Surgery of the Thyroid Gland, with Lantern

Illustrations

ABSTRACT

At the meeting of the Ohio State Medical Society, at Toledo, on May 27th, 28th and 29th, Dr B. Merrill Ricketts, of Cincinnati, after reviewing the Human and Comparative anatomy (miscroscopic and topographic) said that many assigned causes for abnormities of the thyroid gland were given, the most common being heredity, acute infectious diseases, and malignant neoplasms. All vertebrates were subject to the same laws concerning disease and abnormities of the thyroid gland. Nephritis from any cause was a common cause of them, and when it was a cause the growth was of rapid development. Thyroiditis was rare and, when present, followed an operation, or injury. Of the parasites, echinococcus and cysticercus were rare causes, while the bacilli of pneumonia, typhoid, and tuberculosis, and microorganisms of a selective type, were more frequent.

The results of disease of the thyroid gland were insanity, infection, hemorrhage, dyspnea, and rupture. Death might be due to any or all of these causes.

The thyroid gland was subject to nearly all forms of benign and malignant neoplasms. Their treatment he classified as: 1. Medicative. 2. Operative. Medicative treatment was of but little avail, except to palliate. Extracts benefited, but did not cure. They lessened the size of the neoplasm. Only commendable in a certain class of cases as a palliative measure, other remedies were useless. Fresh glands on ice did not produce toxic effects, and the best results were observed in chlorotic patients when raw sheep'sgland was used.

Operative treatment: Dyspnea, stridor, rapid growth, dysphagia, deformity, exophthalmic goiter, malignancy and emaciation, one or all, he said, indicated operation. Removal of all or a part of the gland should be given the

preference to the injection of iodin, zinc, iodoform, alcohol, or any other solution. Excision was more radical, safer, and required less time for recovery. Then, too, none of the neoplasm remained to be the seat of new growth, malignant or benign. All forms of new growth of the thyroid gland should be removed. Even in cases of exophthalmic goiter it should be operated on. All operative experience led to this conclusion. Great relief had been given in exophthalmic goiter.

Method: If the disease was confined to one of the two lobes without the isthmus, the diseased lobe might be completely removed, without much likelihood of recurrence of the growth. If an isthmus was present the other gland might become involved. It was probable that the disease being confined to one lobe might be due to the absence of the isthmus. So far as possible, the presence or absence of the second lobe should be determined at the time of operation. If the second lobe could not be found, the entire diseased lobe should not be removed, unless malignant.

The probabilities were that one or more supernumerary lobes were more frequently present in persons possessing but one normal lobe, no matter where the abnormal ones might be located. Supernumerary glands were more frequent upon the left side. The presence of supernumerary lobes might account for the absence of ill effects in those persons who had been subjected to the removal of an entire right or left gland.

Division of the capsule would permit of a thyroid gland being enucleated with ease and with the loss of but little blood.

The rapid pulse following removal of a thyroid gland was probably due to the rapid absorption of the thyroidin in the process of repair. The pulse would sometimes become much more rapid for from 48 to 100 hours, reaching at times 160 per minute, but it would at the end of this time subside to 80 or 90. If there was any pathologic tissue that

should be excised, it was that of the thyroid gland. In none of the major operations was the mortality less.

The author mentions six operations for various forms. of pathologic thyroid gland with recovery in each case. Fifty lantern slides were shown to illustrate the anatomy, anomalies, kinds of growths (malignant and benign), parasites (animal and vegetable), bacilli and effects upon the trachea from pressure of thyroid neoplasms.

Some Observations on Appendicitis Based on 372 Operations

By GEORGE W. CRILE, M. D., Cleveland

STATISTICAL SUMMARY.

As to the period of operation there were: (a) Interval and chronic cases...

(b) Acute, while the infection was limited to the appendix. 64 (c) Acute, after the infection had extended beyond the ap

pendix

Mortality rate:

For 372 cases..

Interval and chronic cases..

Acute while infection was limited to the appendix

pendix

Interval and chronic cases..

Acute cases

188

11+%

Acute cases after the infection had passed beyond the ap

.120 operations, 0% .252 operations, 8%

To illustrate the discussion they may be divided into the following two classes:

(a) Interval and chronic cases, and those acute cases in which the infection was still limited to the appendix 184 0% (b) Acute cases in which the infection has passed beyond

the appendix

.188 11+%

These tables show a proportion of males to females of about 3 to 2. The average age of the females is slightly higher than that of the males. Of the fatal cases, the number of males is disproportionately large. The average of the fatal cases in the female is lower than that of the males; but the number of cases is too small to be of much statistical value.

In the mortality table the contrast between the cases operated on in the interval, in the chronic stage while the infection was still limited to the appendix, and the cases in which the infection had passed beyond the appendix, is marked. In the former there were 184 operations without a death; in the latter 188 with 21 deaths. Of the former, none were at any time in danger. The average time of confinement in bed was about two weeks. In every instance the recovery from the operation was easy, and the patients resumed their usual vocation early. In none did hernia develop.

In the second group there were 188 operations with the following results: There were 21 deaths, or 11%; the convalescence was in most cases prolonged, in one case 26 weeks; many of the patients became extremely septic. In more than one-fourth of the drainage cases hernia at the site of the old scar appeared within the first year following the operation. In severer cases toxemias were marked long after the patient recovered from the operation.

In some cases the outcome as to life was doubtful for weeks, and even for months. Among the complications were two perforations of the bladder, the pus discharging through the urethra. In three cases there was a suppurative cholangitis; one recovered after 11 weeks of critical illness, and two died, the autopsy showing multiple abscess. In four cases the infection passed into the retroperitoneal glands, necessitating posterior incision and drainage. In a case seen with Dr C. F. Cushing of Elyria, in which the walling-off process was imperfect, an abscess developed in the pelvis extending up the left iliac fossa. This was

opened by a left lateral incision. A fecal fistula appeared soon after. Later a large colon-bacillus abscess developed in the right pleural cavity, following which another developed in the left pleural cavity. At this time there was a bilateral fecal fistula and a bilateral empyema. A rib was resected on each side, and free drainage established. At this stage there developed a severe acute nephritis. The pulse ranged from 170 to 180 to the minute and there was vomiting. The entire illness lasted six months. At present, 16 months after the operation, there is still some albumin in the urine.

In another case, at the time the patient was presented for operation, the abscess extended upward behind the peritoneum displacing the liver toward the median line, and passed through the diaphragm into the pleural cavity. An incision was made into the abscess in the right iliac fossa, another just below the diaphragm. On resecting the fifth rib a large amount of pus gushed out. A tube entering the fifth intercostal space and emerging from the opening at the iliac fossa provided efficient drainage. After 12 weeks his convalescence was completed.

Another case presented multiple abscesses occupying both loins and the lower half of the abdomen. Through a median incision the abscess cavities were converted into a single one and the pus thoroughly washed out. About 10 days later a new abscess formed which perforated into the bladder and was finally discharged through the urethra. The patient recovered after 18 weeks' illness. In another case the abscess was retroperitoneal extending downward precisely as a psoas abscess underneath Poupart's ligament and the fascia lata presenting at the popliteal space; upward it extended to the diaphragm becoming suphrenic, displacing the liver inward, extending through the diaphragm into the pleural cavity. It also surrounded the right kidney. The abscess cavity extended from the sixth intercostal space, the point of the upper opening, through the diahragm, between the liver and the kidney along the psoas