SUCCESSFUL REMOVAL OF THE THYROID GLAND 
FOR BRONCHOCELE OR GOITRE—FULL 
RECOVERY OF THE PATIENT. 
BY ORIN E. NEWTON, M. D. 
OF CINCINNATI, OHIO. 
HISTORY. 
Miss Ida B. Jarvis, residence Huntington, West Virginia, was presented to 
me Feb. I, 1878, for an enlargement of the anterior portion of the throat, 
stating that a lump had first been noticed some seven years ago, since which 
time its growth had been continuous. 
By pressure the tumor could be moved laterally without trouble. During 
the act of swallowing it would rise and fall in a line with the trachea. 
Believing it was not attached to the trachea, I gave it as my opinion that 
it could be removed by extirpation. 
Having given the most rigid directions as to abstinence from food, I pro* 
mised to make the effort for its removal. 
The following day, assisted by Dr. C. M. Greve and G. H. Thuman, at 
12 o’clock, I proceeded to place my patient under the influence of a mixture 
of two parts of ether and one of chloroform. When fully unconscious, I 
caused the patient’s head to fall slightly backward, and made a vertical inci- 
sion, in a line over the center of the tumor and trachea, over four inches in 
length. After dissecting the integuments well down on both sides, I found 
the tumor to be fully covered with muscular tissue, composed of the sterno- 
hyoid, sterno-thyroid, and omo-hyoid muscles. To expose the tumor from 
under this muscular tissue, I used the scissors. I then most carefully dis- 
sected down on both sides of the tumor, approaching the posterior base with 
great precaution. I now laid aside my knife and used my fingers as a gouge 
in separating the tumor from its posterior attachments. When removed, the 
cricoid cartilage and a part of the anterior portion of the trachea were ex- 
posed. There was excessive hemorrhage all the time accompanying the op- 
eration, especially so when the tumor was separated from its posterior base, 
giving me and my assistants much apprehension of danger from this cause. 
But, owing to the manner of the means of separation used—being more of 
the nature of scraping than cutting—and having used my fingers as a 
gouge in its final separation, I was able to manage the hemorrhage more 
easily than I had expected, especially that arising from the superior thyroid 
artery. 
Having fully controlled the hemorrhage, I placed the proper amount of 
stitches to hold the edges of the wound together, over which I applied strips 
of adhesive plaster. 
AH this was done without the patient having the least knowledge of what 
had occurred. 2 
Successful Removal of the Thyroid Gland. 
Having ordered my patient one-eighth of a grain of morphine internally 
and a wet dressing, consisting of tr, aconite root, 3 H, tr. arnica 3 iv., aqua 
3 Hiss., to the wound, I left her until 5 o’clock. I found that during my 
absence she had been very sick at the stomach, delirious part of the time, 
and at the time of my visit the pulse was at 120. 
At 10 o’clock the same evening, with the means that were used, the stom- 
ach was more settled, and the arterial excitement somewhat lessened—the 
arterial sedative being two drops of tr. gelseminum and one of tr. veratrum 
every half hour. As an anti-nauseant: peppermint, spearmint, and cam- 
phor, waters aa 3 >•, paregoric 3 ']• Mix. One teaspoonful every ten 
minutes. The same treatment was continued throughout the night while the 
patient was awake. 
Second day, BA. M.—Pulse 115, nausea less, with irregular periods of de- 
lirium through the night. Had slept about an hour; complains of intense 
thirst, which has existed since the previous evening. Same internal treat- 
ment continued, with the addition of gum aribic mucilage, slightly acidu- 
lated, for the thirst. Five o’clock, P. M.—Pulse 105; nausea arrested; the 
patient had slept nearly two hours during the day. Ordered broken doses 
of two teaspoonsful each, of castor oil, every three hours until the bowels 
were moved. 
Third day, 8 A. M.—Pulse 100, a movement from the bowels after the 
third dose of the oil. Patient quite rational and comfortable; able, for the 
first time to take a little food, at which time discontinued the sedative ; light 
diet, and the mucilaginous drinks continued. 
Fourth day, 5 P. M.—The stitches were most carefully removed, when 
full and perfect adhesive inflammation was found to have taken place in the 
wound. 
The subsequent dressing consisted of simply supporting the wound with 
adhesive plaster, changed once per day. 
Eighth day.—The patient sitting up and the wound almost closed. The 
same treatment continued until the tenth day, when the wound was entirely 
healed and the patient discharged. 
DESCRIPTION OF THE TUMOR. 
