REFORT 
—OF A — 
CASE OF THYROIDECTOMY FOR MALIGNANT DISEASE, 
—WITH A— 
SYNOPTICAL CONSIDERATION OF THE PRESENT 
. 
STATUS OF THIS OPERATION. 
By Rudolph Matas, M, I).* 
Summary.—Extirpation of the Thyroid for Sarcoma of 
the Gland ; Tracheotomy during the Operation 
UNDER UNUSUAL ANATOMICAL DIFFICULTIES ; RECOVERY. 
Subsequent Intra-Laryngeat. Spread of the Disease. 
Secondary Permanent Laryngo-Tracheotomy, with 
Exposure of the Growth and Extraction of Frag- 
ments ; Survival to present Date, Six Months after 
Operation. Description of a Readily Improvised 
Apparatus for Heating Inhaled Air after Trache- 
otomy. Report on Histological Peculiarities of this 
Tumor. Comments on Thyroidectomy for Malignant 
Disease. 
Observation.—James Lines, colored, laborer; mt. 65 
years; native of Virginia; 40 years a resident of Louis- 
iana, was admitted in Ward 2, Charity Hospital, Sept. 
26, 1888. He gave no hereditary history of disease; no 
evidence of syphilis or tuberculosis. His habits have been 
always temperate. He stated that about six months before 
admission he had noticed a swelling in the neck, about the 
region of the thyroid, which steadily grew to its present 
dimensions. He suffered no pain or inconvenience from it 
until about three weeks before admission, when he began 
to experience some difficulty in breathing and swallowing. 
These symptoms became steadily worse, the dyspnoea and 
♦Visiting Surgeon Charity Hospital of Xevr Orleans; Demonstrator of Anatomy 
Medical Department, Tulane University of Louisiana; Instructor in Operative Surgery 
N. O. Polyclinic, etc. 2 
hoarseness becoming quite urgent when he was excited or 
underwent exertion. 
Upon examination an irregularly spherical tumor pre- 
sents itself at the site of the thyroid, evidently origjnating 
in and forming a part of this body. Owing to the thin- 
ness and length of the neck, and the mobility of the skin, 
the outline and limits of the tumor can be readily mapped 
out. The tumor appears to be a little smaller than an 
ordinary Mandarin orange, and is more developed on the 
right than on the left side. Owing to this greater enlarge 
ment on the right side, the right sterno-mastoid and the 
corresponding carotid sheath, with contents, are very per- 
ceptibly displaced outwards, as is well shown in the accom- 
panying illustration. It is also noticed that the tumor is 
very hard, of a fibromatous consistence, in some few places 
presenting a nodulated and almost cartilaginous thickness. 
It was also recognized plainly that the tumor had not 
become infiltrated and was completely encapsulated. 
The growth was entirely painless, spontaneously and on 
pressure, at least in its anterior and lateral aspects. The 
tumor completely covered the anterior surface of the 
thyroid cartilage, crico-thyroid space, cricoid cartilage and 
the four or five upper rings of the trachea. During deglu- 
tition when the larynx was elevated, a space barely 
measuring one and a half inch (vertically) existed between 
the lower border of the tumor (in the median line) and 
the suprasternal notch; after swallowing, with the larynx 
depressed, this space was narrowed to about one inch or 
less. There were no enlarged lymphatics. 
The questions that now presented themselves for con- 
sideration were: What was the diagnosis? What were the 
surgical indications furnished by the case? 
In regard to the first question there was no doubt (i) 
that the tumor was solid and not cystic; (2) that it was of 
rapid growth (six months); and (3) that it had appeared 
late in life. The two last considerations eliminated ordinary 
hyperplastic goitre, inflammatory enlargements, and prac- SARCOMA OF THYROID GLAND: 
Before Extirpation. 
SARCOMA OF THYROID GLAND: 
After Extirpation. 3 
tically all benign growths. The malignant growths were 
now left for differentiation. The diagnosis between the 
sarcomata and carcinomata was difficult and practically 
impossible to establish. The apparent absence of second- 
ary lymphatic enlargements, the rapidity of the growth and 
its hardness suggested spindle-celled sarcoma; the age 
and the hardness also favored scirrhus. Anyway, it was- 
decided that the tumor was of a malignant character—a 
diagnosis which entirely sufficed for clinical purposes ; and 
we now directed our attention to the second .question— 
i. e., what was the indication? 
The most urgent symptom complained of by the patient 
was dyspnoea, which was attributable to several factors : 
(i) the direct pressure backwards of the tumor upon the 
trachea, giving rise to the “scabbard”-like flattening of 
this tube, or the angular stenosis produced by the lateral 
displacement from the more enlarged right lobe; (2) the 
pressure exercised upon the pneumogastrics or recurrent 
laryngeals, giving rise to spastic glottic obstruction; (3)- 
infiltrations with perforation of the cartilaginous frame- 
work of the larynx, with inflammatory and neoplastic 
obstructive formations. 
It was plainly apparent that the obstructed respiration 
would soon call for relief, and that low tracheotomy, at 
least, would be required to avert immediate death from 
suffocation. But this was only a palliative measure at 
best, and the prospects of a radical extirpation of the 
growth had to be considered. The distinct encapsulation 
of the tumor, the apparent absence of secondary glandular 
invasion, the general good condition of the patient, and the 
comparatively small size of the growth encouraged the 
hope of cure by thyroidectomy. But the known fatality of 
thyroidectomy, especially for malignant disease, with its 
secondary physiological, as well as immediate operative 
dangers, led the writer to decide upon the 
first, of the simultaneous ligature of the four thyroid 
arteries, as has been so successfully applied to benign 4 
•goitres by Billroth (see his recent paper in Wiener 
Klinische Wochenschrift, No. i, April 5, 1888*), the 
operative interference being limited to this procedure 
only, if the tumor was found too dangerously adherent to 
surrounding parts and especially if marked evidence of 
neoplastic invasion of the larynx was ascertained; but, if 
the contrary favorable condition existed, it was decided 
that the ligature of the four vessels should be followed by 
the complete extirpation of the neoplastic gland. 
Operation.—Oct. 11, the patient was taken to the 
amphitheatre, where, after the usual antiseptic preparation 
of the field of operation, he was plased on the table in the 
usual tracheatomy position; Messrs. Scherck (chloro- 
form ), Sabatier (interne of the service), and Borde, resi- 
dent student, acting as chief assistants. From the start 
the patient’s dyspnoea and stridulous breathing appeared 
to be much aggravated by the excitement of the impending 
ordeal. lie inhaled the chloroform willingly, however, 
which, after a few inhalations, appeared to calm him. 
