of his lips? The medical profession in my judgment must purge itself from these timeworn and suspicious alliances with conditions that tend only to the destruction of civilization's most cherished institutions-namely the family and the home; the doctor is no father confessor, but a man whose responsibilities reach into the future of the race while that race walks this earth and to the purity and healthfulness of that future he is pledged. The Duty of Organization.-To be able to find fault with and to discover new duties for an already over-worked and certainly underpaid profession is an easy task, the question as to how the purposeful doctor may be able to do these things brings me to my last point, the greatest duty he owes his municipality and that is to get nearer to his professional brethren in more active effective organization than has been his habit hitherto. The local medical society which heretofore has been more or less of a purposeless farce, must come to be the forum where the discussion will not simply be stuff cribbed from some ancient authority and worked over, but pointed, definite essays designed for publication, with purpose in every line. Results the Touchstone.—Our day is a day of deeds rather than of words, and "results" form the touchstone of every activity, so the perfunctory and ill attended local medical society meeting must give way to definite, business-like sessions, in which committee work beforehand shall have reduced matters for discussion to workable shape. Details.-There should be a board of health committee to keep the Society in touch with that body, backing it up with active aid or with the not less important constructive criticism. And then, too, if the local society really means to measure up fully to its duty to the municipality it must have a wise and very alert publicity committee to edit and place before the public in the daily press, matters under discussion which the public should know. The doctor has blamed and laughed at the people for their ignorance of things medical, and yet no steps have been taken by the profession at large to enlighten them; let it be done authoritatively and systematically through a publicity committee. Duty of Study.--This business like committee plan should likewise be applied several meetings in advance in connection with topics for special study, and let it be study, not a farce. The life of the people lies in the hand of the doctor; surely he should give his best thought and study to the most approved methods of treatment. He is not doing his duty to his people if he does not use the opportunity afforded by his society meeting for keeping in touch with the rapid advance in the healing art which the world of thought and investigation lays at his door. The "Regular" says "all methods for the cure of disease are mine to be used for the healing of mankind," yet he frequently passes by many remedial agencies without a look. What does the average doctor know about psycotherapeutics? The quacks take possession under the name of a new cult and the doctor has a black eye. What does he know about the value of manipulation of joints and muscles in restoring strength to wasted tissue? Must the Osteopath "et id omne genus" with their unscientific claims black the other eye? The field is broadening, and of course all knowledge cannot be attained, but the community has a right to demand that the physician who serves it shut up no avenue of knowledge that makes for the health and consequently the happiness of those he serves. This knowledge cannot be gained by listening to a paper on the subject or even by reading an article from the highest authority upon it. It must be gained by painstaking study and the clash of mind with mind in systematic discussion of all the points involved, and if possible by demonstration. This duty to the public may easily prove to be the highest duty to oneself. The pleasure as well as profit to be gained by such a course of study is sure to attract all the best men in the profession and enthusiastic support of the idea, and it needs but the initiative of some two or three earnest men in every place to put it into operation. Can it not be done? I claim no originality for this study plan. The American Medical Association has set its seal of approval upon it and I but emphasize it as a solemn duty the doctor owes the people from whom he gains his livelihood and to whom he has dedicated the greatest possibilities of his life. His profession is advancing with leaps and bounds; the graduate of ten years ago must change his library almost throughout to get into touch with the vanguard of to-day. How much more important, therefore, is it that mutual study cement the fellow ship which should exist between members of a profession whose altruistic deeds are the wonder and admiration of the world? May I for a moment go over the points I have made as to the doctor's duty? 1st. To build and back his board of health-reporting diseases with careful attention to details. 2nd. To throw himself into the political and civic life of his town by standing for office and working for the best and highest good of his people. 3rd. To give freely by tongue and pen his thoughts and observations as to the best methods of control and cure of disease-the articles for publication always being carefully censored by a committee of his confreres. 4th. To instruct and warn men and boys as well as women and girls against the evils that lie in the train of vicious and immoral conduct. 