Seventy-two eases treated surgically. In 33 cases extirpation was performed and in 39 cases enucleation. Where pos sible, enucleation preferred, being sim pler and safer. Encapsulated tumors alone are suitable for enucleation; all others must be treated by extirpation. In 54 cases the operation was performed mainly or solely to relieve dyspncea. De formity should never be the sole reason for operation, but dyspncea almost al ways demands it. Of the 72 cases, 3 died: 1 from chloroform and the other 2 because the goitres were large, render ing operations formidable ones. All the 39 enucleation cases recovered. J. Berry (Brit. Med. Jour., July 7, 1900).
In cases of diffuse enlargement of the whole gland such enucleation is, of course, out of the question, and while complete extirpation of the whole organ is now never dreamed of on account of the imminent danger of development of myxcedema, observers have with a greater or lesser success performed a partial ex tirpation either of a whole lobe or a por tion of a lobe. Kocher especially has em ployed this method, and his results, both by enucleation and by extirpation, have been remarkable.
Tetany following thyroid extirpation is very dangerous. Of more than 30 cases following thyroidectomy recorded there were 7 cures, 13 deaths, and 3 cases in which the disease became chronic. In 53 total extirpations in Billroth's clinic the affection appeared twelve times, of which S were fatal, 2 chronic, and 2 re coveries. Total extirpation to be avoided. In 115 partial extirpations in Billroth's clinic no ease of tetany appeared. V. Eiselsberg (Schmidt's Jahrbiicher, Apr., '90).
Results obtained in one thousand cases of goitre. Excluding the opera tions undertaken for malignant tumors and exophthalmic goitre only 3 patients had been lost out of 900 cases operated on during the last twelve years. One case of surgical myxcedema had resulted, and that was due to the fact that the half-gland that was left behind had be come atrophic,—a point not noted until the removal was accomplished; the symp toms soon disappeared with the use of a sheep's thyroid. In the last 200 cases. not a single patient was lost. Kocher. (La Semaine Med., Apr. 24, '95).
Interstitial injections condemned and surgical intervention advocated. In cases operated upon the mortality was 1.36 per cent. Respiratory difficulties, impeded deglutition, and cardiac troubles regarded as indications for intervention. In 104 cases ablation by Kocher's method was practiced, and in 73 enucleation by Socin's procedure. Roux (Annales des Mal. de l'Oreille, du Larynx, du Nez, et du Pharynx, Sept., '95).
Three hundred operations for goitre performed in the Tubingen clinic. The
proportion of females to males is 2.5 to 1, and in the male sex goitre is apt to begin between the fourteenth and seventeenth years and in the female between the twelfth and sixteenth years. The ma jority of goitres occur in people who are obliged to perform hard, manual labor. The list contains only two cases of complete extirpation. The operation of choice has been intraglandular enuclea tion; but there are a number of ex amples given of extracapsular extirpa tion. These two methods may often be combined with advantage. Non-malig nant goitre which is increasing in size ought to be operated upon, but one should never operate simply to re lieve disfigurement. Bergeat (Annals of Surg., Mar., '97).
Report of a series of 12 successful cases operated on by the method of Kocher. The original method is fol lowed, differing only in the matter of drainage and suture. The operation is done under cocaine, and the important points are the absolute asepticism, care ful litigation, avoiding the wounding of the gland, and the preservation of the recurrent laryngeal nerve. Of the 12 cases, 11 were simple and 1 exophthal mic goitre. Drainage was only used in 4 cases and then abandoned. Subcuticu lar silver wire suture is preferred, and should be removed on the fifth day, to gether with the first dressing, which consists of silver foil and gauze. The second dressing is of gauze and col lodion. One case of Graves's disease was operated on and 3 others which pre sented symptoms all improved and symptoms disappeared. I. Olmstead (Phila. Med. Jour., March 21, 1903).
Operative treatment is indicated, ac cording to J. Collins Warren (Boston Med. and Slug. Jour., Dec. 27, 1900), when a rapidly growing tumor has re sisted medical treatment and when press ure-symptoms arise. A U-shaped in cision is made, sterno-mastoid muscle is drawn aside, and, if necessary, the sterna hyoid, sterno-thyroid, and omo-hyoid muscles are cut. Injuring the capsule of the tumor with the knife must be avoided on account of hiumorrhage. The tissues at the upper and outer margin of lobe are then clamped and divided, se curing the superior thyroid artery if pos sible. Clamping of the recurrent laryn geal nerve must be avoided. The growth is dissected away by cutting the attach ments from the anterior wall of the trachea. A piece of gland the size of an English walnut must be kept, however. to prevent operative myxcedema. Silk is used to tie the vessels." Morphine is ad ministered before or directly after oper ation to prevent vomiting. A loose, but stiff, dressing should be applied to give support. Eighty cases operated in this manner by Reinbach gave a mortality of only 3.75 per cent.