Three Cases of Bronchocele Successfully Removed.
By Wm. Warren Greene,  M. D.  
Extracted from the American Journal of Medical Sciences for January, 1871; pp. 80-87.

ART. III.–Three Cases of Bronchocele successfully removed.  By Wm. Warren Greene,  M.D., Professor of Surgery in the Medical School of Maine, etc. (with three wood-cuts.)

In December of 1866, I published in the New York Medical Record (vol. I. No. 19) the report of a case of large bronchocele successfully removed, and advocated the propriety of an operation in similar cases.  I have now the satisfaction to add two other successful cases, and I cannot but believe that a careful examination of them will convince my professional brethren that excision of an enlarged thyroid gland is, under the circumstances which I shall describe, a legitimate operation.

For a brief discussion of this question, I refer to my first report; but in view of the importance of the subject and the propriety of placing the cases in connection, I take the liberty of quoting from that paper the following account of

Case 1.– “Mrs. K., æt 45, a German lady, residing in Albany, N.Y., consulted me, August 19th, 1866,  for an enlargement of the right lobe of the thyroid gland; there was a slight enlargement of the left side.  She first noticed the tumor twenty-six years ago, but it had never given her any trouble until within a year and a half, during which time it had rapidly increased to its present size.  Its dimensions were now such that the common carotid was crowded behind the posterior edge of the sterno-mastoid muscle, where its pulsations were distinctly felt, and the trachea was pressed firmly to the left side.  So great was the pressure upon these organs and the  œsophagus, that any attempt to swallow or talk gave her terrible spasms of dyspnœa.  She was unable to lie down, and required constant watching during her broken sleep, lest she should die of suffocation.  She suffered very much from headache and giddiness, and could not stoop without losing her consciousness.  All these symptoms had been for two months rapidly increasing in intensity, and for two weeks almost a daily aggravation had been noticeable.  She had recently consulted the leading surgeons of Albany and some other cities in New York, all of whom told her that nothing could be done.  At my request my colleagues, Professors Ford, Palmer, and Storer, and Drs. Smith, Brewster, and others, examined her; and all agreed that a few days at most would terminate her existence, while the thread was liable to snap at any hour.  The patient was already aware of her imminent danger, and her only question was as to the possibility of relief.  I told her in all probability the removal of the growth would be found impracticable; and that even if she survived the operation, which was not likely, the chances were a hundred to one that she would die of secondary affections; but still there was a bare possibility of success, and that while I would by no means advise an operation, yet if she, being fully aware of all the facts, insisted upon taking this desperate chance, I would undertake the removal of the tumor.  I was happy to have my own views as to the propriety of this advice endorsed by Dr. Storer.  She immediately decided upon its being done, and at once.  Accordingly, in the presence and with the assistance of Prof. H. R. Storer, Dr. F. K. Paddock, and several students, I made the operation in the following manner: the patient, being etherized, was placed in the ordinary position for ligation of the carotid, and a single straight incision was made over the tumor, extending from the inferior maxilia to the clavicle.   The anterior external jugular vein, which ran close by the line of the incision, was not injured.  The sterno-mastoid, which was spread over the mass like a thin riband, and the several fasciæ, were successively divided upon a grooved director, and the areolar tissue with the knife and fingers, the handle of the scalpel being employed much more freely than the blade.  On raising upon the director the little thin layer of fascia immediately investing the tumor, several veins were wounded and bled profusely; this was controlled by the fingers of an assistant, and the delicate envelope carefully reflected from the gland; but although this was done with the utmost caution and gentleness, several other veins were ruptured.  I now found that the entire growth was completely covered with a network of these vessels; and so thin and tender were their walls that the forceps tore, and the ligature cut their coats; and now, although the blade of the knife had not touched the surface of the tumor, so many of these veins were opened, that in spite of all the pressure that could be made the hæmorrhage was fearful.  I now rapidly separated the areolar attachments, and in a few seconds was at the pedicle, which I found containing three large arteries whose pulsations were very distinct, and which were my guides for dividing the pedicle into three parts, which I also accomplished with the fingers.  I immediately tied each third with a ligature composed of eighteen strands of saddler’s silk, saturated with wax and loosely twisted.  As I drew the last cord all hæmorrhage instantly ceased.  The pedicle was carefully divided close to the goitre, and it removed.  During the dissection I found at one point the tumor quite firmly adherent to the sheath of the vessels; and while separating it, a gush of venous blood indicated the rupture of a large vessel.  The finger of an assistant controlled it until the ablation of the bronchocele, when examination proved the internal jugular to be wounded.  This was tied with a ligature of three strands of silk loosely twisted; no other vessels needed interference.  The entire operation occupied twenty-two minutes.