5th. To labor for the correction of any tendencies and practices in the profession, however time-honored, which in any degree cloud the purity of his sacred art. 6th. And finally as a means to these duties, business-like organization for careful study of all subjects that can promote efficiency in a calling devoted to the public welfare. Is is too much to bespeak for the doctor, in Tennyson's words A life in civic action warm, A soul on highest mission sent, A potent voice of Parliament, A pillar steadfast in the storm Should licensed boldness gather force, A lever to up-lift the earth, And roll it in another course. Who loves not knowledge? Who shall rail THE CLINICAL ASPECT OF HYPERTHYROIDISM. By MCCAW TOMPKINS, M. D., Richmond, Virginia. The symptom-complex, due to perversions of thyroid secretion present to the clinician the most interesting field in all medicine. Physiologists have recently been pointing out the important position that the thyroid occupies in its relation to health, and indeed have included this gland among the viscera essential to life. We know but little of the physiology of the gland when properly functionating, the preponderance of modern opinion being that its internal secretion to a large extent regulates metabolism, and has a selective influence on vasomotor control and the nervous system in general. Complete removal of the thyroid and its capsule causes cachexia thyreopriva, the symptoms of which may be markedly relieved by the internal administration of thyroid extract; removal of the parathyroids is followed by an acute tetany and death, though even here life may be prolonged for several weeks by the injection of beef parathyroid nucleoproteid.2 When an insufficiency of the thyroid secretion occurs there will develop a group of symptoms that covers a wide range of the organic cavities; lassitude, mental sluggishness and headaches of various degrees of intensity. Metabolism is impaired as evidenced by the atrophic changes that take place in the skin, 2. Beebe Journal A. M. A., October 5th, 1907. hair, nails and teeth. Obesity usually is present, the body temperature being subnormal and the patient sensitive to cold. There is a general tendency to hemorrhage. An excess of thyroid secretion also produces a great variety of clinical pictures, varying from a slight nervous excitability associated with a tendency to become easily fatigued, to the typical case of exophthalmic goitre with well marked exophthalmos, tremor, tachycardia and an enlargement of the gland. The diagnosis of such a case would be easy, but unfortunately few cases are typical until the disease has made such strides that secondary changes have taken place in the liver, kidney or heart which possibly cannot be overcome, though the causative process be arrested. It is to the early stages of the disease and to the atypical cases that I would invite your attention especially. There is no organic condition more generally overlooked by the profession, nor more frequently mistaken for other affections. Without a careful examination of the neck many of the cases are passed over to those convenient dumping grounds for obscure cases, hysteria and neurasthenia,3 and not until they develop all the cardinal symptoms is their true nature recognized. Consequently much valuable time which could have been used in attempting to control the process has been wasted, and in many instances positive harm has been done. The victims of this malady undoubtedly number among the thousands, and, bearing this disease in mind, a routine examination of the neck will clear up many otherwise obscure cases. One common mistake is to confuse the condition with a primary heart lesion; another error is to look upon it as a chlorosis; anæmia, fatigue, emaciation and accelerated heart action may closely simulate chlorosis, but a thorough treatment with iron does not give relief. When nausea and diarrhoea are prominent symptoms the mistake may easily be made of considering it to be some gastro-intestinal disorder. A moderate hyperactivity of the thyroid occurring during pregnancy, or in young girls about the age of puberty, should not be regarded as pathological unless it tends to persist. The modern conception of the pathology of exophthalmic goitre is that there is a hypertrophy of the glandular cells of the thyroid with an excessive or perverted secretion, the secretion acting as a toxin; the whole picture is therefore a true toxemia having a local origin in the thyroid gland. That we are dealing with an autointoxication rather than with an intrinsic neurosis accompanied by disturbance of vaso-motor control, is very strongly suggested, (1) by the experimental production of similar conditions in animals by the administration of thyroid substances, (2) by the exacerbations produced in the symptoms when thyroid is administered in the course of the disease, and (3) by the fact that only with this conception as a basis for treatment can satisfactory therapeutic results be obtained. Again laboratory findings correspond very closely with this theory. Wilson,4 of Rochester, in his studies of 294 cases operated upon, became so expert that he was able to describe the clinical symptoms from his pathological findings, and in less than three per cent. was there a decided disagreement between his pathological conjectures and the clinical facts. Speaking broadly, Wilson found that the parenchyma increase was in direct proportion to the intensity of the symptoms, and cases which were clinically having a remission of symptoms showed within the gland a thick gelatinous substance, the so-called colloid, which prevented the absorption into the circulation of the toxic products. Of all the theories that can explain the origin of the hyperactivity of the thyroid gland, two stand out most prominently; first, that it occurs as a result of nervous causes, since we all know how qualitative and quantitative change can take place in other glandular secretions, e. g. the gastric juice, dependent upon nervous influences, and because it has been pointed out that long continued worry acts as an important pre-disposing cause, as well as immoderate emotions of any sort, religious, sexual or especially those due to fear. 3. Tincker, Long Island Medical Journal, April, 1908. 