Shortly after he again presented ugly symptoms, viz.: very 
rapid pulse, increased stridor and great dyspnoea. This 
decided the writer to begin at once, before the anaesthesia 
was complete, by clearing the trachea above the sternum 
in readiness for immediate tracheotomy. This proved to 
be a wise course, for had it not been adopted as the initial 
♦The ligature of the thyroid arteries, originally recommended especially for vascular 
-goitre, but more often applied in ordinary parenchymatous goitre, was first practiced by 
W. Blizzard, though the idea originated with Ch. Lange (Dissert de Strumis et Scrofulis, 
Wittemberg, 1S07) and Jones (1807). Blizzard’s patient, after a temporary improve- 
ment, succumbed to hospital gangrene. The first successful result was that obtained by 
Walther in 1814; since this time the operation has been practiced a great many times 
and by many surgeons, among whom we could mention Coates, Earle (Arch, de Med., 
1S27, t. xiiij, Green, Larrey (ten times), Langenbeck (Archives de Med., 1829, t. xxix, 
p. 118), Chelius (Arch, de Med., 1835, t. xx, p. 230), Porta (Gaz. Med. de Paris, So 
often in fact that Le Fort (Med. Operatoire) has been able to collect (before Billroth’s 
recent communication) a list of thirty-one cases, vide Krishaber (Diet. Encyclop. des 
Sciences Med., 1883). The revival of this operation, which for various technical and other 
difficulties had been abandoned, is attributed by Billroth to A. Wolfler. In this paper 
Prof. Billroth considers the ligature of thyroid arteries as undoubtedly a most valuable 
addition to the surgical treatment of ordinary goitres, and he asserts that this method 
-would be an incalculable boon if it were equally efficacious in carcinomas and sarco- 
mas of the thyroid gland. “But we have been sufficiently taught,” he adds, “ by the for- 
merly more frequently employed ligatures of the lingual arteries in unextirpable carcino- 
mas of the tongue that this so much desired result will not be attained ; rapid disintegra- 
tion of the carcinomatous neoplasms, but no harmless wasting takes place. Neverthe- 
less we ought not to be disheartened and deterred from submitting to further trial this 
rational mode of treatment with any available modification, although the only attempt of 
his for this purpose completely failed.” (Junker’s Abst., Lond. Med. Recorder, June 20 
1S88). 5 
step of the operation it is more than certain that the patient 
would have succumbed in a hasty attempt at its perform- 
ance when the symptoms became still more urgont, lor the 
reasons that will be detailed in a moment. A lon<j incision 
c5 
was therefore made in the median line, extending from 
the anterior projecting angle of the thyroid cartilage to a 
point below the upper border of the sternum. After divid- 
ing the platysma and deep fascia, the edges of the sterno- 
thyroids were recognized and retracted, the anterior surface 
of the right lobe of the thyroid was exposed, and by 
following its capsule, which was not adherent to the sur- 
rounding parts, its lower border was reached, and the 
inferior thyroid veins and loose connective tissue separated 
with the handle of the scalpel. It was now observed that 
the trachea, which was exposed with considerable difficulty,, 
had been pushed greatly to the left of the median line, and 
bent backwards towards the vertebral column by the rap- 
idly growing and more enlarged right thyroid lobe. 
The right border of the trachea below the tumor was cer- 
tainly one and one-half inch to the left of the median line. 
There existed between the lower border of the tumor and 
the supra-sternal margin barely one inch of space ; the 
trachea itself sinking backwards at least one and one- 
quarter inches towards the vertebral column when it reached 
the level of the sternum. 
Furthermore, the lower half of this small pre-tracheal 
space was much encroached upon by the crossing over the 
trachea and above the level of the sternum of a large pul- 
sating vessel, as large as the common carotid. This vessel 
was believed by the writer to be either a right carotid, 
originating anomalously from the arch of the aorta, or an 
unusually high innominate. Anyway, owing to the pres- 
ence of this large vessel, the only available space left for 
the introduction of the cannula in case of tracheotomy was 
only a small half inch of the anterior tracheal surface, left 
free between the lower border of the thyroid tumor and 
the upper border of the large artery, which was pulsating 6 
most threateningly exactly at the place where the knife 
would have been introduced in a hasty attempt to reach the 
windpipe. 
The available part of the trachea was, however, thor- 
oughly denuded, and all was made ready for any emergen- 
cy that might arise. The dissection was then continued 
upwards towards the upper ends of the right lobe, with the 
view of ligating the superior thyroid artery. The muscles 
and other structures had been detached from the anterior 
surface of the growth, and the whole lobe had been almost 
completely exposed, when for some reason, perhaps in- 
creased compression of the trachea from manipulation, or 
from reflex laryngismus, the patient suddenly began to 
gasp for breath, the veins in the wound became turgid, the 
lips cyanotic, the pulse weak, irregular, almost impercep- 
tible at the wrist; in short, the patient was about to die 
from apnoea. There was no time for delay. The 
trachea was immediately opened below the tumor, and a 
large cannula was inserted into the windpipe. The relief 
was instantaneous. The cyanosis and turgescence of the 
veins disappeared, and the patient at once dropped into an 
easy and calm attitude, which markedly contrasted with 
his previous agitation and anxiety. The chloroform had 
been completely stopped on the appearance of the threat 
ening symptoms, and we now decided to complete the op 
eration without the anaesthetic. The restored tranquility 
of the patient was most assuring, and instead of simply 
ligating the four thyroids, as the writer had originally in- 
tended, we now decided to extirpate the whole diseased 
organ, especially since we were confirmed in our belief 
that the tumor had not perforated its capsule, or become 
adherent by infiltration into the surrounding parts. It was 
discovered that in order to continue the operation the 
tracheal cannula had to be introduced, owing to the great 
depth of the trachea, entirely into the wound; so deeply 
in fact, that the shield of the tube had to lie within the 
wound, resting directly upon the trachea and partly upon 7 
the anomalous arterial trunk already mentioned. This gave 
rise to temporary trouble, owing to the fear that blood 
might get into the trachea through the tube; but the com- 
parative bloodlessness of the remaining stages of the opera- 
tion ultimately obviated this danger. 
We now continued to separate carefully the muscles from 
the tumor. The sterno-mastoid and vascular sheath were 
retracted, and both extremities of the right thyroid lobe 
exposed. The superior thyroid artery was now seen pen- 
etrating at the usual point, and ligated at a short distance 
from the gland. The inferior thyroid was readily discov- 
ered as it crossed the longus colli and vertebral column, 
and also ligated at some distance from the gland. The 
left thyroid lobe, much smaller, was now cleared in the 
same manner, and its nutrient vessels (left superior and 
inferior thyroid arteries) also ligated. The tumor in its 
entirety, with the larynx and trachea, lay quite bare and 
isolated before us. By pulling gently on the tumor the 
finger could be easily swept back of the trachea and larynx 
to the pre-vertebral space. The examination revealed no 
apparently enlarged lymphatics or posterior involvment of 
the pharynx or oesophagus. 
The great danger that was now apprehended was the 
possibility of the tumor proving to be a direct outgrowth 
from the larynx, and the possible necessity of removing 
the attached laryngeal portion. Fortunately this fear was 
not realized. The wire of an ecraseur was guided through 
the base of the tumor at a point corresponding to the orig- 
inal isthmus of the gland and the growth split in two halves. 
The tissue was exceedingly hard and offered considerable 
resistance to the wire ; it was also completely exsanguin- 
ated. Each half was then quickly peeled off from the 
alee of the thyroid cartilage and trachea, which showed 
nowhere evidence of malignant perforation or infiltration. 
There were some adhesions of the tumor with the right 
half of the thyroid cartilage, but the disease did not appear 
to penetrate at all into the fibro-cartilaginous framework 8 
of the larynx and trachea as anticipated; it was evidently 
limited by the external surface of these organs. 
A small fragment representing the lower third of the 
left thyroid lobe was left in situ without removal, as it 
appeared to be perfectly healthy. The inferior thyroid of 
that side was ligated, however, so that as far as its nutri- 
tion was concerned it was practically as functionless as if 
it had been extirpated. The faint hope that it might have 
some influence in averting the cachexia strumipriva, in 
case of recovery, led us, with doubtful propriety, to prefer 
leaving it without removal. 
After the removal of the growth the parts were well irri- 
gated with per cent, carbolic solution, and two long 
drainage tubes were inserted deeply into the wound, one 
on each side of the trachea and pharynx as far back as'the 
retro-pharyngeal space. 
With the removal of the growth the larynx and trachea 
returned almost to their normal position, though the latter 
continued to be directed backward and far from the 
sternum, so much so that difficulty was experienced in ad- 
justing the large cannula employed, as it was too short for 
so deep a wound. 
After the operation, which lasted one hour and twenty 
minutes, the patient was considerably prostrated, though 
much less than would have been expected considering the 
severity of the ordeal he had undergone. After the 
wound had been closed with silver sutures and sublimated 
silk, the patient sat up by himself for the dressing, and was 
sent to the ward in a chair. His pulse rapidly improved, 
though it practically ceased to give us any cause for un- 
easiness from the moment the trachea had been opened. 