“After carefully sponging the wound and allowing the surface to glaze somewhat, the edges were united by interrupted sutures, water-dressings applied, and she placed in bed.  The extremities were cool, and pulse feeble but regular, and less than ninety per minute.  She reacted nicely, and passed a more comfortable night than she had for weeks.  The after-treatment consisted in perfect quiet, water dressings when agreeable, anodynes pro re nata; the exhibition of muriated tincture of iron, twenty drops every four hours, and as much rich broth, gruel, and milk as she would take at regular intervals.  For several days there was considerable irritation of the œsophagus and trachea, but not enough to interfere seriously with deglutition or respiration.  This passed away, and she recovered without a bad symptom.  The last ligature came away on the twenty-sixth day; in another week the wound was entirely healed, and she is no in perfect health and restored to a happy family.

“Figure 1 gives the appearance of the lady before, and Figure 2, after the operation.
“The weight of the tumor was one pound nine ounces avoirdupois.”

This lady has continued in excellent health ever since.

Case II.–Mrs. II., æt. 40, of this city, consulted me in September of 1869, for a tumour, the size of a small orange, occupying the site of the right lobe of the thyroid gland, which was of seven years’ standing.  She was referred to me by my friend colleague, Prof. I. T. Dana, who had carefully examined the growth, and whose opinion coincided with my own, that it was probably goitours.  Yet, although presenting the ordinary characteristics of thyroid enlargements, there was an additional feature, extraordinary for a bronchocele of so small a size, which threw doubt upon the diagnosis, and was the special reason which led her to seek relief.  For a year previous to our examination she had suffered from a constantly increasing difficulty in deglutition.   She denied ever having sustained any injury or local inflammation of the parts; but by a careful process of exclusion, both Dr. Dana and myself became sure that a firm connection of the tumour, whatever it might be, with the œsophagus explained the dysphagia; and while this was the only symptom which threw a doubt upon the diagnosis of goitre, we felt sure that it, in connection with her persistent and positive denial of any cause that could have produced adhesion of the gland and gullet, justified the suspicion of some other growth taking origin conjointly from œsophagus and trachea.

The trouble in swallowing increased so rapidly that, in spite of all palliative measures, starvation threatened, and she became exceedingly anxious for an operation, possessing as she did, a full knowledge of all its risks.

Accordingly, October 25th, 1869, I operated in the presence, and with the assistance of Drs. Gerrish, Hunt, Webster, and Getchell, of this city.  The patient being etherized and placed in the same position as in the first case, I made an incision five inches long over the most prominent part of the tumour, and divided in succession skin, platysma, superficial and deep fasciæ.  The tumour was thus fairly exposed, and was unmistakably an hypertrophied thyroid.  Having divided its delicate fascia propria, I proceeded with the greatest care to separate the fascia and enucleate the tumour.  This was done almost entirely with the fingers and the handle of the scalpel.  The great difficulty of this procedure will be appreciated when I state that the deepest portion of the gland was imbedded in what seemed to be a mass of organized lymph through the medium of which it was firmly attached to the œsophagus.  So firm was the adhesion, that I refrained from completing the separation entirely with the fingers or instruments, lest I might lacerate the tumour and produce sever hemorrhage.  No vessels of large size were found upon the surface of the growth, but two large arteries were felt pulsating powerfully at its base.  Between these I passed a blunt curved needle, armed with a double ligature of eight strands of saddler’s silk, as near as possible to the œsophagus, and yet separate the vessels.  Each portion of the pedicle was then firmly tied, and the tumour removed without the loss of an ounce of blood, and with the ligation of only three small superficial vessels; one end of each ligature being cut short, and the other allowed to emerge from the lower angle of the wound.  This was closed with silver sutures, and a light dry dressing applied.

