57' Postgrad Med J: first published as 10.1136/pgmj.24.277.571 on 1 November 1948. Downloaded from

THYROTOXICOSIS BV SIR CARRICI ROBERTSON, F.R.C.S., F.R.A.C.S., Hon. F.A.C.S. Auckland, New Zealand

A goitre is an enlargement of the thyroid gland. lating hormone (T.S.H.) goes forth from the It may be either a diffuse smooth enlargement or pituitary which causes increased activity in the a lumpy one. The lumps are due to the presence thyroid and a rise in the production of the thy- of nodules, varying in size from a pea to a cricket roxin. The opposite effect takes place if there is ball; this type used to be called adenomatous not sufficient thyroxin in the blood stream. goitre, but the pathologists say these nodules are A few years ago, it was discovered that the pro- formed by alternating phases of hyperplasia and duction of thyroxin by the thyroid gland could be involution (Reinhoff & Lewis) and are not true suspended by administering thiourea, thiouracil adenomata, so it is better to reserve the name or other thio compounds by the mouth. These 'adenoma' for the single adenoma which may drugs act by their toxic effect on the thyroid gland occur in the thyroid as in any other glandular itself: they render it incapable of synthesizing organ. Both the diffuse and the nodular enlarge- the blood iodine into thyroxin. Continued admin- ments can be present without doing apparent harm istration of the drug eventually leads to a state of to the patient: but as time goes on, something myxoedema. secretion of the thyroid hormone It should be remembered that thiouracil has no happens to the Protected by copyright. and an insidious change takes place in the health of action on the anterior pituitary gland, so that with the patient, which we call thyrotoxicosis. These the decreased production of thyroxin, there is a goitre enlargements are prone to occur in parts of reflex increase in the quantity of T.S.H., the stimu- a country where there is an absence of iodine in the lator of cellular activity in the thyroid. A micro- soil. Without iodine, the synthesis of thyroid scopic section of a gland under treatment with hormone or thyroxin, cannot be completed. thiouracil shows a hyperplasia similar to that seen The function of this little gland is to trap the in Graves' disease, but all to no avail, the thiouracil inorganic iodine in the blood as it passes, through inhibits the formation of thyroid hormone in and use it in the manufacture of thyroxin. In spite of the activity in the acini of the gland. spite of its small size, it contains over 20 per cent. It is useful to have a working classification of of all the iodine in the body. It is supplied by four pathological enlargements of the thyroid. One in comparatively large arteries so that all the blood general use is in the body must pass through it many times a day. (i) Nodular or lumpy enlargements: Thyroid hormone stimulates the metabolism of (a) Simple the body and it becomes of great importance at (b) Toxic http://pmj.bmj.com/ puberty, so that children living on an iodine (2) Diffuse or smooth enlargements: deficient soil are very prone to have diffuse enlarge- (a) Simple, such as colloid goitre in the ments of the thyroid gland. It is almost as if the young. enlargement of the thyroid at puberty may rep- (b) Toxic or Graves' disease. resent an addition in the size of the factory, in (3) Inflammatory-thyroiditis, abscess, gumma, order to augment its efficiency in abstracting and Riedel's woody thyroid. and more of the iodine present in New growth-benign or malignant, cysts, utilizing more (4) on September 28, 2021 by guest. the blood. It is in childhood that nearly all nodular hydatids, dermoids. goitres commence their career: for if the diffuse (5) Hashimoto's disease-a rare condition in enlargement persists till about 20 years of age, which the tissue is infiltrated with lympho- small nodules begin to form in the substance of cytes. For full information see article by the gland. Once this has happened, it is unusual Joll. In this paper we are only concerned for them ever to disappear. On the other hand, with thyrotoxicosis as occurring in the toxic administration of quite small doses of iodine or nodular and toxic diffuse groups. thyroid extract before nodulation occurs, is usually a preventive of further goitre trouble. Nodular Goitres The quantity of thyroid hormone in the blood A patient with a nodular goitre need not neces- stream is controlled by the anterior pituitary sarily have a visible tumour in the neck-the nodules gland: should there be too little, a thyroid stimu- may be small and deeply situated, The size of a Postgrad Med J: first published as 10.1136/pgmj.24.277.571 on 1 November 1948. Downloaded from 57:2 POST GRADUATE MEDICAL JOURNAT, Novenmber T948 puberty goitre often decreases, even without treat- (3) All kinds of psychotic symptoms- ment: possibly the extra fat and development of emotional, depressive, irritability and the neck muscles, as the patient grows older, phobias of various kinds. covers any swelling that may remain, so that even It is obvious that there are many causes of such if there was a recognizable swelling as a child, it is symptoms, for example, the anaemias, early forgotten. Later in life, pregnancy, general infec- phthisis, anxiety neurosis. The first can be ruled tion or some serious emotional disturbance, such out by obtaining a blood count, the second by an as domestic unhappiness occurs, and the simple X-ray of the chest. A former H.S. of mine who is gland becomes a toxic one. The nodules increase now an authority on chest diseases, told me that in size and the goitre again becomes obvious. when he first went into the wards of the Brompton During acute systemic infections, or even during Hospital for Diseases of the Chest, he thought all chronic infection elsewhere in the body, the thy- the patients looked like early Graves' disease. roid gland, especially the already diseased one, There are some further points in the signs and (whether diffuse or nodular) may become inflamed. symptoms of thyrotoxicosis which