Having uncovered the tumor during the operation, I punctured it, when 
blood flowed freely from it, but the tumor still preserved its previous density 
and oblong shape. Its color was a brownish red. 
EXAMINATION AFTER REMOVAL 
, Shape oblong, with a smooth surface, covered by a thin fibrinous capsule, 
which could, however, be easily separated with the handle of a bistoury. 
The right upper part was composed of distinct cells, the size of a common 
grape pulp. There was a distinct circular band of concavity surrounding 
the tumor, showing the division of its lobes. After discharging the blood 
by puncturing, it still retained its firm, compact nature, though much 
lessened in size by this waste of blood. Successful Removal of the Thyroid Gland. 
3 
BRONCHOCELE. 
In “ Liston's Elements of Surgery.” By Gross. Pp. 383, 384. 
Extirpation of such growths has been repeatedly attempted, but the pa- 
tients, almost without exception, have perished from hemorrhage, under the 
hands of the knivesmen. The immense supply of blood to the gland in the 
healthy state must be kept in mind, as also the enlargement of the vessels 
proportional to the increase of the part. Not arteries alone, but enormous 
veins are to be encountered. The tumor is in the vicinity of important 
organs, and of the trunks of large vessels and nerves, and probably has 
become attached to them. In short, the operation is attended with such 
risks, with so absolute a certainty of almost fatal results, as not to be war- 
ranted under any circumstances, far less for removal of deformity alone. 
Enlargement of the isthmus alone gives rise to more severe symptoms appa- 
rently, and may warrant an attempt at removal; but this can scarcely be 
accomplished altogether by incision. Such is my impression, and under this 
impression, I proceeded very cautiously in a case of this nature with which 
I had to deal. 
J. R., a rat-catcher, aged 47, from the Highlands, was admitted 
into the Royal Infirmary. The isthmus of the thyroid gland was 
enlarged to the size of a goose’s egg. The tumor was extremely hard and 
irregular on its surface, but not painful when touched. It appeared to be 
adherent to the trachea, and did not admit of much motion. The voice was 
considerably impaired, and breathing much impeded, inspiration being diffi- 
cult and attended with a loud, wheezing noise. On making unusual exer- 
tion, even though inconsiderable, the dyspnoea was much increased; and on 
ascending a height, or even remaining for some time in a stooping posture, 
it amounted almost to suffocation. There was no pain or uneasiness in the 
larynx or trachea. The disease was of three years’ duration. A seton had 
been introduced, but effected no diminution, and rendered the tumor more 
dense and less movable than formerly. I surrounded the lower part of the 
tumor by two semi-circular incisions, and dissected cautiously beneath its 
base, detached it from its more loose connections, not interfering with the 
central portion and its connection to the trachea. During the progress of 
the dissection, the blood flowed most profusely from both arteries and veins, 
but was restrained by securing the former with a ligature, and compressing 
the latter with sponge. An armed needle was then passed through the cen- 
ter of the tumor, as close to the trachea as possible, and its remaining 
attachment inclosed by the separate portions of the ligature firmly applied. 
Everything proceeded favorably. The tumor soon came away, the wound 
healed with a firm cicatrix, and in about a month, the patient went home 
well. I met him by chance in Aberdeen twelve months afterwards, free of 
complaint, and breathing easily under all circumstances, his neck presenting 
no vestige of the tumor.” Successful Removal of the Thyroid Gland. 
BRONCHOCELE. 
From Syme’s “ Principles and Practice of Surgery,” By R. S, Newton. Pp. 486,487. 
“ Of bronchocele, sometimes the whole gland is equally enlarged, but it 
generally exceeds on one side, and occasionally the swelling is limited to the 
right or left lobe entirely, particularly the latter. In this case the surgeon 
must be on his guard against supposing the disease is an aneurism of the 
carotid artery, or an independent tumor admitting of excision, which opinion 
he may be led to adopt by the seeming mobility of the growth, owing to the 
flexibility of its substance. The symptoms of bronchocele are swelling in 
the situation of the thyroid gland, which follows the motions of the larynx 
during deglutition, and cannot be moved without a corresponding displace- 
ment of it. There is seldom much obstruction, either in breathing or swal- 
lowing, The deep situation, muscular coverings, firm connections, and large 
blood-vessels of bronchocele, forbid excision, and the attempts which have 
been made with this view afford a sufficient warning against their repetition, 
by the fatal issue which has almost invariably immediately followed them. 
The operation has sometimes been found extremely difficult, owing to the 
displacement and overlapping of the vessels by the tumor.” 
BRONCHOCELE, OR GOITRE. 
