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Supplement

gland, thyroid, trachea, goitre, children, extirpation, isthmus and tube

SUPPLEMENT Goitre In certain localities where goitre is prevalent its excessive growth and especially the difficult respiration it causes may demand operative interference. As long as we have only to deal with a diffuse hyper trophy of the thyroid, the usual medicinal treatment with iodine oint ment, potassium iodide internally, an ice cravat, and internal adminis tration of thyroid gland, will have the desired result, especially in those cases of diffuse swelling of the thyroid gland at puberty.

In cases of partial hypertrophy, of the formation of nodules and cysts, which do not react so well to medicinal treatment, things will be different. In children the proper indication for operative interference is given by the dyspnma. Disturbances of circulation, palpitation and arrhythmia are rarely observed in children.

Dyspncea may be caused by displacement, compression, or sur rounding of the trachea. Lateral or frontal flattening will arise espe cially in those cases in which part of the goitre reaches down behind the sternum, where it will find a resistance to further growth, and then narrow the lumen of the trachea, and even cause the trachea to atrophy from pressure.

This type, and the one in which the isthmus is drawn tightly over the trachea and in which at times an upper lobe which grows from the isthmus is grown onto the larynx or around this, are the ones which most frequently cause dysprvea.

The diagnosis is easy, as movement of the tumor simultaneously with respiration characterizes it as a struma.

The displacement of the trachea may be shown by palpation or by skiagraphy after the introduction of a jointed intubation tube. Short exposures will clearly show the tube of the trachea against the surrounding soft parts.

When we cannot in fluence the dyspinua by con tinued medicinal treatment, we will have to operate, as otherwise the life and the health of the child will be permanently threatened (thyroid asthma,thyroid death, heart affections).

The is no 11101'12 difficult in chil dren than in adults, as long as lye do not use narcosis. In older children we can operate quite easily under local finstheAia with of 1 per cent. novoeain solution (injecting around the gland according to Hackenbruch).

Partial extirpation is done after Kocher's direc tions as follows: Transverse incision, intermuscular ex posure of the gland, dislo cation of the struma, liga tion of the blood-vessels. We then make, after com pression and separation of the isthmus, a frontal cut through t he glandular tissue in such a manner that the posterior wall of the goitre together with the site of en trance of the ligated arteries remains. The remaining capsule of the goitre is united with fine sutures.

Thus we avoid extirpation of the epithelial bodies. By ligating the afferent blood-vessels we avoid hemorrhage.

Damaging the epithelial bodies by the ligature is less to be feared, because their embryonal origin is independent and without any eon nection with the thyroid, and they have t heir own blood-supply. Before closing the skin incision we make a small incision immediately above the jugulum, through which we introduce a glass drainage tube into the wound. We thus aid the flow of the secretion, which is more con siderable owing to the wide wound in the gland, without interfering with the healing of the large skin wound.

After the operation we fix the head and neck in starch bandage with wooden splints, to avoid the danger of late hemorrhage from the motions of lively children. The chil dren are put to bed in a half-sitting posture; after forty-eight hours the drainage tube is removed and the child allowed out of bed.

By avoiding narcosis we will almost always succeed in preventing pneumonia, which is always threat ened, even in children, owing to the difficulty in expectorating and the suppression of this from pain.

A separate position is held by the congenital goitre.

This consists frequently of fetal adenomata (Fischer). In other eases we find a uniform hypertrophy of the gland which is often combined with hypertrophy of the thymus.

By bandaging the head back with an adhesive plaster strip from the forehead over the nape to the back (Langer), we are often able to lessen a severe dyspnma.

Operation offers some hope. Dur ing the winter of 1907 we operated an infant- six weeks old with a large struma and severe dyspncea (Fig. 109). The operation was done without narcosis and the child stood it well. We did a one-sided extirpation of half of the thyroid together with the adenomatous tumor. In another case we only divided the protruding isthmus, which was easily done with an angiotribe and double ligation. Bleeding was inconsiderable and the dyspncea was cured permanently.

Hyperplas.ia of the (hymns may also cause symptoms of stenosis. We may be able to diagnose this with percussion or with skiagraphy. Reba and Konig opened the mediastinum from the jugulum, and at tempted to give relief by operative dislocation or extirpation of the gland, and they succeeded in two cases.