should be men- As a result, a severe thyrotoxicosis can develop. tioned before discussing differential diagnosis, There may still be people who advocate removal of especially the difficult problem of distinguishing septic tonsils for thyrotoxicosis-it used to be a between mild thyrotoxicosis and anxiety states. very general treatment-but it fell into disrepute A palpable thyroid gland : It is quite unusual to because the thyrotoxic symptoms once started, are find a normal sized thyroid in a thyrotoxic patient, not appeased by taking out the septic focus. How- even in primary Graves' disease, which attacks an ever, as a prophylactic measure, it is sound pro- apparently normal gland; the sequent hyper- cedure. plasia makes the gland larger. A normal thyroid, except for the isthmus, cannot be felt except in a Diffuse Goitres very thin neck, so if the gland is palpable, it is The other common form of toxic goitre is probably enlarged. A useful test is to ask the Protected by copyright. primary Graves' disease. This may appear at patient to stretch his or her neck and swallow: almost any age and, in what up till then, has been this will sometimes induce a hidden swelling in a perfectly healthy gland. The same causes that the lower poles to come out from behind the ster- turn the simple nodular into a toxic nodular goitre num, because all thyroid swellings move up and are probably present. The symptoms are so down during deglutition. This sign is also useful simnilar that no useful purpose is served by dif- in distinguishing a large nodule in the upper pole ferentiating them. from a swollen lymphatic gland or other tumour A microscopic section of a toxic diffuse goitre of the neck. shows great increase in the size and activity of the In doubtful cases, it is helpful if the patient cells lining the vesicles throughout the gland. admits to a goitre during adolescence, because this Exactly the same hyperplasia is seen in toxic greatly increases the chances of there still being nodular goitre except that it does not occur some enlargement remaining. throughout, but only in patches. Tachycardia which does not settle after a short rest. The heart sounds will be found to be loud http://pmj.bmj.com/ Diagnosis of Thyrotoxicosis and slapping. When asked if they have any dis- When the signs are well developed, there can be comfort it' bed at night, they will frequently com- no difficulty. The combination of staring eyes, plain of a ' bumping of the heart.' nervous restless movements, tachycardia or short- A fine tremor on holding out the hands, difficult ness ofbreath with a visible almost pulsating goitre, to describe and of unknown cause, but very can hardly be mistaken. In such a case, a B.M.R. characteristic. Eye signs: This will vary from a staring appear- is not necessary for the diagnosis, but may be on September 28, 2021 by guest. useful if taken from time to-time\in checking the ance to marked exophthalmos, usually in both progress of whatever treatment is adopted. eyes, but may be more marked on one side than However, in the early stages, or milder cases, the other. diagnosis may be anything but easy; for in such Lid Lag (von Graefe): This is a very distinctive a case, the following symptoms will be found:- and helpful sign. On following an object down- wards, the lid moves more slowly than the eye- (i) The predominant symptom of all cases is ball and a momentary glimpse of the white sclerotic 'tiredness ' and this in spite of the fact that between the cornea and lid is obtained. This is they feel full of energy and can often do a due to a spasm of the eyelid and not to exophthal- full day's work. mos (Joll). (2) Shortness of breath on exertion and tachy- Other symptoms: Flushes, especially of the neck cardia. and upper chest, free perspiration, clammy hands. Postgrad Med J: first published as 10.1136/pgmj.24.277.571 on 1 November 1948. Downloaded from Novaember 1948 ROBERTSON: Thyrotoxicosis 57.1 Insensitivity to cold, loss of weight and yet good It is well to remember that the patient before appetite. Weakness of the quadriceps femoris, coming to the consultant, may have recently been shown by difficulty in walking upstairs. prescribed iodine; without the knowledge of this, The basal metabolic rate will be raised. it may be difficult to find enough evidence on which to base the diagnosis. It is best to cultivate Differential Diagnosis the habit of always asking a goitre patient for her Anxiety state in a young woman with a slightly iodine history. Some patients with a fairly high enlarged thyroid is a difficult problem, not always degree of thyrotoxicosis have been found taking helped by a B.M.R. test, because the anxious Lugols m. x, t.d.s. for a year and in one case, for patient finds it hard to breathe quietly during the nearly three years. These patients make light of test. Their fear makes them nervous, tremulous their continuous tachycardia and exhaustion after and inclined to sweat, but these symptoms are not slight exercise, for their faith in the treatment is associated with increase in appetite, loss of weight such that they have developed a psychological or increased tolerance for cold: they may even mask, difficult for the examining doctor to pene- have cold blue hands. While talking to you, they trate. It must be remembered that iodine does not take deep sighing respirations. Tachycardia differs cure thyrotoxicosis. Mellanby says, ' It is un- in that it does not persist when the patient is lying doubted that during the administration of iodine, comfortably in- bed-they never complain of heart the patient feels better and the basal metabolic ' thumping' when resting. The pulse pressure in rate is lowered and remains lower while the iodine thyrotoxicosis is commonly found to be raised but is continued, although not so low as in the early not in anxiety states. I believe this test to be more days of treatment.' valuable than a B.M.R. in this type of case. There is never any need for hurry in advising a (i) Microcytic anaemia with Plummer Vinson patient with a doubtful thyrotoxicosis to have an