For four or five days the parts were very sore, the efforts at swallowing were very painful, and there was marked throughout severe symptomatic fever.  After this time she steadily improved; the wound healed by first intention, except in the track of the ligatures, and these were removed on the 20th day, at which time the dysphagia was almost entirely overcome.  More or less of purulent discharge from the opening left by the ligatures continued until the first of December, when the parts entirely healed, and up to the present date Mrs. II. Has been in perfect health, with no return of her old symptoms.

The extraordinary adhesion in this case remains a mystery, but from facts in the domestic history of the patient that have since come to my knowledge, I think it fair to assume the existence at some former time of such inflammation as a severe blow or gripe might induce.

Case III.–In the autumn of 1868, I received a letter from Dr. S. T. Clark, an eminent physician of Lockport, N.Y., describing the case of Miss M. D., of that city, æt. 35m and inclosing photographs, from one of which Fig. 2 is a copy.

From Dr. Clark’s communication, as also from a correspondence with the patient herself at about the same time, I learned the following facts:– 

The swelling first appeared at the age of fifteen.  It attained a considerable size within a few months after it was first noticed, since which time its progress has been very slow.  Almost from the first it had induced more or less of the dyspnœa.  This had latterly increased to an alarming degree, and in connection there had arisen such suffering from dysphagia, headache, and vertigo, with a constant sense of weight and dragging at the tumour, that she was anxious to undergo an operation at any hazard.

I wrote her, portraying as vividly as I was able, the fearful risks of the operation, and stating that I would never, under any circumstances, undertake its performance unless I was morally sure that it gave the only possible chance of obviating an immediately fatal issue, and that I did not feel that she had reached that point; promising her, however, that if she should in the future, in my own judgment and in that of her other medical advisers, reach that condition, I would make the operation if she desired.

In August, 1869, I visited her at Niagara Falls, and examined the tumour carefully.  The external appearance is very well shown in Fig. 2, except the increased size; the photograph having been taken nearly a year previous, and the gland steadily although slowly augmenting in volume.  The tumour extended from the chin, which it supported in an elevated position, to the sternum, upon which it rested and overlapped in front.  Involving both lobes of the gland it pushed outward toward either shoulder, farther on the left than on the right side, and dipped so far down behind either clavicle that I could not touch the bottom.  To the fingers, as to the eye, the surface of the tumour pulsated everywhere.  Large veins were seen coursing superficially in all directions, and numerous venous channels furrowed on the surface were felt by the fingers.  Steady and firm compression notably diminished the size of the mass, although she could not endure it but for a moment on account of the giddiness produced.  Upon the right side, midway of the tumour, where the arterial pulsations were most numerous and powerful, there was felt what was diagnosed as, and what afterwards proved to be, an irregularly shaped calcareous mass.  At this point there was a very distinct ancurismal thrill and bruil.  So marked and peculiar was it that an eminent hospital surgeon of Buffalo had pronounced it an ancurism of the common carotid, and told Dr. Clark that he considered the whole tumour as “principally ancurismal.”  Finding, however, that pressure above the calcareous portion arrested the thrill, I was confirmed in my suspicion that it was due to the very large branches of the superior thyroid coursing over this hard mass.

The sufferings of the poor girl were terrible, and her life a burden.  She was herself anxious for an operation, but had to encounter the most violent opposition from a very large circle of relatives and influential friends, and also a surgeon of deserved reputation, a near relative.  Dr. Clark was the only one from whom she gained any encouragement beside myself, the degree of which I have already indicated.  Under the circumstances we advised her to postpone any operation at present, and if she decided to make the trial at last, to leave the question of time to Dr. Clark’s judgment.

On the 15th of January, 1870, I received a noted from Dr. C., saying that Miss D.’s condition had become such as to render death liable at any moment.  Constant distress from weight and pressure, cephalagia, vertigo, and dyspnœa to such a degree that her strength was failing, and so laboured was the respiration that she required watching during her broken sleep lest suffocation should occur.  His own opinion, with which from his statement mine accorded, was that if ever extirpation was to be attempted now was the time.