From Smith’s “Operative Surgery,” pp. 305-809. 
“ The thyroid gland is subject to two kinds of enlargement—one of a tem- 
porary nature known as goitre, the other a permanent scirrhus.” True goitre 
exists at all periods of life, especially in the female sex, and consists in a 
chronic inflammation of the thyroid gland itself, which, beginning at some 
one point, is apt to extend until, as in a case related by Alibcrt, it reaches to 
the thighs of the patient. The changes in a goitre vary with its develop- 
ment, presenting sometimes a soft, gelatinous matter, or a more hardened 
structure, Interspersed with cysts, containing a serous, glairy, or melicerous 
substance, and occasionally pus, fibrin, calcareous concretion, or pure blood. 
Vascular derangement being here very evident, the thyroid arteries are com- 
monly found to be much enlarged. In some cases the swelling seems to 
consist of a congeries of varicose veins, and, under these circumstances, there 
may be considerable sanguineous effusions, the blood being poured into the 
enlarged vesicles or into the connecting cellular substance of the gland. 
The scirrhous goitre presents a tumor covered by a firm, fibrous capsule, 
and consists of a spongy texture, in which appears a considerable number of 
cells, some of which are of a large size and contain a bloody fluid. Its con- 
sistence is often firm, but not scirrhous, except at the upper part, which 
sometimes has the texture, consistence, and white color of a true scirrhous. 
Diagnosis.—The goitrous tumor has a smooth surface, a somewhat elastic 
feel follows all the motions of the larnyx, especially in swallowing, and gives 
no sensation of crepitation, fluctuation, or pulsation. The propriety of 
operating on these tumors is a point on which most surgeons are very Successful Removal of the Thyroid Gland. 
5 
decided, the opinion being almost universal that any attempt to extirpate 
them is most hazardous. Although the extirpation of a goitre cannot be 
regarded as a justifiable operation in most instances, the distress of breathing 
and swallowing which it sometimes causes may render it imperative on the 
surgeon to attempt some means of affording relief.” 
A CASE OF EXTIRPATION OF A SCIRRHOUS THYROID GLAND. 
“ The patient being in the upright position, an incision nearly (4) four 
inches long was carried along the anterior edge of the sterno-mastoid muscle, 
so as to expose the platysma myodes, which was incised so as to present the 
edge of the sterno-mastoid. On turning this aside, the sterno-hyoid and 
thyroid muscles were perceived to cover the tumor in such a way that it was 
necessary to separate them and dissect between them. The surface of the 
tumor being then brought into view, was fully exposed by dissection, and 
separated from the sheath of the carotid artery by the handle of the knife. 
This apparently loosened its attachments, but a solid adhesion being formed 
to the trachea for one or two inches, and also to the oesophagus for a small ex- 
tent, which required the use of the knife, the dissection was pursued upward 
and backward, in order to extract the superior corner of the gland. 
J. C. Warren, of Boston. 
The superior artery being divided in so deep a position as to prevent its 
ligation between the muscles, the common carotid was therefore tied. The 
inferior thyroid did not bleed, or was supposed not to exist, and the patient, 
after serious symptoms, recovered in about one month. Although I have 
placed among the preceding operations an account of the extirpation of the 
thyroid gland, as performed by Warren, it has been done rather to complete 
the record than from a wish to lead any one to its repetition, even when 
sanctioned by such excellent anthority. Though occasionally performed, an 
attempt to extirpate a goitrous tumor is so liable to cause immediate death 
from hemorrhage, that few, as before stated, deem the operation justifiable, 
more than on 6 patient having died on the table. The ligature, both by the 
subcutaneous method and also after the exposure of the tumor, has succeeded; 
yet the obstruction of the circulation through the part by this method has 
been followed by alarming symptoms of suffocation and congestion of the 
brain. Every surgeon should therefore avoid operating on any case of true 
goitre unless fully prepared to encounter great difficulties, or with a view of 
relieving certain suffocation. In the operative treatment of this tumor it 
may be well said that discretion is the better part of valor.” 
THYROID GLAND, 
“ This gland is situated on the upper part of the trachea, and is of a red- 
dish brown color. It is embraced by a delicate, closely adherent proper 
membrane, which gives it a polished appearance. Examined internally, the 
gland is observed to be lobulated.” 
From Morton’s “ Human Anatomy,” pp. 880, 381. 6 
Successful Removal of the Thyroid Gland. 
THE THYROID GLAND. 
Quotations of Dunglison’s Dictionary. 