syndrome: The major complaint will be operation-no harm comes to them by waiting Protected by copyright. difficulty in swallowing, but if the patient for a clear indication, whereas, removal of thyroid has a goitre, she may regard it as the cause. tissue in a patient whose symptoms are due, say, The anaemia will have made her tired and to anxiety neurosis, only adds hypothyroidism to rather short of breath, so that there is more her troubles. than a semblance of toxic thyroid. However, Treatment of thyrotoxicosis is either by one of so seldom does real difficulty in swallowing the thio compounds or by partial thyroidectomy. occur from enlarged thyroid alone, that They both reduce the production of thyroxin or other causes of dysphagia should be sought. thyroid hormone. In surgery, this is effected by In my practice, I have often seen this assoc- reducing the size of the factory, while thiouracil iation of goitre and Plummer Vinson syn- inhibits the synthesis of thyroxin by the thyroid drome, so there may be some connection gland and in spite of increased activity ofthe acinar between the two. cells caused by pituitary stimulation-in other (2) Hypothyroidism: Although a patient may words, the factory is enlarged, but the output ialls. have some thyroid enlargement, feel tired Thiouracil treatment: This has to be carried and become easily out of breath, these symp- out for long periods. The advantage is th4t, http://pmj.bmj.com/ toms can be due to a hypothyroid state. except in severe cases, this treatment may be rrheir general appearance, loss of eyebrows, carried out while the patient continues with her puffy hands and lack of nervous energy, normal work, but it has to be carried out under with forgetfulness and headache, should supervision for long periods. The dose of the drug lead to the correct appraisement. should not be more than o.2 gms. t.d.s. During (3) Remissions: The fact that there are remis- the whole time thiouracil is being taken the patient

