of saline solution prior to operation. During operation careful hæmostasis and the avoidance of handling the gland are important. In regard to the time for the operation, it is best to avoid those periods when nausea and intestinal relaxation are present.

One important factor in operative mortality is an acute thyroid intoxication, resulting from mental excitement and from traumatism to the glandular struc ture. An interesting case illustrative of this acute hyperthyroidism and followed by recovery occurred in the service of Drs. Johnston and Willis: Mrs. M. E., aged twenty-eight, suffering from a colloid goitre superimposed upon an exophthalmic goitre, had noticed neck enlargement for sixteen years, but her neck had increased markedly in size lately. Under observation for several days previous to operation, her pulse ranged between 90 and 100, her temperature was always normal. After operation her temperature ran sharply up to 1042, and her pulse to 150, and the patient appeared very seriously ill. She was given 1⁄2 an ounce of sodium phosphate and was flooded with saline, receiving within twenty-four hours 12 quarts under the skin, a like amount by bowel, and a quart of water by mouth. These measures were followed by a prompt subsidence of symptoms and recovery.

That this serious intoxication was evidently due to the mental phase of the patient can be seen by noticing that the symptoms began with the waking hours of the morning of the operation and that the temperature had reached 101 and the pulse 140 before the operation was actually begun. (See accompanying chart.) The operation was a short one and accomplished with an unusually small amount of traumatism; the case was likewise interesting in that it produced a rare specimen of a beautiful calcified process within the goitre. (Plate I.)

We do not feel justified in indiscriminately advocating surgical procedure in exophthalmic goitre until it has been clearly shown that the process cannot be controlled by the best non-surgical measures, for the medical treatment of this disease has a very substantial basis for existence.

The use of drugs alone, however, in the treatment of thyroidism has certainly not produced encouraging results; their very number itself declares their inefficiency. Among those which have been employed from time to time might be mentioned digitalis, strophanthus, atropine, iodide of potash, quinine hydrobromate and the various bromides. Of this number, atropine, and the bromides have occasionally been useful in our hands. The well known power of the Roentgen ray in causing glandular atrophy and in diminishing the blood and lymph supply more or less permanently has led to its use; undoubtedly a small percentage can be cured by the X-ray, and a larger percentage temporarily relieved. Great care should be exercised in choosing a well-trained man to treat these cases or more harm is likely to be done than good. The ray can also be used to advantage in conjunction with other methods of treatment, as for example, with operative measures as suggested by Carl Beck.5

But the rest treatment is the most important aid to any of the other methods, and alone, it will cure a fair percentage. To be of value, however, it must be of sufficient duration, and in severe cases, attention to the most rigid details is essential, here, absolute rest in bed for several weeks or months will be necessary, with a gradual resumption of ordinary life as improvement takes place. Mental rest is as important as physical, consequently emotions, pleasurable or otherwise are to be avoided. Company must also be forbidden. After the period of absolute rest in bed, the patient should be advised to lead a quiet, uneventful life, the emunctories should be kept open, long hours of sleep encouraged, and an hour or two during the middle of the day should be spent lying down. Exercise should always stop short of fatigue, dancing, stair climbing and long walks to be avoided. Theatre going, etc., must be judged by the effect on the patient. The diet should be generous and varied, nothing to be omitted except notoriously indigestible articles of food and stimulating condiments. The aim should be to build the patient up rather than to restrict the diet, and in this connection, milk, from one to two quarts a day between meals will be useful. General massage is helpful, but massage over the gland is contra-indicated, as is the application of any ointment requiring rubbing. The use of iodine, either locally or internally, will prove harmful except in selected cases.

5. Carl Beck, Post Graduate, Twenty-fifth Anniversary, Vol., 1908.

Three years ago the treatment of hyperthyroidism by means of a specific, cytotoxic serum attracted our attention, and the results obtained apparently justify us in recommending it as the best primary method of treatment in all cases of hyperthyroidism with the exception of certain distinctly surgical types as above mentioned.

To produce a permanent cure in this disease any serum must not only be antitoxic, but also specifically cytolytic for thyroid epithelium, for not only must the toxemia be neutralized, but the source of the toxic substances must be limited.

That the Rogers-Beebe serum possesses antitoxic principles there is in my mind absolutely no doubt. Every one of our cases showed a marked improvement while under our direct treatment, though after leaving us a certain percentage soon relapsed to their original condition. That there are also specific cytotoxic properties seem to me very probable, from the permanence of some of our results after discontinuing the serum.