I reached Lockport on the morning of the 20th, and found the patient as Dr. C. had described, the tumour having developed in a marked degree since I saw her in the summer previous.  Her morale was excellent.  There were present at the consultation Drs. Clark, Gould, McCollum, Leonard, Palmer, and Foot, of Lockport; Clark, of Niagara Falls; Aberdeen, of Suspension Bridge; Carleton, of Norwich, Conn.; and Gerrish, of this city, all of who agreed that without interference the case must end fatally in a very short time, and was liable to at any moment.  I then said to these gentlemen, and to her personal friends who were present, what I desire here to repeat, so that my brethren in the profession shall clearly understand my position with regard to this operation.

We had to decide whether an attempt at removal gave her a possible chance for life; for my own rule of action is, when a certainty of death stands opposed to a possible chance of safety by operative procedure, to give the patient the chance, no matter how small it is, provided he or she makes the choice with a full understanding of all the facts, and with no prompting by the surgeon.  Admitting the extreme danger of such operation, and that the weight of authority, the world over, was decidedly against it, yet I had demonstrated in 1866, and again in 1869, that extirpation of a bronchocele was practicable (in the first case of large size and extreme vascularity), both patients having made a good recovery.  But it was certain that this case was more formidable than either of the others–involving both lobes, being of immense size, and more vascular than any goitre I had ever seen; and I did not believe that removal by the ordinary mode of enucleation of morbid growths, attempting to control hemorrhage step by step, was possible.  Yet I considered the chances to be a hundred to one that she would die upon the table, or of secondary accident soon after.  She had deliberately elected the operation, with a clear knowledge of all its risks, without any advice whatever from myself or Dr. Clark, and in spite of the most determined opposition from all her friends.

After making these statements I asked each gentleman personally whether in his opinion,  under all these circumstances, I was justified in attempting the excision, and I was relieved to receive an affirmative answer from each one.

Preparations were immediately made, and in the afternoon of the same day I made the operation in the presence of all the gentlemen above named, and with the especial assistance of Drs. Gould and Clark, of Lockport; Carleton, of Norwich, Conn., and Gerrish, of Portland; and I am deeply indebted to each of these gentlemen for the calm, quiet, and prompt manner in which they displayed the qualities of the true surgeon.

The patient, taking her place on the operating table, with head and shoulders elevated and firmly supported, was etherized, when I made an incision in the median line from chin to sternum.  Dividing the successive layers of fascia upon the grooved director, I cam directly down upon the tumour, and began to reflect from it its thin investment.  Immediately, as in the first case, at very many points the thin coats of superficial vessels gave way, and uncontrollable oozing resulted.  Still, the hemorrhage was not immediately alarming until the dissection, which was carried on by the fingers, reached the calcareous portion of the tumour on the right side.  Here adhesions were encountered of considerable firmness, and as they yielded to the most careful efforts I could make, the large branches, which had given the ancurismal thrill, and whose coats were extremely attenuated, burst, and immediately we had the most fearful hemorrhage, such as one who has not seen it can hardly realize.  This took no one by surprise, as I had already forewarned my assistants of its probable occurrence, and in such event of the entire futility of any expedient, except the rapid completion of the enucleation and seizure of the vessels at the base of  either lobe.  This I accomplished in a very few seconds, and was enabled so to seize the pedicle with the fingers as to suppress the bleeding measurable until I could transfix it with the blunt needle, armed with double ligature made of eight strands of saddler’s silk.  This was carried in the median line, from below upward, close upon the trachea, and either ligature tightened sufficiently, by a single know, to control the hemorrhage and give time for examination.  I had hoped to separate either half of the pedicle into as many parts as there were arteries, as I did in my first case.  This I found impossible from the firmness of the tissue, unless I used a cutting instrument, which I did not dare to do.  I, therefore, tied either half as tightly as possible, and carefully severed the tumour from its attachments.  This being done, seven small arterial twigs, not connected with the growth, were tied, when all hemorrhage ceased.  The wound was now kept open, only ether enough being administered to keep her quiet, and time given for glazing of the surface and reaction of the circulation.  Within ten minutes the vessels in every part of the exposed surface were throbbing violently, and in fifteen minutes from the ablation of the tumour the inferior thyroid artery of the left side escaped from the ligature and spirted with great violence.  In my own opinion, as in that of the attending surgeons, this vessel was equal in size to the common carotid in its normal condition.  In a moment this was seized and secured; and, the entire left half of the pedicle was transfixed with a tenaculum, a new ligature of twelve strands was carried underneath both the original one surrounding the pedicle, and the separate one around the inferior thyroid artery, and drawn as tightly as possible.  From this time all bleeding was arrested, and in a few minutes the wound was closed with silver sutures, a light dry compress applied, and the patient placed in bed with a fair pulse of 100 per minute, and presenting no marked signs of collapse.  She took some gruel in the evening with little difficulty, and passed a more comfortable night than she had for years.  The following afternoon at two o’clock I left her entirely comfortable.  For the subsequent history of the case I am indebted to Dr. Clark.  Everything went well until the tenth day, when secondary hemorrhage occurred, which was controlled by digital compression, which was continued for seventy-two hours.  Whether it was necessary or not for so long a time is impossible to say, but it is an illustration of the caution and prudence which characterized Dr. C.’s excellent management throughout.  During this time, and for some days subsequently, all nourishment was administered by enemata, only small lumps of ice being given by the mouth.  With this exception the convalescence was uninterrupted.  The last ligature separated on the twenty-first day, and within four weeks from the operation she was off the bed.  She has since remained in excellent health.  One week before the operation she her voice entirely.  Since the removal of the tumour she has fully recovered it.