In order to avoid the risks of pneumonia consequent 
upon the admission of cold air into the lung through the 
tracheal cannula, it was desirable to secure its uniform 
warmth prior to its admission to the trachea. A sponge 
frequently pressed in warm water and fixed over the can- 
nula has been heretofore the method generally resorted to 9 
by the writer to attain this end, but this method is not 
well suited for hospital practice, where nurses are over- 
taxed with work, and where the devotion and personal 
feeling towards patient is not always to be relied on so 
much as among interested relatives, who will continuously 
and assiduously watch the cooling of the sponge and warm 
it again the moment it is cold and dry. To meet this indi- 
cation, and, at my suggestion, Messrs. Sabatier andBorde, 
internes of the hospital, exercised their ingenuity and con- 
trived a rubber coil for warming the inhaled ajr by sub- 
merging the tube in a warm water bath, kept at a tolerably 
constant temperature by a device shown in the annexed 
figures. The contrivance devised by these gentlemen 
consisted simply in a long (two yards), red rubber, non- 
perforated drainage tube, about 20 or 28 mm. in circum- 
ference. One end was attached to the cannulated trocar 
that is used as a guide in introducing the cannula, and the 
other was coiled in a metallic can filled with water, which 
was kept warm by immersion in a water bath heated by a 
spirit lamp. A sand bath was subsequently substituted by 
myself, though a water bath will do well, provided a ther- 
mometer is appended to the can to indicate the tempera- 
ture, though this instrument ought to be appended to all 
receptacles that may in future be constructed for this pur- 
pose. Since describing the contrivance, at an informal 
meeting of the New Orleans Medical and Surgical Asso- 
ciation, my friend, Dr. J. Farrar Patton, has suggested a 
most valuable improvement to the apparatus, which, by 
this addition, is made very serviceable in all cases in which 
the natural aperture of the larynx is closed, and the patient 
has to breathe entirely through the cannula and not, as in 
our patient’s case, who, shortly after the tracheotomy, 
could breathe with tolerable comfort (at short intervals), 
when the cannula was stopped up. Dr. Patton’s improve- 
ment consists in the addition of two valves of rubber, 
attached over two openings made in the tube, which at this 
point should be solid (a short perforated glass drainage 10 
tube would do) and placed at a short distance from the 
tracheal attachment of the tube. By this arrangement, 
the rubber valves will be pushed outward by each expira- 
tion, giving ready exit to the expired air, while, during 
inspiration they will be closed by atmospheric pressure, 
and will not interfere with the inward movement of the 
warm air passing through the coiled tube. 
Various other contrivances have been suggested to meet 
the indication in question, but it appears to the writer that 
in many cases of tracheotomy, especially in adults, and 
even in children, much benefit may be derived by the use 
of this apparatus, which can be readily improvised, needs 
little watching and can be kept clean without great diffi- 
culty. 
Returning now to the patient, we will state that on the 
day succeeding the operation his temperature was joi° F.; 
pulse, 90; the patient breathing easily through both mouth 
and tracheal tube, which day and night was kept attached 
to the cannula. The patient spoke distinctly when the 
cannula was closed. 
Oct. 16.—The sutures were removed, as union had 
taken place along the whole of the incision, excepting at 
the points where the cannula and drainage tubes pro- 
jected. 
Oct. 17 (seventh day after operation).—As the patient’s 
temperature continues normal and he breathes comfortably 
through the mouth, with tracheal cannula completely 
closed, the warm-air coil is discontinued and the cannula 
plugged. As a matter of precaution the cannula is allowed 
to remain in situ, though the patient breathes entirely 
through the natural passages. 
Oct 18 (eighth day).—The patient sits up out of bed in 
a chair, the sutures are removed, the drainage tubes also, 
and the patient is considered as practically out of danger. 
Oct. 20.—Since this date the patient has been up, and 
has been quite comfortable. The parts about the wound 
have consolidated firmly, excepting only the point where WARM AIR COIL FOR TRACHEOTOMY. 
1. Rubber valves fitted over openings in glass tube to allow expired air to escape. 
2. Coil of gas rubber tubing immersed in can of warm water. 
3. Porcelain capsule filled with sand (sand bath) on stand heated by alcohol lamp. 
4. Free end of coil to admit inspired air. 
[The rubber tube is attached to the cannulated trocar (see diag. 5) by the tracheotomy cannula 
and can be readily removed whenever the cannula needs cleaning.] 
5. Trocar for cannula with rubber tube adjusted. 11 
the cannula is situated, owing to the fact that the trache- 
otomy tube has not been removed until recently. 
The voice, however, though distinct, is not normal and is 
of a low pitch, and, what is more noticeable the breathing, 
though easy, is yet in inspiration distinctly stridulous. The 
respiratory stridor, which was heard at a great distance 
prior to the thyroidectomy, has improved greatly, but its 
persistence leads the writer to fear that mischief may yet 
be brewing within the larynx. 
Nov. 27 (one month after thyroidectomy).—In view of 
returning difficulties of breathing an incision was made 
into the larynx and trachea, dividing the cricoid cartilage 
and the three upper rings, and the interior of the larynx 
explored. Several fragments of a very vascular and 
granular looking mass, which nearly obturated the windpipe 
at level of incision, were removed with forceps and a large 
cannula introduced. The patient was greatly relieved 
thereby, and has continued breathing with some comfort, 
though the canula needs constant watching, as it is very 
frequently plugged with ropy mucus, blood and even small 
fragments of neoplastic material. At times when this 
plugging occurs the patient can only be relieved by pass- 
ing a large No. 10 gum bougie into the trachea, in 
order to penetrate beyond the growth which evidently 
exists below the lower opening of the cannula. Very re- 
cently, signs have developed which lead the writer to believe 
that the bronchial lvmpathics are participating in the mor- 
bid process, and that the end of the unfortunate patient, 
whose life has thus far been prolonged six months since the 
operation, is fast approaching. A thorough scraping of the 
intra-laryngeal surface and accessible portion of the trachea,, 
and even a laryngectomy, had been thought of by the writer 
at the time the secondary tracheotomy was performed; but 
the belief that the disease had involved portions of the 
trachea deeper than a tampon canula could reach and pro- 
tect dismissed this suggestion as impracticable and injudi- 
cious. 12 
The tumor shortly after its removal was examined and 
pronounced a large cellular sarcoma of the thyroid gland.* 
Since that time a section was photographed for me by Dr. 
Gray, the able microscopist of the Army Medical Museum, 
Washington, D. C., who stated his opinion that it was an 
alveolar sarcoma. I examined the slide for the first time 
since its return, and could not fail to recognize the excel- 
lent reasons for differing with the original diagnosis. The 
perplexing histological peculiarities of this tumor are re- 
markable, however, and they are well stated by Dr. Henry 
Dickson Bruns, the present pathologist of the hospital, to 
whom the slides were submitted, and whose conclusions, 
after very careful and repeated examinations of both the 
extra and intra-laryngeal growths, harmonize with those of 
Dr. Gray. I append Dr. Bruns' report with pleasure, feel- 
ing that in the present very incomplete state of our knowl- 
edge regarding the histological peculiarities of thvroid sar- 
comata, that contributions of this character will prove 
especially valuable. 
REPORT OF 1)R. BRUNS. 
Thyroid Tumor. 