No precise rules for the routine administration of this serum have as yet been formulated, and in order to treat a case intelligently it is of prime importance to recognize the specific type of the particular case. It might almost be said that there are as many types of this condition as there are varieties of streptococcic infection. A small proportion of cases where there is the associated condition of myxedema will require careful thyroid administration in addition to the serum. Those very chronic cases which have existed for years and where marked secondary changes have taken place, respond least of all to the serum; all of our failures have been among cases of this kind.

The cases favorable for serum treatment are the early typical cases of hyperthyroidism, whether mild or severe. In the severe rapidly developing type of exophthalmic goitre, the improvement resulting from the serum is so wonderful as to compare with the effect of diphtheria antitoxin. Chronic cases which have existed for some time in a sub-acute condition with occasional exacerbations, but without marked secondary changes, respond well to treatment and many are entirely cured. By a cure we do not wish you to understand that we mean an entire disappearance of exophthalmos and grossly hypertrophied goitre, which are secondary changes resulting from the continued action of the toxin in neglected cases. We mean that an end is put to all toxic symptoms and that no further pathological changes will take place. The pulse is reduced to normal, the weight is markedly increased, and the strength is such as to enable the patient to compare favorably with the average well person. The nervous and gastro-intestinal symptoms are permanently and entirely relieved. The exophthalmos and goitre are usually lessened and may clear up altogether. Let us remember, however, that one of nature's ways of curing this disease is by superimposing a colloid condition upon the hyperthyroidism, thus preventing the absorption of the toxic secretion, and the disease itself may be undergoing a favorable change, although there may be an increase in the size of the tumefaction.

In a small number of cases, those having a history of acute development and with soft thyroid glands, we may have a striking improvement in the symptoms within a few days; the majority, however, will show a gradual slow improvement, yet one that is quite positive.

The dosage must be regulated according to the nature and severity of the local and general reactions, together with a careful watch upon the improvement in the symptoms. It is best to increase the dosage very gradually until there is either a marked general or local reaction; if increased too rapidly, the cytotoxic element in the serum may cause a rapid destruction of the glandular epithelium with a resulting severe or even fatal toxemia from the decomposition products of the thyroid.6 If by chance the serum should be injected directly into a vein, as happened in a case of one of my colleagues, there will occur a serious collapse on the part of the patient.

When a proper reaction has been obtained, our plan has been to decrease the dosage until the serum produces only a slight reaction or none at all, and this dose is maintained for one or two months after the symptoms have been overcome, then the dose is gradually decreased and given at increasing intervals for several months longer.

6. Beebe Journal A. M. A., September 1st. 1906.

In general we can know that we are using a mild or an active serum, but here again the personal idiosyncrasy of the patient will come in, and a serum which will produce a mild reaction in one case may make another very ill. At times it is necessary to change the variety of serum until the proper one is found. The dose in an individual case can be ascertained by trial, and like the other potent remedies, this one can be productive of as much harm as good if improperly employed. Good results can only follow when a serum of suitable activity is administered to a proper case, in the right dosage, and under favorable environment. During the first few weeks of treatment, when the reactions are being produced, it is essential that the patient be kept at rest in bed and without any company.

Of 246 cases reported by Drs. Rogers and Beebe, thirty per cent. were cured of subjective symptoms, with objectively nothing more than a slight enlargement of the thyroid discoverable on deep palpation. About fifty per cent. were markedly improved, most of their subjective symptoms being relieved, and the goitre itself being reduced. About twenty per cent. failed to show improvement, and of these ten per cent. ultimately died.

In conclusion it might be of interest to note the results we have obtained in sixteen cases treated by the serum; five, or thirty-one per cent., have been cured, the oldest case having been without symptoms for over three years, the last for about six months. One of these cases was very toxic, her pulse being over 180 on exertion, and with a great deal of nausea and diarrhoea; within six weeks she was practically relieved of all subjective symptoms, her pulse being reduced to about eighty. Seven, or forty-four per cent., were markedly improved so that their lives have been rendered much more comfortable, and this improvement apparently is permanent. Two of these cases were very serious ones, and three have taken the serum treatment twice, with an additional improvement the second time. Four, or twenty-five per cent., do not appear to have made any permanent improvements, though all of these were certainly better while under our direct charge, but relapsed more or less promptly after being sent home. Only one case treated has died.

THE PRESENT STATUS OF THE TREATMENT OF GOITRE.