I regret exceedingly to have failed in securing a photograph of Miss D. since her recovery.  In answer to a letter requesting one, Dr. Clark writes, under date of October 20th, 1870: “Miss D. has had several sittings since her recovery, but has failed to secure a picture to suit her, perhaps too fastidious, taste.  I doubt if the scar would show as all in a photograph, and is growing beautifully less.  She is in excellent health.”

Fig. 3 represents the appearance of the gland after section.  Unfortunately for the purpose of illustration, as also for an accurate estimate of its weight, the tumour was cut open and soaked in water for several days before its photograph or weight were taken.  By this means not only were numerous large blood vessels emptied of their contents but large masses of soft atheromatous matter scattered throughout the fibrous stroma were dissolved.  The weight upon removal, as nearly as could be estimated, was five pounds.

In closing the report of this case I must again bear witness to the most excellent assistance I received during the operation, and to the unremitting and skilful care which Dr. Clark and his confrères bestowed upon the case afterwards.  With such assistance a surgeon can certainly do his best; and with such after-treatment a patient has all the advantages that professional skill offers.

I prefer to submit these cases to the profession with very little comment.  They are the only ones in which I have ever attempted the excision of the bronchocele, and if they are the last I shall not regret it.  For while their issue has been so fortunate, I am sure that no man could witness even, much less perform, these operations, and envy the man upon whose lot it fell to undertake them.  Yet under similar circumstances I should not shrink from such responsibility, and this for the reason that the possibility of successful extirpation, even of the worst cases, is established; and I believe the operation, performed in the manner I have indicated, may claim quite as secure a place among legitimate dernier resorts as amputation at the hip-joint.

The several steps of the operation, as I perform it , are briefly these–
1st.  Exposure of the tumour by linear incision of ample length, avoiding most sedulously any wounding of the tumour or its fascia propria.
2nd.   Division of the fascia propria upon the director.
3rd.   Its reflection and the enucleation of the tumour with the fingers and handle of the scalpel, paying no attention to hemorrhage, however profuse, but going as rapidly as possible to the base of the gland and compressing the thyroid arteries.
4th.  Transfixion of the pedicle from below upward with a blunt curved needle armed with a double ligature, and tying each half, or, when practicable, dividing the pedicle into as many portions as there are main arterial trunks and tying each portion separately.
5th.  Excision of the gland and subsequent dressing of the wound as in ordinary cases.

In conclusion, I cannot refrain from one word of warning to my younger brethren whose ambition may make their fingers tingle, lest they should in the light of these successful cases be too easily tempted to interfere with these growths.  It is and always will be exceedingly rare that any such interference is warrantable; never, for relief of deformity or discomfort merely; only, to save life.  And if it is beyond all question, determined in any given case, that such an operation gives the only chance for snatching a fellow-being from an untimely grave, be it remembered that accurate anatomical knowledge, and a perfect self-control under the most trying ordeals through which a surgeon can pass, are indispensable to its best performance.

Portland, November 2, 1870.