» 
It is with no little difficulty that the true nature of this 
growth is to be determined, the difficulty arising from the 
size, appearances and grouping of certain large cells, which 
are disseminated through some portions. In a section the 
main portion is seen to consist of connective tissue, at 
many places dense, adult in appearance; at others fine, 
light, resembling myxomatous tissue. There are many 
lymphatic spaces and a fair supply of vessels. Many of 
these latter are evidently old and well developed; others 
very young and thin-walled. Here and there the eye is 
caught by the peculiar large cells with distinct, large nuclei, 
surrounded by a goodly proportion of “formed material,” 
referred to above. These cells are most abundant in the 
* The first examination was made in the Pathological Department of the Charity Hos- 
pital, but doubtless owing to the illness of Dr. Schmidt, the now lamented pathologist, 
the examination of the section was not as thorough as it would otherwise have been. 13 
delicate areas of the connective tissue, though sometimes 
met with in the denser portion. They are as a rule gath- 
ered into clumps of from three to four, or less frequently 
five to six or more, and around these clumps the connect- 
ive tissue seems to form quite definite alveolar walls. These 
appearances closely resemble carcinoma with small alveoli, 
and it is only by close study that the following points are 
made out, which I believe indicate the true nature of the 
growth and its mesoblastic origin. 
In the first place, nowhere in the sections can any trace 
or remnant of the original gland substance be discovered. 
In the second, many isolated cells precisely like those 
gathered into clumps are to be found in the neighborhood 
of the latter. These cells are closeL embraced by the 
connective tissue. In some instances the young connective 
tissue cell with its plump nucleus lying so closely in contact 
with the large cell as to give it the appearance of having a 
second crescentic nucleus situated at its periphery. 
Thirdly, though many of these large cells, especially the 
isolated ones, whose form can be most clearly made out, 
are spherical or but slightly poligonal, many of them appear 
to be of a stout spindle-shape, while others have long, fine 
processes—one or more—which I cannot conceive as hav- 
ing been produced by mutual ceil compression. Moreover 
many of these fine processes seem to come into intimate 
connection with the fine fibrillae of the alveolar wall. 
Lastly, the closest observation of certain alveoli, from 
which some of the cells have fallen, show them to be inter- 
penetrated by most delicate fibrils running out from the 
alveolar walls. Of course all the connective tissue is rather 
embryonic in type. It is moderately infiltrated within dif- 
erent cells, and the nuclei of its spindle cells and fibres are 
larger than in the mature tissue. These structural pecu- 
liarities, made out only after long and attentive study, drive 
me to conclude that the growth is a large celled alveolar 
sarcoma, originating from the connective tissue of the 
gland ; but, as I said before, it is a most puzzling tumor— 14 
the hand is the hand of Esau, but the voice is the voice of 
Jacob. The structure is that of alveolar sarcoma, but the 
cells closely resemble carcinoma. 
Tumor from Larynx. 
As was the case with the thyroid tumor, I began the 
examination of this growth with a firm conviction of its 
being carcinomatous. This has only broken down after 
prolonged study has convinced me that it manifests the 
same peculiarities as the thyroid tumor, although its alveo- 
lation is yet more carcinomatous. Still I believe it to be 
less definite and regular than that of cancer ; connective 
tissue fibrillae seem at certain points to run between the 
cells contained in the alveoli, and the cells themselves are 
sometimes spindle shaped, bipolar or stellate. 
Henry Dickson Bruns. 
REMARKS. 
In a recent contribution to the subject of thyroidectomy 
an able writer* has stated that “this operation, amongst 
English-speaking communities, is infrequent enough to still 
offer many points of interest.” This statement is certainly 
well borne out by our experience in this community, which, 
notwithstanding its very large, cosmopolitan composition, 
rarely offers an example of thyroid disease of a char- 
acter sufficiently serious to call fo* operative interfer- 
ence. It is certain that disease of the thyroid in gen- 
eral is comparatively rare, especially in New Orleans, if 
we are to judge by the evidence furnished by our Charity 
Hospital reports, which very faithfully reflect the patholog- 
ical tendencies of'our population, and which show that 
during the whole decade ending in 1887 there has been 
only one solitary admission into the institution for goitrous 
disease. The significance of this statement may be estima- 
ted when we state that according to the last report (1887) 
a total of 5999 inmates were treated during the year of the 
report, and that in addition to this there were 12,085 visit- 
* T. F. Chayasse on Thyroidectomy, Annals of Surgery, vol. 51,1887. 15 
ing patients. The diagnoses of these last cases are not 
given in the reports, and it is therefore quite possible that 
some cases of thyroid disease may have presented them- 
selves at the clinics, though it is almost certain also that, if 
they have existed, they have not been of a very serious or 
malignant character, as it is more than likely that they 
would have sought admission into the hospital. It may be 
therefore stated that out of a total 75,697 indoor patients 
treated in the Charity Hospital in the decade ending 1887, 
only one case of thyroid disease, excluding the present case, 
in 1888 has been reported. Furthermore,the operation of 
thyroidectomy is not mentioned in any of these reports, and 
it is almost certain this is the first instance of its perform- 
ance in our institution, if not in our city. 
The operation itself, though one of the most formidable 
in surgery, does not present any extraordinarily novel fea- 
tures, especially since its technique has been so thoroughly 
perfected by the great continental masters, who are so fre- 
quently called to perform it; but there are some peculiar- 
ities and considerations involved in the surgical treatment 
of cancerous or malignant goitres, which are still rightfully 
the subject of discussion, and which lead me to record this 
case, and which I hope will justify a critical, if imperfect 
presentation of the question. 
Cancer or malignant disease of the thyroid, called also 
since Walther JVeue Heilart des Kroffes, page 13 (quoted 
by Krishaber,*) scirrhus or cancerous goitre, is a rarer dis- 
ease than the ancients believed, who frequently regarded as 
such any enlargements of this body which simply sugges- 
ted to the naked eye the idea of malignant growth. Recent 
observations, based on histological investigations, have, 
however, positively determined the fact of the existence of 
malignant growths in this body and a sufficient number of 
cases have accumulated to allow of a definite description 
of the affection. 
*D»chambre.’s Dictionnaire ies Sciences Medic&lcs, 1883. 16 
From the histological standpoint, Lucke (Cancroid der 
Schildriise mit schr. a Rutem Verlauf Archiv. f. Klin. 
Chir., 1867, vol. ix, page 88), recognized three varieties 
of cancer of the thyroid, scirrhus, encephaloid and epi- 
thelioma. Cornil and Ranvier (Pathological Histology, Am. 
edition, 1880) admit encephaloid, but they consider it as 
very rare, and they believe that the majority of primitive thy- 
roid cancers is constituted by epitheliomatous formations. 
They do not even mention sarcoma of this gland. Rose 
(Archiv., f. Klin. Chirurg., vol. xxiii, band 1, 1879), a 
collection of twenty-four observations of cancer which he 
reports, records three cases of sarcoma. This, I believe, 
is the first mention made of the existence of sarcoma of 
this body, and allows us to conclude tliatup to present date 
malignant disease of the thyroid may manifest itself in 
diverse forms, which, in the order of frequence appear to 
be: Epithelioma, encephaloid, scirrhus and sarcoma. 
Notwithstanding these histological differences we must 
admit with Butlin (The Operative Surgery of Malignant 
Disease, 1887) that all these types of malignant disease 
are all one to the clinician, and that so far as the operative 
treatment is concerned there is no essential difference be- 
tween them. In all there is a probability that the lym- 
phatic glands will be affected and that the disease will be 
disseminated in other parts of the body. Therefore all of 
them may be properly embraced under the more general 
and unifying designation of malignant disease, or the more 
common, if unscientific, name of cancer. 
Cancer of the thyroid may be ■primary or secondary, 
and the relative frequency of these two conditions has not 
been yet definitely determined, observers disagreeing on 
this point, this divergence of opinion being due very often 
to the fact that the pharynx, oesophagus and larynx are 
involved simultaneously with the thyroid, and it being very 
difficult to state positively where the disease originated 
primarily. In the case here reported it is almost positive 
that the disease began primarily in the thyroid, and sec 17 
ondarily involved the larynx. In some cases the disease 
is manifestly secondary, as in the case of a patient reported 
by Virchow (Tumors, vol. iii, page 244), who had been 
operated upon two years previously for cancer of the testi- 
cle. Stromeyer (Handbuch der Chirurgie, vol. ii, page 
395), Lebert, Linke, Virchow and others have observed 
that cancer of the thyroid body attacks goitrous subjects 
by preference, a tendency which accounts for the greater 
frequency of the disease in countries where goitre is epi- 
demic (Krishaber). 