By LE GRAND GUERRY, M. D., (Invited Guest), Columbia, S. C.

The present status of the treatment of goitre is one of the splendid achievements of modern surgery; in our country, however, judging from the comparative scarcity of cases operated on, the disease is not comprehended in its true light.

In seeking to establish the best method of treatment we have to consider two propositions: First, the mortality rate of the two given methods, medical and surgical; and, Second, the permanency of cure. The subject must be viewed candidly and from this objective, namely, there is no difference between medicine and surgery in the broadest and most philosophical sense; each method should be prescribed absolutely on its merits, not that such and such a case could be operated on, but does surgery or does medicine give the lowest mortality rate and the best number of end results? An operation should be prescribed from the same standpoint as one would prescribe a dose of quinine; does it best conserve the welfare of the patient? By conservatism we do no mean a dilatory policy of being "penny wise and pound foolish," but rather we mean a method that conserves life or limb or usefulness.

Ten to fifteen years ago a mortality rate of ten to twenty per cent. was considered to be a fair average; it is little wonder then that the operation was

to be greatly dreaded and fell into practical disuse, except for those cases in which it was a question of operation or death-usually both. The mere fact that people would not submit to surgical relief until they were absolutely forced into it, is one of the real explanations of the mortality rate.

The best known surgeon in the world to-day is, probably, Kocher, and it is largely due to his monumental work along this line that we have so completely changed our ideas of treatment; whenever the subject of goitre is mentioned, we instinctively couple his name with it.

We will divide this subject, for our purposes, into two classes. In the first class we will include the simple goitre, cystic, adenomata, that are encapsulated; and the diffuse adenomata; these varieties furnish the great majority of cases. So far as we know to-day, medical treatment has little or no influence over the condition. It is not within the range of possibility, with the present knowledge before us, that by any known medical means we can produce absorption of ar encapsulated goitre. How can we?

It is true, however, that the danger to life is very slight; they cause deformity, much suffering, hoarseness, severe neuralgia and pressure symptoms, but rarely death; the proposition in so far as this class of cases is concerned is one of expediency rather than of necessity. The reasonable ground is to put the facts plainly before the patient and let him determine for himself what he wants done, for, after all, the goitre belongs to the patient, and should he wish to keep it, he is within his sovereign right. Even in this class of cases operation is occasionally demanded for the relief of urgent symptoms, such as pressure and the like.

The simple goitre described by Bloodgood, which occurs in young girls about the age of puberty, usually gets well whether anything or nothing is done; the medical treatment of these cases is to be conducted along general lines to be referred to later.

Surgery presents a mortality somewhere in the neighborhood of one-half of one per cent. In advising delay in any case, however, we must remember that from about three to five per cent. of all goitres become malignant when left alone.

"If the thyroid gland (struma) continues to enlarge after the age of puberty, in spite of correct interval treatment, it is the physician's duty in discussing the advisability of operation, to call attention to the possibility of malignant degeneration taking place. If a thyroid gland (struma) begins to grow after thirty-five years of life without any apparent cause malignant chang should be suspected."-Kocher.

The danger from malignancy alone is greater than the danger of the operation. Kocher has a record of three deaths in one thousand operations, not including the cases of Basedow's disease; other surgeons of equal standing show about the same results. In making the decision for or against operation in this type of the disease, we should consider, things being equal, that medical measures are only of temporary benefit; we should keep in mind the five per cent. chance of malignant degeneration against the practical safety and radical relief of surgery. There is scarcely an operation that can be approached, with the present day understanding of technique, that is more favorable, both for immediate and remote results. As we have already indicated, the simple goitre, the encapsulated, adenomata, etc., can be left alone unless for special indications should the patient so desire, for death from this source is very rare. The indications for operation are those of deformity, pressure and the like.

We should get the laity and many of the profession, for that matter, to under stand that, by operation in this class of cases, we not only do not remove the thyroid, but in reality the good gland is saved; the tumor which is enucleated, was destroying, by pressure of its growth, the good secreting gland. In reality, then, by an operation so pre-eminently conservative, we not only do not remove the gland, but prevent it from being removed or destroyed. We can form some idea of the great importance of this gland to human economy when we reflect that nature gives it one-sixth as much blood as goes to the entire brain, and this from the same source. Surely an organ that nature has seen fit to so wonderfully safeguard must be of paramount importance. We wish to lay stress on this point; it is not only possible, but it frequently happens, that in a colloid goitre without symptoms of toxæmia, symptoms of toxæmia may suddenly