sions in Graves' disease is troublesome, for must be under supervision, for it is a toxic drug on September 28, 2021 by guest. the patient may arrive for consultation in and about 20 per cent. of cases get toxic rash, one of her good weeks, and yet only the enlarged glands, pyrexia, or a feeling of depression, week previously she may have been showing but the most important toxic effect is on the white obvious signs of a severe thyrotoxicosis. A corpuscles in the blood, so that an estimation of therapeutic iodine test is often valuable, for the leucocytes should be made at least weekly. At if ten drops of Lugols solution given t.d.s. the end of the first week of treatment, there is for a week gives marked relief, the cause is usually a fall in the number of leucocytes. If it is surely one of thyrotoxicosis. Thiouracil has not less than 4,ooo and the polymorphs are still in also been used.as a therapeutic test, but its excess of the lymphocytes, there is no need to stop drawbacks are that it has to be given for the treatment until the next count is taken, when some weeks before there is clinical improve- very often the number of leucocytes has -risen to ment. the normal number. Postgrad Med J: first published as 10.1136/pgmj.24.277.571 on 1 November 1948. Downloaded from 574 POST GRADUATE MEDICAIL JOURNAI, November T (49 I have seen a case which had been treated for In the operation of thyroidectomy as we do it, just about a month without any blood counts. a very small piece of the posterior part of the She became very ill and was sent into hospital gland is left lying closely along each side of the where we found she had not a single white cell in postero-lateral aspect of the trachea. the blood counting chamber, She very quickly Fourthly, it has been strongly advocated, espec- died, in spite of anything we could do for her. ially by the Lahey Clinic, as pre-operative treat- In a suitable case, there is usually a very great ment in cases of severe thyrotoxicosis. One of improvement at the end of a few months, and at the thio compounds is given, until the B.M.R. has the end of six or seven months, the patient thinks come down to o. After that, at least two weeks she is completely cured, but if the drug is then treatment must be given with iodine, so that stopped, there is very likely to be a relapse, so that altogether, two or three months may elapse before a continuance of the drug in small doses, say, .05 the operation is performed. The iodine is neces- gm. per day, has to be carried out for a long time, sary because there is no doubt that a thiouracil- perhaps a year, or even two. It seems that treat- prepared case is more difficult to operate upon ment for such a long time may not be entirely than one which has been prepared with iodine. without danger, for in rats at least, Purvis and The use of iodine makes the gland less vascular Griesbach have produced adenocarcinoma of the and so the operation is easier. thyroid in 50 per cent. of the experimental animals It is less difficult to be certain about contra-indi- by administration of thiourea for a period of two cations. First, those who cannot carry on the treat- years. It is only fair to state that we have no evi- ment because of toxic reaction such as leukopenia. dence of thyroid carcinoma in man which could be Secondly, nodular goitre. It has been pointed out attributed to this treatment. previously in this article that the administration As against this long period of treatment, thyroid- of thio drugs causes an increase in the hyperplasia

ectomy usually gives full recovery in three or four of the thyroid gland. This means that the volume Protected by copyright. weeks, and if it is performed in a good goitre of the gland is increased. In many cases of nodular clinic, mortality is low, under I per cent. When goitre, though not all, the trachea is compressed thiouracil was first introduced, we treated 45 cases or displaced, so that some interference of the of all types of thyrotoxicosis with this drug and at airway is experienced. In an extreme case, there the end of eighteen months we were able to say is a whistling inspiration due to the narrowing of that 50 per cent. had done very well. Since that the trachea and the patient is very short of breath- date, however, six of these relapsed ana so the in fact, she may be regarded as a thyrotoxic when percentage of recovery in these original cases is she has no other reason for shortness of breath now only 35 per cent. It would seem that a selec- than the insufficient capacity of the trachea. Such tion of cases for this treatment is important. Can extreme cases are rare, but it is not uncommon to we say which patient with thyrotoxicosis will be see, at an operation on a nodular goitre, indenta- relieved by this drug.? tion and softening of the trachea as a result of the First of all, I would put the young patient with pressure. The patient may have complained of a smooth goitre-and a small one at that. Many no symptoms of this-for so slow and insidious is of these have done very well, but there are certain its development that the patient adjusts herself http://pmj.bmj.com/ reservations, which will be elaborated later when to it, and is unaware that she has any obstruction we are dealing with toxic nodular goitre. to her airway. These are easy to see at operations, Secondly, the elderly thyrotoxic patient of 6o but there is another type, not so easily recognized, or 70, whose heart and kidneys have become where a small nodule in the posterior part of the damaged owing to the length of time during which gland has insinuated itself between the spinal the toxin has been circulating in their-blood, makes vertebrae and the oesophageal-tracheal tract. When