With the exception of a certain number of recorded 
instances of congenital sarcomatous disease of the thyroid* 
cancer of this organ is a disease of adult age, and occurs 
more frequently after forty years of age than in earlier 
life. According to Butlin it attacks men rather more fre- 
quently than women, probably in about the proportion of 
five to four; a very singular circumstance, as this writer 
observes, when the far greater liability of women to sim- 
ple enlargement of the gland is remembered, and the 
further circumstance that certainly many of the cancerous 
affections have been noticed in glands which have during 
some years been the seat of simple enlargement. The 
history is not at all uncommon that the patient had suffered 
from goitre for years; that the goitre had very slowly 
increased, or been actually quiescent; that suddenly rapid 
growth had taken place, and the case terminated fatally in 
the course of a few weeks or months. The disease often 
produces general and almost uniform enlargement of the 
whole gland, and resembles in this respect the cancerous 
affections of the liver and the testis; but it may form a dis- 
tinct and clearly defined tumor, which may be situated in 
the isthmus or in either lobe. In other cases the gland 
may be the seat of a great number of cancerous nodules,, 
disseminated and separated by zones of healthy tissue, 
which may, however, finally become involved secondarily 
in the infiltration. According to Houel infiltrated cancer 
is more commonly found in primary neoplasm, and the 18 
multiple, disseminated nodules in the secondary neoplastic 
affections of the gland. 
The great peculiarity of cancerous disease of this gland 
is that, once the process of infiltration begins, the gland 
either in part or as a whole, 7‘apidly enlarges. The surface 
of the tumor may be uniformly enlarged or tuberose. It 
may remain for a considerable time, even after attaining 
very considerable dimensions, entirely encapsulated. Co- 
incident with the enlargement the neighboring organs are 
pushed away, compressed or welded into the mass of the 
tumor. The effects of pressure on the air and food 
passages are soon felt, and then the real distress of the 
patient begins. 
According to Rose (loc. cit.) disphagia is a more fre- 
quent and earlier symptom in malignant enlargements of 
the thyroid than in the benign growth. This symptom is 
especially noticeable in cases of backward enlargement. 
Infinitely more troublesome and dangerous is the dyspnoea 
which soon follows the compression of the trachea and lar- 
ynx and which is only comparable to the distress produced 
by non-malignant “suffocating” goitre. Cancerous enlarge- 
ment of the thyroid may produce stenosis of the trachea, 
as in benign goitre, either by direct compression or by dis- 
placement, or by both conditions combined. Bonnet 
(An. Academie des Sciences, 1855) ascribed the obstruc- 
tive deformities of the larynx to flattening of the trachea by 
compression from before backwards, by monolateral or by 
bilateral compression and stenosis, by deviation or angular 
deformities, as in our case. The deformities, by compres- 
sion first mentioned, frequently give rise to the “scab- 
bard” or sword-sheath trachea, first described by Demme 
(Medizin. Zeitschrift, Wurzburg, 1861, vol. ii), and since 
by Rose, Koclier and other later authors. This difficulty 
alone may call for operative interference, even before per- 
foration of the thyroid capsule has taken place, as in the 
present instance. With the further progress of the disease, 
the skin over the tumor becomes red, adherent and in- 19 
flamed, and at this stage it is difficult, if not impossible, to 
differentiate it from the inflamed goitre. “Soft spots may 
be observed ; a puncture results in the escape of a thick semi- 
fluid material, and is frequently followed by a fungous pro- 
trusion of the tumor . ” The ulcerative period now begins, 
and the trachea, larynx or oesophagus may be perforated, 
fragments of the tumor expelled by the natural 
passages(Lebert, Path. Anat., p. 202). The trachea may 
be still further compressed by the growing mass, and its 
walls infiltrated in such an extensive manner that tracheot- 
omy with an ordinary tube may be practically impossible, 
and special tubes or even catheters may become neces- 
sary in order to pass the strictured portion. The neighbor- 
ing vessels and nerves of the neck become welded to the 
growing mass. The internal jugular may become obliter- 
ated, or, on the contrary, perforated by a penetration 
into its lumen of neoplastic granulations. The carotids 
generally resist longer, but Lebert records a case in which 
this vessel was perforated with fatal results. The pneumo- 
gastrics and the recurrent laryngeals may become involved, 
and finally become totally destroyed and incorporated into 
the infiltrating mass. The nerve lesion readily explains the 
respiratory disorders and alteration of the voice, which, 
independently of other causes, frequently attract attention. 
Secondary generalization of cancer of the thyroid is 
almost the rule, the lungs and mediastinal spaces suffering 
most frequently, the pharynx, oesophagus, larynx and cer- 
vical lymphatics are more frequently involved by contin- 
uity. The bones of the cranium and pelvis, the brain, the 
kidneys and the heart itself have been the seat of second- 
ary deposits. 
In regard to the natural duration of the disease I will 
quote Butlin, who has obtained his data from the latest and 
best sources. He says : “ It is very difficult to form a cor- 
rect estimate of the natural duration of the disease, not on 
account of the frequent interruptions caused by operations, 
but because of the many instances in which malignant dis- 20 
ease has been engrafted on simple enlargement of the thy- 
roid. Edmund Rose calculates it at from six to eight 
months, the -extremes being nine weeks and a year and a 
half. If this estimate is correct—and there seems to be 
fair reason to accept it—malignant disease of the thyroid 
is among the most malignant of all cancerous diseases; for 
even in cases which have been fatal from suffocation within 
six months of the apparent commencement of the disease, 
secondary affection of many parts of the body has been 
found, while other cases have been fatal in a shorter period 
by reason of these secondary tumors. The causes of death 
are various: some of the patients die of suffocation, some 
of suppuration and gangrene, some of exhaustion and the 
production of cancerous cachexy.” 
Diagnosis.—The early diagnosis of cancerous disease of 
the thyroid is one of the most unsatisfactory problems con- 
nected always with these sad and difficult cases. It is stated 
that it can be usually recognized by its rapid development,, 
the lancinating pains which it causes and which radiate to the 
head, the early adhesion to the skin, the secondary enlarge- 
ment of the lymphatics, and the distressing respiratory dif- 
ficulties which precociously present themselves. There is 
no doubt that when that stage is reached in which these 
conditions exist that the diagnosis is easily made, but we 
must then say of the diagnosis, cni bono ? The diagnosis 
at this stage is then of no value to us or to the patient; it 
is, from the operative standpoint, a superfluous luxury, or 
at best a conclusion, which will bid the prudent surgeon 
limit himself purely to the work of palliation, and not rashly 
undertake a useless if not fatal operation. As Butlin again 
observes, after a study of the collected cases ol his disease, 
there are two circumstances which are particularly worthy 
of notice—the large number of instances in which second- 
ary affection was discovered at the autopsy, even when 
death occurred within a few days after the operation, and 
the frequency with which it was found impossible to entirely 
remove the tumor. These circumstances are the more ex- 21 
traordinary, as he remarks, and the more significant, in 
respect to the question of extirpation, when it is taken into 
account that many of the cases were selected because they 
appeared to be far better fitted for the operation than most 
•cases of malignant disease of the thyroid gland. 
“ It must be apparent to every surgeon who considers 
these matters that the attempt at radical cure was delayed 
until too late in the course of the disease, and this impres- 
sion will be confirmed when we come to consider the fur- 
ther history of the cases in which recovery from the oper- 
ation took place. Then follows the question : Why, know- 
ing the necessity for early operation, was the operation 
deferred until the primary disease had become adherent to 
and involved vital structures, and until secondary disease 
of the lymphatic glands, the lungs and other parts of the 
body was present? Braun has laid down very clearly and 
emphatically the conditions which are favorable to an 
attempt to remove malignant disease of the thyroid. 
