iliac fossa, the sensation of breaking fine ice crystals on a frosty windowpane is experienced. This sensation I have never felt in any other disease. The temperature rises quite rapidly, reaching its highest point-if properly treated-in four or five days. The fever has a morning remis. sion and evening exacerbation. The duration of the fever under the treatment in vogue is from three to eight weeks-with antiseptic and antipyretic treatment from ten to twenty days. This statement is based on a record of the treatment of forty-four cases with three relapses. Eight of these patients had been using water from the same well. The average duration of the fever in five of these patients that I treated from the beginning was seventeen days, while in the other three it was thirty-eight days. Of these three I saw the first case October 7, the second October 14, and both were progressing favorably on October 18, when I was taken ill and they passed into the hands of another physician. November 10, having resumed practice, I was again sent for and found the first patient much emaciated, with a temperature of 102°, the heart's action very weak, a cough, et cetera. The second case presented the usual symptoms of typhoid in the fifth week with a temperature of 104°. A third case I now saw for the first time. The patient had been sick since October 20, and was suffering from a thrombus of the left leg. His temperature was 1032° and his condition serious. In the first case the temperature became normal in five days, in the second in ten days and in the third not for fifteen days, but I think the thrombus kept up the temperature in this case for about seven days. Another patient contracted typhoid fever while caring for a sister ill with the same disease and who was treated by another physician. The duration of the fever in her case was about forty days. The brother had the higher temperature of the two, but I used the treatment to be recommended and his temperature became normal on the nineteenth day. Lest some of the audience say these were not typical cases, I would state that the sister was a servant in a family in which the husband died of typhoid fever and she was taken ill with the disease shortly after his death. Again, three other patients using water from the same well were seen by three other physicians who confirmed the diagnosis of typhoid fever.

One thing to which I would call your special attention is the rapidity with which the fever leaves the patient. There will be no change in some cases until about the seventeenth or eighteenth day, when the fever chart will show a marked morning remission and in less than three days the temperature will be normal. This can sometimes be predicted by the pulse becoming full and soft twenty-four hours before the thermometer shows any particular change.

The treatment is both antiseptic and antipyretic. The antiseptics employed are prepared in the form of pills and soft capsules. These pills are similar to but not identical in composition with Woodbridge tablets number one, from the use of which I did not derive as good results owing to them producing nausea and being so volatile. In severe cases give the pill day and night every fifteen or twenty minutes for about three days. Place it in the patient's mouth and he will swallow automatically without becoming thoroughly awakened. If the bowels do not move four or five times each day, I give a tablespoonful of castor oil in hot milk. The stools at first are dark, then green, later becoming yellow. In a case in which vomiting occurs, it is generally relieved when the bowels move freely. When severe vomiting occurs in alcoholics, the

prognosis is grave. After giving the pill for about three days alternate with the soft capsule, giving one every four to six hours for thirty-six hours, and thus avoid ptyalism. Give the pill continuously if possible, only using the soft capsule as a safeguard. In severe cases apply to the abdomen an ointment composed of one drachm of carbonate of guaiacol and three drachms of adeps, using the whole amount in twenty-four hours. Give the oil of eucalyptus freely. I administered three ounces in ten days in a case in which the temperature was 1061⁄2° Fahrenheit, and the outlook was very gloomy, owing to a severe hemorrhage as well as a high temperature. Indeed it did not seem possible for the patient to live through the night. On the twentieth day his temperature was normal, and remained so; although he had eight hemorrhages within the next few days. Recovery was complete. In a case of hemorrhage give the soft capsule for two or three days and use other remedies as indicated -ergot, morphin, or turpentine; A severe hemorrhage is not always followed by a high temperature.

A man, aged forty years, had a temperature ranging from 103° to 1032. On the fifteenth day of the fever he had a hemorrhage and lost about four quarts of blood. On the sixteenth day his temperature was normal; on the seventeenth day it registered 100°; on the eighteenth it returned to normal, where it remained. He made a complete recovery. Afterwards his wife and two daughters also contracted the disease - the wife's fever continuing twenty-one days, the daughters', fifteen and sixteen days respectively.