the surgical risk greater. such a nodule is found, you may notice as it is on September 28, 2021 by guest. Thirdly, those cases which have already had withdrawn that it is shiny, glistening and of a thyroidectomy and have recurred. It is well known, greyish colour, like a waterworn stone. The that in this recurrent type, the dangers of appearance vanishes very quickly, once it has a surgical operation are greater than when an been contaminated with the blood and serum of operation is done for the first time. There is a the wound. It is probable that the up and down much greater risk of injury of the recurrent laryn- movement of the trachea during swallowing has geal nerve and of the parathyroid glands. These caused a thickening of the capsule of the nodule, cases often respond quite quickly to small doses thus altering its external appearance from the rest of thio, say .2 gm. daily, but we have had severak of the gland. In these cases, there will be no failures, because the swelling of the remnants ha& indentation of the trachea, but it must surely cause been increased by administration of the drug and discomfort such as a tight feeling in the neck. caused a choking feeling, Several such cases have been found i cases Postgrad Med J: first published as 10.1136/pgmj.24.277.571 on 1 November 1948. Downloaded from November 1948 ROBERTSON: Thyrotoxicosis 5'75 had become normal, or nearly so, at first one thought these patients were not making sufficient effort or were neurotic. That this was not the case is shown by their complete recovery after thyroid- ectomy. Another reason for advocating operation in a toxic nodular goitre is that only very seldom have we seen nodules disappear after the treat- ment. They usually remain, and therefore must be a latent source of a recrudescence of the disease, or they may eventually become malignant. Thirdly, all patients who live too far away from centres where blood counts and B.M.R.s can be done. Fourthly, a patient whose heart symptoms are predominant. The first symptoms to clear up on FIG. i.-a. Sup. thy. art. breaking up into three thiouracil are the flushes and the nervous excite- branches. b. The upper pole covered by the ment: tachycardia last of all. It may take several sternothvroid muscle. Until this is retracted or months before the tachycardia is relieved. divided the arcery is not seen sufficiently. Although there are cases of fibrillation which have c. Nodule behind the larynx. got better on this treatment, there is no doubt in treated with thiouracil who refused to carry on our mind that surgery is more suitable and can be because they felt uncomfortable especially notice- relied upon to cure the tachycardia and the fibril- able whcn swallowing. lation with more certainty and in a much shorter Protected by copyright. A similar experience has been found in operating time. on primary Graves' disease, which had failed with A further contra-indication is exophthalmos. thiouracil treatment. In these cases, no nodule Under thiouracil the exophthalmos may increase will be found behind the trachea, for nodular for- although the other toxic symptoms abate. Dobyns mation has not begun: however, the upper pole of the Mayo Clinic believes that the thyroid stimu- will be found to have insinuated itself between the lating hormone of the pituitary produces exoph- larynx and the spine. Practically all cases of thalmos owing to alteration in fat metabolism and Graves' disease have an enlargement of the upper fibrous tissue reaction. Thus many of the changes pole, and in very many of them, part of the pole will in the orbital tissue which produce exophthalmos be found behind the larynx. In one case, a tiny are expressions of generalized tissue changes early nodule was found in this retro-laryngeal por- (Dobyns). tion as shown in the photograph and drawing. The administration of thio will increase the size of the Pre-operative Treatment

gland, including the part behind the larynx, and The preparation of mild cases consists of giving http://pmj.bmj.com/ make the patient conscious of discomfort such as them iodine (Lugols, m. x t.d.s.) for two weeks a slightly constricted feeling in the neck or some before the operation. They need not come into alteration in swallowing. Although their B.M.R. hospital. In the severe cases, patients are taken II on September 28, 2021 by guest. Ll0.| ......

