EXCISION OF THE CERVICAL SYMPATHETIC GANGLIA FOR EXOPHTHALMIC GOITRE.
Exophthalmic goitre is a disease whose etiology, pathology, and treatment are still in an unsettled condition. It has been a mooted point among some whether any drug possesses a decidedly beneficial influence in this affection. Others, who favor therapeutic agents, are by no means of one opinion as to what drug is efficient, though it is generally agreed now that any preparation of the thyroid gland is con traindicated. As to the pathology, we are probably justified in assuming that in this disease there is nearly always an ex cess of thyroid-gland secretion. But whether this excess stands in a causal relation to the exophthalmos and the cardiac symptoms, or whether it is merely coincident, is still sub judice. The preponderance of evidence, however, together with more recent experimental work on this subect, seems to favor the latter view. According to this theory, the whole complex group of symptoms relating to the eye, heart, and thyroid gland is the result of a derangement of the central sympathetic centres.
Dr. Alfred Gordon (Philadelphia Medical Journal, Vol. v, pp. 1384-1425) has ably sustained this view as against the hyperthyroidization theory. He quotes the fact that a number of competent observers have seen cases of exophthalmic goitre without struma ; that experimental irritation of the central sympathetic centres produces all symptoms of this disease ; that Tillaux (Rev. Intern. de Med. de Chir., 1895, p. 305) observed exophthalmic goitre in a patient upon whom he had done a thyroidectomy four years previously. Gordon also calls attention to cases cured by ovariotomy and other opera tions that could not have diminished the thyroid secretion, but must have acted through the nervous system. He cites the fact that experimental hyperthyroidization produces none of the symptoms of exophthalmic goitre, except the rapid heart.
It is, then, upon this theory of derangement of the sym pathetic centre that excision of the cervical ganglia is based. The idea is to interrupt permanently morbid impulses from the sympathetic centres in the medulla. The history of this operation has been given by Dr. James Moores Ball, of St. Louis, in two articles (New York Medical Journal, Vol. Lxx. p. 17, and the Journal of the American Medical Association, Vol. xxxiv, p. 1384). Though it has been performed by a number of continental surgeons, Professor Jonnesco, of Bucharest, has had by far the largest experience in this work. and has been its most enthusiastic advocate. In a series of ten cases operated upon by him for exophthalmic goitre, six were absolutely cured, and four greatly improved. Other operators. as Jaboulay, Schwartz, Gerard-Marchant, have obtained al most as good results. This seems so far in advance of any thing obtained by other known methods of treatment that the operation deserves our most serious consideration. Of course, it is too soon, and the number of cases are too few, to pronounce final judgment ; yet this much seems certain, that beneficial results are obtained by this procedure when by other means they were unattainable.
The following so far as I have been able to ascertain, constitutes the first operation for excision of the sympathetic cervical ganglia for exophthalmic goitre done in America.
marked ; thyroid gland considerably enlarged, and pulse varied from 120 to 140. She complained of a disagreeable throbbing in the neck and of cardiac palpitation. Up to this time she had been treated with various drugs, chief reliance being placed in arsenic, but she continued to get worse. On August 6 she was admitted to the hospital, and the following day I operated with the assistance of Dr. Schuster and Dr. H. T. Safford, the latter giving the anaesthetic. Dr. H. H. Stark, Dr. Howard Thompson, and Dr. M. 0. Wright were also present. Chloroform was used. An incision of about four inches was made on the right side of the neck downward from the tip of the mastoid process, the lower part of it being behind the sternomastoid muscle. The fascia just in front of the anterior tubercles of the transverse processes of the second, third, and fourth cervical vertebra was reached. Con siderable difficulty was experienced in identifying the ganglia, the middle one having numerous communications, and the superior being abnormally high. I had previously rehearsed the operation three times on cadavers, and each time was impressed with the irregularity in appearance and connections of all the cervical ganglia, particularly the middle. The middle and the superior ganglia were finally identified and removed. On account of the patient's condition, and particularly because of the rapidity of her pulse, no attempt was made to extirpate the ganglia on the left side, though this had been my intention. We closed the wound with subcuticular catgut sutures. Considering the unusual heart action, chloroform was most skilfully administered. During most of the time the pulse, though too rapid to be counted accurately, varied between 170 and 200, except on two occasions during the later stages of the operation, when for about a minute it suddenly dropped to 72, but immediately recovered its former rate. This was probably due to irritation of the pneumogastric by uncon scious traction upon it. Four hours after the operation, the pulse was 160 and temperature 104° F., and six hours later the pulse had dropped to 140. Vomiting now set in and continued at inter vals for twenty-four hours. The following morning the patient was more comfortable, with pulse xio and temperature too°. She improved rapidly from this time, the wound healing by first inten tion. August 12 she left the hospital with pulse of 92. She voluntarily expressed great relief from the throbbing which had previously been so annoying. On December 27, 1900, her pulse was 9o. She complained of occasional pain on the right side of the head and face. She has gained in weight, and has had no return of the throbbing or palpitation since the operation. The exophthalmos has markedly diminished, though there is but little decrease in size of the thyroid gland. She feels well and is in good health. A keloid growth has developed in the scar.
The case may be recorded as one greatly improved. I f she does not continue to progress favorably, I shall advise ex tirpation of the left cervical sympathetic ganglia.