The tumor should be movable and completely encapsu- 
lated, its lower limit should be above the sternum, the pul" 
sation of the common carotid artery should be perceptible 
on its external surface, and there should be no affection of 
the glands or metastases. But he adds—and in this lies 
the whole gist of the matter—tumors of the thyroid in 
which the circumstances are so favorable are scarcely to 
be recognized as malignant new growths.” 
The difficulty of diagnosis is indeed the great obstacle 
to the prospect of successful extirpation of cancerous 
disease of the thyroid. * * * So exceedingly difficult 
is the diagnosis of malignant disease of the thyroid in an 
early stage, at a time when removal might not unreason- 
ably be expected to be successful, that Braun says : “It 
appears to me that the time will never come when we will 
be able to diagnosticate the early stages of malignant 
struma.” The study of the present case will only tend 
o confirm this gloomy expectation. In this instance all 
the favorable conditions desirable for an operation were 22 
present, and the malignant nature of the tumor was diag- 
nosticated before the operation (six months after its ap- 
pearance and the moment he presented himself at the clinic) 
and still secondary involvement of the larynx followed 
quickly after operation, or very likely existed already, 
though slightly at the time, and the operation has only 
proved to be of a palliative character. I would, therefore,, 
add that, in addition to the requirements specified by Braun, 
that a very careful laryngoscopic examination should be 
made, in order to prove that the respiratory difficulties are 
not all due to pure displacement or pressure distortion, and 
that the larynx is not involved in the neoplastic process. 
And, furthermore, even when there is no apparent involve- 
ment of any other organ than the thyroid itself—i. e., even 
if we operate in the earlier stage of the disease, when the 
conditions of the tumor are clinically identical with those 
of benign or simple hypertrophic goitre—we cannot even 
then feel in the least assured as to the non-recurrence of the 
growth. In other words, it is the conviction of the writer 
that by the time the growth has become simply perceptible 
to either the patient or the surgeon, it has already become 
disseminated beyond the thyroid tissue and is not eradi- 
cate even by the immediate and total extirpation of this 
body. This may appear to be an ultra-pessimistic opinion, 
but the history of my case and the unusally favorable en- 
capsulation of the tumor practically reducing it to the con- 
ditions of a benign growth, coupled with the unfavorable 
experience of every other observer, and the histological 
peculiarities of the thyroid, tend to convince me that 
the operation of thyroidectomy for malignant disease 
is to be relegated to the category of the purely palliative 
measures which may prolong life for even a comparatively 
long time, but will fail to cure radically any true case of 
cancerous disease of this body. 
Technique of the Operation.—Notwithstanding the dis- 
couraging opinion which I have formed in regard to the 
radical value of thyroidectomy in the class of cases under 23 
consideration, I believe that it has a field of useful appli- 
cation which, no matter how restricted, still justifies and 
necessitates the perfection of all the technical details in its 
performance, in order that its ever-present dangers and dif- 
ficulties may be reduced to their minimal proportions. 
Firmly believing that all malignant growths of the thy- 
roid which have invaded in any marked manner the sur- 
rounding tissues and organs, especially the larynx, 
pharynx, oesophagus and carotid sheath and its contents, 
and the lympathics, are beyond redemption, and should be 
severely let alone, except only to relieve immediate distress 
of the respiratory functions by low tracheotomy, I would 
limit the performance of extirpation solely to those cases in 
which the isolation of the morbid tissue is obtainable and 
the operative conditions are identical with those for benign 
strumectomy. By adhering to this rule the essential dif- 
ference between thyroidectomy for malignant disease and 
thyroidectomy for benign growth is eliminated, and the 
conditions are simplified; for, by the adoption of this prin- 
ciple, the surgeon is limited to the task—serious enough— 
of removing only thyroid tissue. If the surgeon will per- 
sist in the attempt to extirpate an infiltrated cancer he must 
be prepared not only to follow enlarged glands in danger- 
ous mediastinal depths, excise portions of the carotid 
artery and internal jugular vein, resect the pneumogastric 
and perhaps the sympathetic, and remove partially if not 
wholly the larynx, pharynx and oesophagus, and several 
other comparatively unimportant organs, as the sterno- 
mastoid and other muscles. This may all be done, and has 
been done, but though illustrative of the daring, or, better, 
the recklessness of some modern surgeons, is not calcu~ 
lated to prolong the life of the patient or to impress the 
outside world with the safety of modern surgery. Cer- 
tainly the operations are brilliant, but the statistics are lugu- 
briously sombre and dark. 
Discarding, therefore, all cases in which the extra-thy- 
roideal structures are involved we will limit ourselves to a 24 
few points connected with pure thyroidectomy, a systematic 
description of which is here unnecessary, since it is now a 
part of all surgical texts. Simple and straightforward as 
this operation might appear it must not be forgotten that 
the peculiarities of the growth, its size, etc., involve differ- 
ences which vary in remarkable extremes. From the cases, 
as in the present, where the four nutrient arteries were 
readily secured, and all the hemorrhage was prevented by 
the use of four or five artery forceps, to the formidable 
operation described by Senn, as he saw it performed by 
Kocher of Berne (letter to Journal of American Medical 
Association, page 380, vol.ix, 1887), in which 60 or 70 ar- 
tery forceps were needed, and the patient nearly col- 
lapsed from hemorrhage, or in the case related by McCor- 
mac (British Med. Journal, 1884, 11, 229), in which no 
fewer than 100 ligatures were applied, there is quite a leap. 
Even in cases in which the conditions are apparently most 
favorable there may be room for a large supply of worry, 
as in a patient operated by Billroth (Clinical Surgery, 168, 
New Sydenham Society, 1881, quoted by Butlin), in whom 
a tumor, no larger than a lien’s egg, was the cause of con- 
siderable anxiety to this eminent and most skilful surgeon.* 
The accidents and special operative complications which 
are peculiar to thyroidectomy may be summed up in—(a) 
excessive hemorrhage ; (/;) suffocation; (c) entrance of air 
in veins ; (d) accidental wounding of the oesophagus; (e) 
lesions of important nerves, especially the recurrent laryn- 
geal and sympathetic, pneumogastric, even the h}rpoglossal, 
which was cut on one occasion by Maas, and was followed 
by subsequent lateral paralysis of the tongue. 
As regards the first danger (hemorrhages) there is no 
doubt that primary ligature of the four leading thyroid 
trunks is the most positive method of securing the patient 
against it. But this “ preventive ligature” (of Michel, 
* I extirpated the tumor and found the operation ne of the most difficult which I 
have ever performed. There was great difficulty in separating the tumor from the 
trachea and the deeper parts. The hemorrhage was very severe, and attacks of suffocation 
occurred, and she seemed several times during the operation on the point of death from 
asphyxia. 25 
Heron, Watson, etc.) is not easily accomplished in very 
large tumors; in which case the tumor can best be removed 
by splitting it in two, as in the present case, by transfixing 
the isthmus with an armed needle and dividing it with a 
wire ecraseur, then peeling it off the larynx and trachea 
without involving the thyroid tissue proper. In extirpa- 
tion for malignant goitre, in the smaller operable cases de- 
scribed above, the preliminary ligature should be, it ap- 
pears to me, always feasible. If there are bleeding ves- 
sels, however, the artery forceps should avoid too much loss 
of blood. 
In connection with the ligature of the inferior thyroids 
great caution should be observed not to ligate too liberally 
en masse, as the recurrent laryngeal will be almost certainly 
involved. The artery should be ligated at some distance 
from the thyroid, and as near as possible to the common 
carotid, as Kocher, Maas and Rotter have taught. 
