The Medical Record, 186_, pp. 441-443.

SUCCESSFUL REMOVAL OF A LARGE BRONCHOCELE
By WILLIAM WARREN GREENE, M.D.

PROFESSOR OF SURGERY IN BERKSHIRE MEDICAL COLLEGE AND IN THE MEDICAL SCHOOL OF MAINE.

It is well understood by the members of the profession that extirpation of an enlarged thyroid gland is one of the most fearful operations ever undertaken by the surgeon.  While there is always great danger from shock, secondary hæmorrhage, inflammation of the cervical vessels and of the  œ sophagus and respiratory organs, the danger which overshadows all others, hanging like a thunderbolt over patient and operator, is terrible and uncontrollable hæmorrhage; and while each of the other causes has in its turn produced fatal results, the great majority of deaths have occurred from that last named.  In fact, so extremely vascular are these growths, both from the great enlargement of the original vessels, and also, in some cases, from an almost infinite multiplication of their branches and anastomoses, that even in small tumors, no larger than a hen’s egg, such surgeons as the Coopers, the Bells, Ferguson, Velpeau, and others, have been obliged to abandon the operation; and in more than one instance the patient has died upon the table before the growth could be removed or the bleeding arrested.  I have quite carefully examined the literature of this subject, and so far as I can learn, all bronchoceles that were ever successfully removed (and there are very few) were small.  I am very confident that none were as large as that which I shall describe.

It is in view of the above facts that all surgical teachers of the present day look with great distrust upon any radical procedure for the removal of goitre, and the majority discountenance the operation altogether.  I believe that most excellent surgeon, Professor Gross, expresses the views of the profession in general, when after speaking of the use of iodine and the seton, he says: “When the tumor resists our curative efforts and endangers suffocation, it has been proposed to afford relief by extirpation.  But the question arises, is such a procedure proper or justifiable?  In a word, can the thyroid gland, when in a state of enlargement, by removed with a reasonable hope of saving the patient?  Experience emphatically answers---no!  This conclusion is not invalidated by the fact that the operation has, in a few instances, been successfully performed.  By no means.  It only proves that an undertaking may occasionally be accomplished under circumstances apparently the most desperate.  But no sensible man will, on slight considerations, attempt to extirpate a goitrous thyroid gland.  Should a surgeon be so adventurous or foolhardy as to undertake the enterprise, I shall not envy him his feelings while engaged in the performance of it, or after he has completed it, should he be so fortunate as to do this.  Every step he takes will be environed with difficulty.  Every stroke of his knife will be followed by a torrent of blood, and lucky will it be for him if his victim live long enough to enable him to finish his horrid butchery.  Should the patient survive the immediate effects of the operation, if this it may be called” (the italics are mine), “death will be almost certain to overtake him from secondary hæmorrhage, or from inflammation of the cervical vessels, œsophagus, and respiratory organs.  When the tumor is large, the wound is of frightful extent, involving all the most important and delicate structures of the neck, and rendering it altogether improbable, from the constant motion of the windpipe and œsophagus, that much of it will unite by first intention.  Thus, whether we view this operation in relation to the difficulties attending its execution, or with reference to the severity of the subsequent inflammation, it is equally deserving of rebuke and condemnation.  No honest and sensible surgeon, it seems to me, would ever engage in it.”  This language is certainly unequivocal.  No man, I presume, holds a higher estimate of the author of the work from which the above extract is taken, or would be more slow to differ from him, than myself; but, while the danger attendant upon and following the operation can hardly be exaggerated, and no “honest and sensible” man would approach such a case without feelings that no man need “envy” him, still I cannot endorse the statement that “no honest and sensible surgeon * * * would ever engage in it.”

With the surgeon, as with the physician, his first duty is always to his patient; his own feelings, tastes, and anxieties for reputation are all secondary.  He professes to carry to his patient all the means of relief known to the profession; and I have always held, as I now do, that in those extreme cases where speedy death is inevitable on the one hand, and on the other operative procedure offers a chance of life, and the patient, understanding all the facts, elects the operation, it is the duty of the surgeon to give him that chance.  No matter how small it may be, so long as we know that we are exchanging a certainty of death for the possibility of life, the rule is the same.  Unless a surgeon takes this position, it seems to me that he is constantly tempted to shirk responsibilities, either from timidity, fear of the public tongue, or a consciousness of inability to do what can be done.  I cannot express my own feelings when I hear a man who professes to be a surgeon excusing himself for not giving his patient the only chance, because he was afraid if he “operated and the man died, it would make a great deal of talk, and he had better die on his own hook.”  Any man who has not the moral courage to rise above all personal considerations at the bedside of him who throws all his earthly interests into his hands, and to do for him all that can be done, or, should he feel himself incompetent, to say so honestly and at once secure efficient aid, has no business in our profession, or any other position of trust and responsibility.  Suppose we could name fifty or a hundred cases like the one here reported, or as nearly like it as cases ever are, and that out of as many operations only one saved, nothing is lost; for to those who died, immediate destruction was inevitable without interference; but in the fiftieth or hundredth case you have saved a devoted wife and mother to her family, and a noble woman to the world.

I have been repeatedly asked by patients, as has every surgeon of much experience, to excise bronchoceles, when small, from an apprehension of increased growth, and when large, to relieve deformity or discomfort from weight and pressure, but have never before seen a case in which I should have felt a shadow of justification in using the knife; still I knew such cases did occur, and have often, with myself, discussed the surgical possibilities under such circumstances.  Upon a careful examination of the books, I inferred that in most instances the knife had been used freely around the tumor, and that in several instances the attempt had been made to remove a part only of the morbid growth; and one surgical writer of distinction alludes to a case of this as being remarkable, on account of the uncontrollable hæmorrhage   (the patient dying on the table), when a removal of only a small portion of the mass was attempted.  Now, each lobe of the thyroid gland is supplied by two arteries usually, sometimes three; no matter how large the goitre, these arteries, however much enlarged, are found entering the base of the tumor into which they pass, and their branches ramify through its substance, comparatively few arterial vessels being found on the surface, which is covered with a network of veins, oftentimes of large size, having extremely thin, delicate walls, and which inosculate freely with those in the substance of the gland.  It had occurred to me that in the event of wounding these superficial veins, it might be useless to undertake to ligate them, they are so tender, and operations might have failed which would have otherwise succeeded, from the attempt to control the hæmorrhage completely during the dissection, in which the knife was perhaps too freely used; and that it was worse than folly to remove a part of a lobe, as almost invariable we should thus open scores of vessels whose bleeding would be uncontrollable.  I believed that if they could be removed at all, it must be accomplished by keeping clear of the tumor as far as possible, and rapidly pushing down to the pedicle, which consists mainly of vessels and areolar tissue.

On the 19th of August last Mrs. Klopf, aged forty-five, a highly respectable and intelligent German lady, residing in Albany, N.Y., consulted me 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 wich 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-dressing 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.

Pittsfield, Mass., Nov. 10, 1866.