are derived from the middle and inferior cervical ganglia of the sympathetic. Pulsation of the superior thyroid may be felt at the upper pole of the gland, a hemostat placed upon it within the capsule, and another hemostat, which included. some of the gland, is placed a short distance from the first, followed by division between the hemostats, will completely free the upper end of the gland.

If but one lobe is to be removed, division of the isthmus between two clamps permits delivery of the mass and exposure of the ascending vessel, which is caught in a hemostat and the entire lobe removed by one or two strokes of the scissors.

The vessels are ligated with chromicized catgut. The operation as described has been wholly within. the capsule, and we are assured that the parathyroids and recurrent laryngeal nerve have escaped removal or injury.

Brouardel has happily styled the neck as one of the privileged regions of the body, and one should ever remember, in operating upon neck structures, that death from inhibition has followed slight traumatism-so slight, indeed, that no visible marks presented at autopsy.

In most of our cases we have, by longitudinal separation of the hyoid muscles, and slightly flexing the patient's neck, been enabled to retract the muscles and deliver the mass without transverse division of the muscles. If division becomes necessary to deliver the gland or secure the vessels, division

should be made well toward the hyoid attachment, in order to preserve the nerve supply, which enters the lower one-half or two-thirds of the muscles.

The ends of the severed muscles should be carefully coapted, and ample provision made for drainage through an independent stab wound. Some cases will drain freely for ten days or more. The capsule is closed by a continuous suture, the platysma is closed by interrupted sutures, and the skin margins are coapted and held together by skin clamps. Saline per rectum, preferably by the drop method, oxygen, ice-cap over cardiac region, sufficient morphia for the first thirty-six hours to quiet the patient, constitute in a general way the post-operative treatment.

A portion of the gland should be left in doing a thyroidectomy. If, however, operation is followed by over-correction, and myxedema supervene, this may be relieved by transplantation of thyroid tissue or by giving the patient thyroid extract. The parathyroids have been successfully transplanted experimentally, but it is important to remember, in doing this work, that the herbivora do not have tetany after removal of these bodies.

DISCUSSION.

DR. A. E. STERNE: This whole question of operative versus medical treatment of thyroid affections, including exophthalmic goiter, was gone into very carefully and very beautifully at the Mississippi meeting at St. Louis, and the best exposition it has ever been my privilege to hear was given by Dr. Crile, of Cleveland. The essential feature of this whole question, as far as treatment is concerned, lies in the fact of converting a poor surgical risk into a good surgical risk before operation is done.

Another essential feature is to stay within the capsule absolutely, and see that your structures are completely dry before closing. It is the action of the thyroid secretions on the operative surface that later gives such ill effects. So far as technique is concerned, my own experience is that so long as you stay within the capsule you can go very rapidly, putting on clamp after clamp, regardless of what you strike-one hundred, two hundred if necessary--then tie them off or stitch them off, as the case may be, and the results then are good so far as the operation itself is concerned.

Now, further, what does an operation do? That is a point about which I want to speak. When we operate on a case of exophthalmic goiter we are not removing the cause of the disease. We are removing the possibility of hypersecretions of the thyroid, which are responsible for the major and most distressing symptoms of the patient's appearance, but we are not removing the underlying factor of this disease. We cannot, therefore, expect complete recovery after removal of the thyroid gland in cases of exophthalmic goiter. We can expect complete recovery in mere hyperemia of the thyroid gland, the malignant disease of the thyroid where the exophthalmic variety has not arisen; there we are doing a simple operation for removing a deformity. But in exophthalmic goiter there is a mystery.

There are the three so-called cardinal symptoms, and there are other symptoms which are frequently met, any one of which may be absent and the diagnosis still be confirmed. When we remove that gland we still must look for the conditions which brought on the disease in the first place, minus such symptoms as are caused by the increased secretions sufficient lapse of time are altogether at this time within the body. The results, therefore, after a a question. I have seen many and many cases that have been operated upon that afterwards had recurrence of the nervous disease which we call Basedow's or Graves' disease. It is not an absolute cure for this condition.

I was surprised not to hear mention made of the newer operation of ligation of the upper pole of the thyroid in preference to the more radical operation. The ligation of the upper pole completely within the capsule cuts off the lymph supply to the system, and it is possible that this operation may be used instead of the more radical operation done now in the extirpation of goiter as a comparatively simple procedure. It is in its infancy, this operation, but results are good.

DR. RICKETTS: This subject has taken on the character of a symposium, and there might be a great deal said. I am somewhat surprised at the last gentleman in his statement that there are none of the exophthalmic goiters cured by surgical operation. The strides of the operation have been marvelous during the last sixty years. In 1856 there had been 51 operations; in 1865, 176 operations, and in 1896 something like ten thousand, and still increasing since then.

Now, the technique described by the dector is interesting. I saw him remove a parotid gland by that operation. The operation is slow, of necessity. In those cases of exophthalmic goiter where we have the so-called tripartite symptoms-exophthalmos, tachycardia and neuroses, I have had two or three cases that are absolutely cured.. I had one case that resulted in tetanus and death some five weeks after the operation. As to the operation spoken of―Jack's operation-ligating the upper-pole, I cannot see how by ligating that portion of the gland we would have sufficient atrophy to eliminate that part of the gland.

I believe the conclusion arrived at in St. Louis was about as follows: That all enlarged glands are operable; they should be operated upon, whether cystic or otherwise; that before the operation the patient should have rest, and after the operation, rest. As to serum, I have had no experience, and have to accept the conclusions of those who have. I do not know that the mortality in such cases should be over 6 or 7 per cent. You saw the statement of Blackman that in 1854 this operation was so desperate, the hemorrhage so great, and the mortality so high, that it was hardly justifiable, but that he would predict the future operation would be ligation of the vessels en masse. My method has always been to open the capsule and keep within it.

In these cases we have a pulse of sixty to eighty afterward, when it was one hundred before the operation. This is due to the fact that absorption is very rapid, and this increases the cardiac action.