In ligating the inferior thyroids the excessive brittleness 
and thinness of these arteries, recently pointed out by 
Billroth ( Wiener Klinische WochensNo. i, April 5, 
1888), should not be forgotten. It happened to him in 
three instances that this artery gave way, once when raising 
and isolating it with the grooved director, once when intro- 
ducing the aneurysm needle, and on another occasion 
whilst tying the artery. In one of these instances he was 
obliged to divide the scalenus, behind which the artery 
had retracted, in order to clamp it. 
A danger of equal if not greater importance is that of 
suffocation during the operation. This danger has been 
typically illustrated in my case, and the method of neutral- 
izing it has been also satisfactorily illustrated by the trach- 
eotomy which was performed. It has also been demon- 
strated that tracheotomy, when hastily performed under 
these circumstances, in which there is great displacement 
and distortion of the trachea, is fraught with great danger, 
and is in itself a formidable operation, especially if, as in 
our case, there are anomalous arterial trunks at the root 26 
of the neck and intersecting the field of operation. The 
question, therefore, arises: should preliminary tracheot- 
omy be regularly performed as a preventative ? Rose has 
advocated its performance always for various reasons. 
But Kocher has met these reasons with valid arguments, 
and has furthermore urged that the tracheotomy wound 
renders the wound septic, and increases the post-operative 
dangers by the additional risk of septic broncho-pneumonia. 
Statistics are certainly against the indiscriminate and gen- 
eral application of Rose’s method. Thus we find that out 
of Kocher’s 43 last thyroidectomies (in 1883) 39 were 
performed without tracheotomy, and 39 recovered; 4 with 
tracheotomy, and 3 died. Billroth’s 54 last cases (col- 
lected by Wcelfler) were divided into 45 without trache- 
otomy and 43 recoveries ; 5 with tracheotomy and 3 
deaths. It is certainly plain that tracheotomy must 
not be resorted to indiscriminately, but it is also equally 
plain that it is the patient’s only salvation when suffocation 
is imminent. Furthermore, it appears to me in the light 
of my very limited experience, that in order to avoid the 
danger incurred in the hasty performance of this operation, 
that it should be the rule to begin the thyroidectomy for 
malignant disease always by exposing and denuding the 
trachea, preparatory to any emergency that might arise. 
Certainly prudence would counsel this course. 
..The entrance of air into veins with the characteristic 
sucking or whistling sound has been the cause of immedi- 
ate death on the operating table. In a case of Woelfler’s, 
other patients reported by Schininger (of Freiburg), 
Kroenlein, Borel, succumbed in two or three days after the 
operation, and it is questionable whether they died solely of 
entrance of air into the circulation. A patient of Billroth’s 
recovered after thrombosis of the internal jugular and the 
subclavian (A. Broca). 
Wounds of the oesophagus are very rare, and the cases 
reported in which this complication occurred (four cases 
by Baum) were almost all inflicted during thyroidectomy 
for malignant disease. 27 
We have already referred to the lesions of nerves which 
are liable to complicate this operation; blit outside of the 
recurrent laryngeal no other nerves should incur the risk 
of injury in operations on the thyroid, for non-infiltrated 
malignant goitre. Reverdin, Kappeler and Bruns have 
noticed pupillary disturbances; and in consequence of 
wounds of sympathetic, Lticke, Maurer and Fisher have 
had to resect the pneumogastric, but this has only occurred 
in cases of thyroidectomy for malignant struma. We have 
referred to Maas, case of resection of the hypoglossal, fol- 
lowed by unilateral paralysis of the tongue. 
The alterations undergone by the recurrent nerves after 
this operation are frequent, and have received various 
interpretations. There is no doubt that this nerve is divided 
occasionally in ligating or separating the inferior extrem- 
ities of the thyroid lobes. In a total of 322 thyroidectomies 
collected by Liebrecht there were nine cases of certain 
section of the recurrents and four doubtful. A sharp par- 
oxysm of cough notified Wagner that the recurrent had 
been irritated while operating on a case. An artery forceps 
had caught the nerve, and cough instantly ceased when 
the forceps was removed. Hamilton induced dangerous 
signs of suffocation while ligating en masse the inferior 
extremity of a thyroid lobe, and the threatened apnoea was 
immediately averted by untying the ligatures. Woelfler 
insists, when the section of the nerve is complete, on the 
■paralysis of the epiglottis. This cartilage is deviated, as 
sumes an oblique position, and only imperfectly discharges 
its obturating function; hence, septic pneumonia from vis- 
cious deglutition (Schluck Pneumonia of the Germans). 
When the section is bilateral the aphonia is complete, 
a new and very grave phenomenon is added to the operation. 
It is an intense dyspnoea which caused the speedy death of 
two patients of Kappeler, and others of Maas and Richelot. 
According to Jankowski this complication necessitated 
tracheotomy in three cases. In addition to the laryngeal 
disturbances produced by mechanical irritation or division 28 
of the recurrents, other peculiar phenomena, hoarseness,, 
etc., have been attributed to the chemical irritation of 
these nerves by the antiseptic solution employed in irri- 
gating the wound. J. L. Reverdin has especially called 
attention to this aspect of the subject, and his views, with 
those of others, will be found admirably summarized in A. 
Broca’s recent and masterly article, “ Thyroidectomie in 
the Diet. Encyclopcd. des Sciences Medicates,'’' 1887, to 
which the reader is referred, and from which I have gath- 
ered many of the important facts previously presented. 
As the immediate surgical complications of thyroidectomy 
we would simply specify septic infection, suppurative me- 
diastinitis, septic pneumonia, and even secondary hemor 
rhage.* 
* Nothing has lieensaid ot the special accidents which are peculiar sequel* to the oper- 
ation of thyroidectomy. The immediate complications above mentioned are more or less 
common to all operation wounds, the topography of the operative field causing the only 
differences. But there are other accidents which appear to be 1 nked in a very specific 
manner with the suppression of the thyroid gland, and which other operations in the 
neck do not appear to cause. These phenomena may supervene almost immediately 
after the operation, viz.: cerebral disturbances (acute mania and tetany), and tardily as 
the cachexia strumipriva of Kocher (myxcedema, Ord, pachydermic cachexia, Charcot). 
The study of all these complications is highly interesting and instructive, but to consider 
them as they deserve would be out of place in the present communit ation. I cannot 
repress a few remarks, however, in regard to the relations ot mvxoedeina with thyroidec- 
tomy for malignant goitre, as this complication has exercised such a revolutionizing 
influence on our physiological notions respecting the thyroid, and on the surgical treat- 
ment of its affections since its discovery by F. L. lleverdin in 1SS2, and by Kocher 
almost simultaneously. 
The accumulated observations which have gathered since Reverdin’s discovery tend 
only to confirm the belief that the thyroid is an active organ, discharging very important 
functions, and that its total suppression is liable to b. followed by a general cachexia 
and mucoid deposits in the subcutaneous tissues, etc. The ,eneral tendency is at present 
to accept Horsley’s theory that the thyroid is the organ chiefly interested in mucin 
metabolism. F. L. Reverdin (vide Guitera-’ Summary of the Diseases of the Thyroid 
Gland in Sajous’Annual for 18SS) gives a late summary of the results obtained bv dif- 
ferent surgeons. Of ninety-five thyroidectomies recorded thirty w re followed by surgical, 
myxcedema. Trombetta of Messina, who has gone over the literature of the subject, 
finds a percentage of 27. On the other hand, no cases are reported from the Vienna 
clinic, and Bottini has operated on fifty-two cases without having a single case of sur- 
gical myxcedema. Still, and without attempting to explain these discrepancies, it 
suffices that a well established percentage of cases of thyroidectomy are followed by this 
very grave and fatal cachexia to cause surgeons to prefir always partial to total ex- 
tirpation, when dealing with benign diseases of this gland, and this is no doubt the 
present tendency, especially since the technique has been so thoroughly perfected by 
Socin of Basle, the Reverdins, Hahn, etc. 