4. Journal American Medical Science, December, 1908. The second commonly accepted possibility is that during chronic or repeated infections and toxemias, the thyroid undergoes a compensatory cellular hyperplasia which persists after the necessity for increased thyroid secretion has ceased. Hyperthyroidism, unless promptly controlled, promises to be essentially a chronic disease, a duration of from ten to twenty years being not uncommon. Many years may pass with a freedom from severe symptoms and the patient may be able to lead a comparatively useful and comfortable life, but with some nervousness, muscular weakness and increase of pulse rate on slight exertion. There is often a tendency for a typical condition of hypersecretion to progress through an indefinite type to the opposite condition of myxedema. There likewise occurs a mixed type of the disease where there exists a hypersecretion of certain globulin bodies and at the same time a hyposecretion of other elements. It is of extreme importance to recognize these classes of cases, for in the latter class thyroid extract must be carefully administered in addition to our efforts to reduce glandular secretion, while the first class must be treated just as cases of primary myxedema, although they present enlarged goitres and exophthalmus, evidences of a long standing hypersecretion which has previously existed. Do not be confused by the fact that such a patient may have a rapid pulse and muscular weakness, for these may be present in myxedema as well as in hypersecretion. The mortality of hyperthyroidism is very hard to fix definitely on account of the many mild cases that exist, but in well marked cases of exophthalmic goitre, the death rate is so high as to place it among the very serious diseases; here the ultimate mortality more or less directly dependent on the condition will probably average about ten per cent. Among the causes of death cardiac weakness is most important, next comes exhaustion from pernicious vomiting and diarrhoea. It is quite certain, however, that many cases of hyperthyroidism never progress beyond the early stages, and these, after an indefinite period of impaired health, tend to recover spontaneously. Even where the condition is moderately advanced, some undergo improvement and a few get entirely well without any, or in spite of, treatment. At present there is a widespread belief that surgery offers the only rational and successful method of treating thyroidism. This belief exists because of the brilliant success of a few expert operators working under the most favorable circumstances. These men, after a vast amount of goitre work, have finally been able to reduce their immediate mortality to about four per cent., and have reported the remarkable proportion of seventy per cent. of cures with fifteen per cent. of improvements. Let us remember, however, that in the hands of the average good surgeon this mortality rate will be more than doubled, some even admitting as high as thirty per cent. Again, except when dealing with an expert, we are liable to have the most distressing conditions of hypothyroidism or myxedema substituted for the hyperthyroidism, and the patient's last condition may be worse than his first. I firmly believe that the surgical treatment of thyroidism should be confined to a very few men who possess the requisite technical skill together with keen judgment in selecting suitable cases. When thus properly restricted there is no doubt that surgery occupies a very important place. As a primary measure, it is positively indicated in all cases where mechanical pressure symptoms are present, and where a simple colloid goitre is superimposed upon a condition of hyperthyroidism. As a secondary procedure it is indicated in those cases which have resisted non-surgical treatment, for there are cases apparently not amenable to medical treatment which can be cured by skilful surgery. Again, medical treatment may be a useful adjuvant to surgical treatment by diminishing the intoxication to a point where surgery can complete the cure with a reasonable degree of safety. In these more serious cases also, thyroidectomy should be preceded by a preliminary ligation of the superior thyroids; this is especially indicated where the pulse cannot be reduced below 130 by rest in bed. Surgery acts by removing the origin of the toxemia by diminishing the blood supply to the gland, or by actually removing a lobe or more, thus breaking the pathological chain of the disease. When surgery has been decided upon, general anesthesia should be adopted with as little mental excitement or fear as possible on the part of the patient. Careful selection of the type of operation, the time, the preparation and the after-care of the patient is necessary. He should receive morphine and atropine, or possibly bromides, and an abundance |