“ Glandula Thyreoidea ”is an organ the uses of which are not known. It 
covers the anterior and inferior part of the larnyx, as well as the first rings 
of the trachea, and seems to be composed of two lobes, flattened from before 
to behind, which are united by a transverse prolongation of the same nature 
as themselves, called the isthmus. (The tissue of the thyroid is soft, spongy, 
and of a brownish color, but its intimate structure is unknown. It is formed 
of several distinct lobules, collected in lobes of greater or less size.) The 
thyroid gland receives four large arteries called thyroideal, as well as corres- 
ponding veins. Its nerves proceed from the pneumogastric and from the 
cervical ganglia. No excretory duct has ever been found in it. Its uses are 
not known. 
THYROID GLAND. 
Gray’s “ Descriptive and Surgical Anatomy,” p. 787. 
“ The thyroid is situated at the upper part of the trachea, and consists of 
two lateral lobes, placed one on each side of that tube, and connected to- 
gether by a narrow transverse portion—the isthmus, and is of a brownish red 
color. Its weight varies from one to two ounces. ‘ Structure.''—The thyroid 
consists of numerous minute closed vesicles, composed of a homogeneous 
membrane, inclosed in a dense capillary plexus, and connected together into 
imperfect lobules by areolar tissue.” 
THYROIDEAL ARTERIES, 
Quotations from Dunglison’s Dictionary 
Ist. •“Thyroideal are two on each side. The superior thyroideal, supe- 
rior laryngeal, superior guttural, arises from the anterior part of the external 
carotid, and proceeds to the upper part of the thyroid gland, after having 
given off a laryngeal branch and a crico-thyroid. 2d. The inferior thyroideal, 
inferior guttural, much larger than the last, arises from the upper part of the 
subclavian. It passes in a serpentine manner to the inferior part of the 
thyroid gland.” 
THYROIDEAL VEINS. 
From Dunglison’s Medical Dictionary, 
“Thyroideal veins are: Ist. A superior thyroideal, and several middle 
thyroideal, which open into the internal jugular vein. 2d. An inferior thy- 
roideal, much larger than the preceding, whose branches form (by anasto- 
mosing with those of the opposite side in front of the trachea), a very 
remarkable venous plexus, which J, Cloquet calls the infra-thyroideal plexus. 
The inferior thyroideal veins open—the left into the corresponding subcla- 
vian, the right into the vena cava superior.” Successful Removal of the Thyroid Gland. 
7 
PRACTICAL CONCLUSIONS. 
After this operation and the minute examination of the tumor, I have 
come to the conclusion that all such cases should be treated at as early a 
period as possible, by charging the hypodermic syringe with iodine or Mon- 
sell’s solution, and thrusting the tube into the centre of the tumor, or gland, 
and injecting it every fourth day, so long as the tumor shows contraction or 
decrease—fully believing that a majority of cases of primitive bronchocele 
would be arrested by this in their growth. 
The therapeutic action would tend to close the arterial supply, and this 
done, the tumor would most certainly cease to grow, and its growth having 
been checked by destroying the vital action of the tumor, the absorbents 
would take up and carry off the dead tissue. 
This stopping of the vital supply by the previous general treatment, which 
has, in my hands and others, cured such cases, (though very tedious), would 
be much more promptly accomplished in my opinion, by injecting these tumors. 
The tediousness of the treatment with all previous means—the alterative, 
strapping, and the local application of iodine, electricity, or any other means 
which have been credited with occasionally curing these cases—have worn 
out the majority of cases before a cure was effected. 
Early and prompt treatment is highly necessary in these cases. 
DANGER OF DELAY 
In the treatment and arrest of these cases is certainly very great, it being 
from very many causes. 
The principal danger grows out of the probability that, by the increased 
growth, the pressure may become so great that by absorption the large blood 
vessels connected with and underneath the tumor are eaten off, and the 
patient may bleed to death. 
I have had two patrons who neglected the treatment of their cases—though 
enjoying very good health at the time—die in a few moments from this sud- 
den internal hemorrhage. 
The result of the operation can be known by reading the following letter 
received from the brother of the patient; 
Huntington, W. Va., April, 1878. 
Dr. O, E, Newton.—Dear Sir; I am most happy to state to you that 
the wound is now healed, after the surgical operation for the removal of a 
Bronchocele from my sister’s neck, which you performed on the 2d of Feb- 
ruary, 1878. When I write you, that we are all under many, many obliga- 
tions to you, for the wonderful cure you have performed, I am only stating 
the very least of our thoughts, for what we consider her life saved. 
And now once more thanking you, I will close 
Yours Very Truly, 
JOHN H, JARVIS.