These partial extirpations are as a rule free from the danger of myxcedema, as the re- 
maining portion is adequate to discharge the functions of the whole organ. It can hardly 
be doubted that other lymphoid organs in the body (Thymus’ amygdala;, Beyers’ patches, 
•tc), as Hale White’s, i<ogowitsch’s, Fuhr’s observations tend to prove, are capable of 
compensating for the loss ot the thyroid; still the time needed for the establishment of 
this functional equilibrium has not been determined. Four months between the extir- 
pation of the two lobes (Stokes of Dublin), and nine months in one of Kocher’s cases,, 
were not sufficient to prevent the appearance of the disease. The risk of myxcedema is 
therefore more to be dreaded after thyroidectomy for malignant disease than in the par- 
tial operation for benign growths, since in malignant goitre, if any radical operation 
is attempted, it must practically necessitate the complete removal of the whole gland. 
Furthermore, if the operation is performed at all, it is only justifiable in the early 
stages and it is plain that the economy will not have time to accustom itself to the grad 
ual histological substitution of the t]ivroid tissue, and will, of necessity, be more liable to 
resent the removal of this organ. 29 
Finally, we must now enter into a most important prac- 
tical consideration: What are the immediate and perma- 
nent operative results of thyroidectomy for malignant 
disease? Nothing is more conclusive as to relative merits 
of the two operations—thyroidectomy for benign and the 
same operation for malignant disease of the gland. Noth- 
ing emphasizes more vividly the disastrous perils of the 
one and the comparative security of the other; nothing 
demonstrates better the inherent malignity of thyroid 
cancer and the comparative innocence of simple goitrous 
enlargement than the comparative statistics of the opera- 
tion of extirpation for both affections—i. e., the statistics 
illustrating the immediate operative results. 
In regard to thyroidectomy for simple benign goitre we 
find that in 322 operations compiled by Liebrecht there 
was a general mortality of 7.92 per cent., and the results 
are still more satisfactory.if we examine more recent col- 
lections. In 1883 Kocher led the van with 101 cases, 
with a mortality of 12.8 per cent. The 43 last operations 
performed, in the course of seventeen months, were 
accompanied by a net mortality of 9 per cent., and of 5.1 
per cent, if only 39 pure benign goitres are considered. 
In 1885 the same surgeon again tells us that his last 70 
cases were all operated without a single death! In 1882, 
1883, Bottini performed 10 thyroidectomies, of which 8 
were total extirpations, and without a death. (A. Broca, 
loc. cit.) 
Now note the contrast in the immediate results of thy- 
roidectomy for malignant disease. I will condense from the 
latest and most complete data gathered by Butlin in his ex- 
cellent work already quoted (op. cit., page 203). Very 
excellent information on this subject is afforded by three 
papers in three volumes of Langenbeck’s Archives, xxiii 
(1879); xxv>ii (1883,) and xxxi (1885.) 
The first is by Dr. Edmund Rose, the second byDr.H. 
Braun, the third by Dr. J. Rotter. They may be regarded 
as supplementing each other, so far as the diagnosis and 30 
treatment of cancerous disease of the thyroid is con- 
cerned. The total number of instances of removal of the 
disease in the third paper is fifty, of which thirty-four had 
been collected by Braun and sixteen by Rotter. Thirty 
of the fifty patients died of the effects of the operation, a 
mortality therefore of sixty -per cent.{ !) The fatal issue 
took place in the first twenty-four hours after the operation 
in eight cases ; in from two to four days in ten cases ; in from 
four to nine days in five cases; in from one to eight weeks 
in five cases. In two instances the exact period of death 
is not mentioned. The causes of death in many of the 
cases, not single, but multiple. For instance, dyspnoea, 
collapse, and the presence of secondary diseases—pneumo- 
nia, mediastinitis, and enlargement of the bronchial glands, 
whether cancerous or not—combined to produce death. 
The immediate deaths took place almost wholly from the 
severity of the operation, and those which occurred within 
two to four days after the operation were attributable to 
mediastinitis and septic poisoning. In two or three cases 
severe secondary hemorrhage occurred and proved fatal. 
So much then for the immediate results of thyroidectomy 
for malignant disease. Now what is the showing in regard 
to the ultimate, final or radical cure of the disease after the 
operative ordeal ? Again continuing with the same authority 
we find that “ in the twenty cases which remain after de- 
ducting thirty fatal cases from the fifty which were treated 
by operation, there were two in which the operation was 
not completed and which really should be left out 
of account, except in so far as the fact should be men- 
tioned that it was found necessary to abandon the operation 
in a certain number of instances. In three cases the further 
history was not known, and in one case the further observ- 
ation only extended to a period of two months after the 
operation. In ten cases there was recurrence, which was 
either fatal or rapidly promised to be so. Only in four in- 
stances was a favorable result obtained. One of these was a 
patient treated by Bircher, who was known to be alive and 31 
well eleven months alter the operation. The second was 
operated on by Bruns. Some enlarged glands were removed 
a year after the first operation, and two and a quarter years 
later the patient died of inflammation of the lungs. The 
third case is of Maas, and was reported to be quite well 
nearly four years after the operation; and the fourth 
patient, also under the care of Maas, died at the end of 
twelve months of some affection of the lungs of uncer- 
tain nature. 
In my own case the patient has thus far survived six 
months after the operation, but secondary tracheotomy 
was required one month after, owing to secondary 
involvement of the larynx; and it is not probable that the 
patient will survive many weeks longer, as the disease 
shows a manifest tendency to encroach deeper down into 
the trachea and bronchial glands. 
Though these fifty cases compiled by the Germans do 
not represent the complete list of thyroidectomies for 
malignant disease, still it will be admitted that they quite 
adequately represent the status of the operative treatment 
of the disease under consideration. Furthermore, as 
Butlin observes, at least four-fifths of the cases in Braun's 
and Rotter’s lists were treated within the last ten years— 
within the period, therefore, of modern antiseptic surgery. 
The statistics of operations for the removal of innocent 
tumors of the thyroid have improved steadily with im- 
proved surgery, but the same statement cannot be made 
with regard to the extirpation of cancerous tumors of the 
thyroid. Braun particularly draws attention to this, show- 
ing that the dreaded inflammations of the tissues of the 
neck and mediastinum only exceptionally occur, and that 
the real difference lies in the local relations of the malig- 
nant tumors, in the frequent affection of the cervical, 
mediastinal and bronchial glands, in the metastasis in dif- 
ferent internal organs, aud in the great difficulty in the 
diagnosis of malignant thyroid tumors generally. 
The state of evidence in regard to this subject could not be more fairly stated, and the final could not be 
better expressed than in Bulbil’s' language above quoted. 
It harmonizes with and endorses the position assumed and 
the conclusions adopted by the writer, who believes, as 
previously stated, that malignant disease should never be 
surgically interfered with unless the disease presents the 
limitations of strictly benign goitre—/. e., that when posi- 
tive signs of extra-glandular involvement tire discovered 
that all operative measures should be of a_purely palliative 
character; viz. : tracheotomy, section of the isthmus, liga- 
ture of the thyroid arteries (of very doubtful benefit), etc. 
Again, that even when the disease appears externally to be 
strictly encapsulated that a very thorough exploration by all 
means at our command should be made for the discovery 
of incipient secondary involvement of the neighboring 
organs ; more especially the larynx, the involvement of 
which may be disguised by the mechanical disturbance of 
its functions, consequent upon extrinsic pressure, etc. 
And, lastly, that in all doubtful cases, a partial thyroid 
ectomy be proposed to the patient with a view of settling 
the true nature of the growth bv a careful histological 
examination of the excised portion; such treatment being 
as a rule curative of the goitre if benign, and permitting 
of an early and more complete extripation by a final 
operation if malignant, though it is the writer’s belief also 
that even a thyroidectomy for cancer under the most 
favorable operative circumstances will prove to be merely 
a palliative operation, as the very fact of its recognition as 
a simple enlargement will be coincident with at least its 
extra-glandular lymphatic dissemination. 
32