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FIG. 2.-Three stages in severing the branches of the superior thyroid artery.

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FIG. 5.-To show a glistening nodule behindI the Protected by copyright. trachea. This obviously cannot be seen from the anterior aspect.

FIG. 3.-Left lobe of thvroid removed at operation. A glass tube replaces the trachea and larynx. This illustrates the fold of the upper pole lying behind the larynx. http://pmj.bmj.com/

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FIG. 4.-A line drawing made in explanation of the FIG. 6.-Post-operative dressing. photograph. Postgrad Med J: first published as 10.1136/pgmj.24.277.571 on 1 November 1948. Downloaded from November 1948 ROBERTSON: Thyrotoxicosis 577 into hospital after a few days at home on iodine and the three or four branches of the artery on the rest. In hospital, they are put to bed, the iodine lateral and posterior surfaces. These are caught in continued, sedatives administered freely if neces- forceps and divided as they appear. sary, and they are encouraged to drink large quan- Only areolar tissue and the blood vessels them- tities of water. Patients with thyrotoxicosis use up selves are grasped. No thyroid tissue should be more Vitamin Bi than normal-the amount of included. this vitamin contained in the daily food is not The upper pole now peels out freely, all the enough, and much benefit accrues when they are guy ropes or branches of the artery holding it in given large doses of Vitamin Bi. During the time position having been divided. When the pole is they are waiting a daily dose of 50 mgm. of a high one, there is nearly always a piece of it thiamin chloride is given intravenously. Added curling under the thyroid cartilage. Its removal to this, we give them oxygen to breathe for half an will be assisted by putting the forefinger of the hour, two or three times a day. This was originally right hand behind the gland and pushing the pole started to enable patients to get used to the B.L.B. gently forward. It is very important to leave mask, or a catheter through the nose, for the none of the upper pole: by this method it is easy administration of oxygen after the operation. It both to see and make sure. was found that practising breathing oxygen before Attention can now be turned to the lower pole the operation gave the heart considerable relief which is pulled up or out from behind the sternum and we now use it as a pre-operative routine. with Lahey forceps. It is amazing to see how easy Most patients are ready for operation in a week. it is to enucleate even a very large substernal pro- It is rare that they need Io days of this treatment. longation once the upper pole is free. On the morning of the operation heavy pre- Release of lower pole: The inf. veins running nedication is given. On arrival in the theatre, from the lower pole into the mediastinum are they are given a local analgesic in theineck and a clamped and divided. The trachea is not yet Protected by copyright. light oxygen and ether anaesthesia. visible because it is covered with areolar tissue: this tissue is parted with scissors until the trachea Details of Operation is seen. The scissors are then passed up between Position: A small pillow under the shoulders the isthmus and the trachea, so as to protect the to extend the neck. trachea when the isthmus is cut with a scalpel. 7'he incision: T'his is made about two fingers Release of left lobe: Two or three artery forceps breadth above the manumbrium, reaching from now grip the gland tissue lying on the left side of ornc external jugular vein to the other and made in the trachea, thus picking up invisible branches of ' the line of cleavage ' of the skin. When the goitre the inf. thyroid artery as they pass into the hilum. is large, it is better to make the incision rather 'Phe lobe is grasped in the fingers of the left hand higher, as th, skin flaps tend to sink and the final and by further clamping and cutting from the scar may be just above the sternum or even on it. midline outwards, Z7 of the gland is removed, the tIThe higher scar is less noticeable. fingers feeling for deep or retrotracheal nodules.

The skin, superficial fascia and platysma are A branch of the inferior thyroid artery runs in http://pmj.bmj.com/ incised and the upper and lower flaps thus made a tiny groove of the gland between the upper pole are dissected up and down, respectively, displaying and the isthmus, and must be carefully clamped the deep fascia. T'he special goitre retractor is now before removal of the lobe. This artery lies near inserted. the site of entry of the recurrent laryngeal nerve A longitudinal incision is now made in the mid- into the cricothyroid membrane and if it slips out line through the cervical fascia. The left sterno- of the forceps, the nerve may be injured while hyoid muscle is retracted laterally and the left diving for it. Should bleeding occur from there, sterno-thyroid divided between forceps. This will it is better to ligate the main inf. thyroid artery as on September 28, 2021 by guest. expose the left lobe except the summit of the upper it emerges from under the carotid sheath, and pole. A pyramidal lobe is sometimes present and before it turns up to spread over the gland. The should be completely removed at this stage as a artery forceps are now replaced by ligatures of recurrence makes an unsightly reminder of an linen thread. operation that has not been sufficiently thorough. Freeing and removal of right lobe: This is a The so-called suspensory ligament of the thy- similar operation to the left side but the sterno- roid is divided as this enables the upper pole of thyroid rarely needs to be divided. the gland to be pulled down slightly. Haemostatic The stumps of the gland on the two sides are forceps seize the visible anterior branch of the now inspected and if there is any oozing at all, superior thyroid artery, which is divided between two things may be done. The stump may be them; giving a little more freedom to pull the sutured with linen thread on a Mayo needle sutur- upper pole downwards, exposing one after another, ing the capsule on the outer side to the remains of Postgrad Med J: first published as 10.1136/pgmj.24.277.571 on 1 November 1948. Downloaded from 578 POST GRADUATE MEDICAL JOURNAL November I948 the hilum on the trachea. Care must be taken that of the recurrent laryngeal nerves and should be the needle does not go too far into the hilum as treated by an immediate tracheotomy. The trach- there is a risk of including the recurrent laryngeal eotomy tube can be removed in a day or two when nerve in the suture. If the oozing continues, the spasm goes and no evil effects in the wound have main inferior thyroid artery may be tied near the been noticed, and since the use of penicillin in thc carotid sheath. wound there has not even been undue delay in Closure of wound: The cut ends of the sterno- healing. thyroid muscle are united with a ligature. The Tetany may occur. It is usually noticed about sides of the sternothyroid muscles are brought 48 hours after the operation. As soon as it is diag- together over the trachea with a single stitch. nosed we give an intravenous dose of calcium The median incision in the cervical fascia is gluconate and continue for the next two or threc closed by three separate sutures, picking up tissue days to give calcium lactate by the mouth, together outside the ant. jugular plexus to avoid the veins. with Vit. D. in the form of cod liver oil. In nearly rfthe skin edges are then closed with a continuous every case there has been no further trouble. horse hair suture and no drain is inserted, for if Difficulty in swallowing, especially in the swallow- all the vessels are clamped before division, the ing of fluids, due to bruising or injury of thc wound will be bone dry. superior laryngeal nerve, so interfering with the The wound is now compressed with a marine sensation of the larynx that drops of fluid may go sponge dressing and two strips of elastoplast as in ' down the wrong way.' This clears up in a few diagram. This is left on for 48 hours and then this days. In the meantime solid or semi-solid fopd dressing and the skin sutures are removed. is given without any trouble. In male patients, it is sometimes necessary to Loss of voice is due to bruising or injury to the divide the sternohyoid and even part of the sterno- recurrent laryngeal nerve, causing paralysis of a mastoid muscles to give a good exposure. When vocal cord, which may be permanent. If theProtected by copyright. suturing these muscles at the end of operation, be paralysis does not appear for .48 hours or more, sure to include in the suture the blood vessels then it is probably due to pressure on the nerve which bleed from the cut ends. from the general oedema and-outpouring of serum in the wounded tissues. This type improves, Post-operative Complications leaving no sign of cord paralysis. A patient with Haemorrhage: This usually occurs in the first a permanent unilateral paralysis will whisper for few hours. It cannot be too strongly pointed out two to three months. After that the active cord that if the bleeding occurs under the

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