If nephritis should occur as a complication, I do not alter the main treatment. I once had a patient with typhoid fever accompanied by nephritis, in whom the urine contained fifty per cent. albumen. Pursuing my usual treatment her temperature became normal on the nineteenth day and she made a complete recovery.

Control a high temperature with acetanilid. I give four grains every hour until the temperature is partly reduced, for example: reduce a temperature of 104° to 102°, never lower; then take the temperature every two hours and when it rises above 103°, again reduce it about two degrees. In this way the temperature can easily and safely be kept so that the patient has no subsultus or delirium.. The height and persistence of the temperature is a measure of the severity of the attack. I give enough of the acetanilid to reduce the first high temperature. Later, I give only enough to produce the desired effect. Often late in the disease the tem

perature can be reduced from 103° to 100° by giving one or two grains with a little whiskey in hot water, thus changing a hot dry skin to a moist one, adding much to the patient's comfort, and, I believe, producing a safer condition.

Sponging the patient every four or five hours with vinegar or whiskey and water before giving the acetanilid never after-also adds to his comfort. Phlebitis, should it occur, is to be treated in the usual way, the regular treatment of the. fever being continued. Giving plenty of water relieves the smarting of the stomach, although this is generally borne patiently in expectation of an early recovery.

I would say in conclusion that I have never seen marked delirium in a patient treated by the foregoing method, and have derived great benefit from the conservative use of acetanilid. Only well-marked cases have been considered. In one case the temperature three times reached 107°, in three 106°, and in several 105° Fahrenheit. I have employed this treatment in the management of forty-four patients, three of whom relapsed and one died.

GOITRE AND ITS TREATMENT*.

By H. WELLINGTON YATES, M. D., DETROIT MICHIGAN.
[PUBLISHED IN The Physician and Surgeon EXCLUSIVELY]

I HAVE no other purpose in the writing of this paper than to call attention to a few of the characteristics of this disease and lay emphasis upon the fact that all goitres should receive medical or surgical attention. It is not my intention to announce any new feature in diagnosis or treatment; neither do I claim any original thought along this line. I hope, however, to be able to generalize a treatment that will correspond to the condition as classified herein. I, of course, have no reference to Graves' disease, nor to other enlargements of the thyroid, only as they affect a differential diagnosis.

As yet, we do not know the true nature or function of this gland, and until the physiologist has demonstrated it, the pathology will be uncertain and the treatment quite empirical. Some believe that the active constituent of the secretion, whatever it may be, is constantly poured out into the blood current and through some effect upon the cells of the body by it, assimilation and waste are controlled. All agree that the gland has a most important influence upon metabolic change.

Simple goitre is found sporadically, endemically and epidemically; it has certain localities mapped out for an abiding place. One of these seems to be the Alps of Switzerland. OSLER quotes Dock as saying that the disease is prevalent in certain parts of Michigan and New York, especially the eastern border of Lake Ontario. E. J. MEYER, of Buffalo, says it is endemic in Detroit. The disease, certainly, affords a good clinic here. Why should certain portions of the world see so much of it and others so little? Some observers believe it to be most prevalent in high altitudes. If this were true, why do not those who live up in the mountains have the disease more commonly than those in the foot-hills of the Alps, whereas the opposite is true. If this is looked upon as a cause, why, indeed, should we of Detroit or they of lower Canada be affected by it at all?

* Read before the DETROIT MEDICAL SOCIETY.

Someone has called attention to the fact of streams of water being goitrous, and that persons drinking from them would soon be victims. of the disease, and that they would afterward become cured by drinking the same water if boiled, or by moving to some other part of the country. While all these outward influences may tend to cause goitre, yet there must be some general cause for its appearance other than an extrinsic one; some diminution or perversion in the gland secretion, possibly some other bodily influence. There is, undoubtedly, a marked sympathy between goitre and the female pelvic viscera, as is evidenced by the increased swelling of the gland during menstruation and pregnancy; by its first appearance, in the majority of cases during the months of puberty, and its occasional appearance, for the first time, with fibroid tumors of the uterus. But we are, as yet, wholly ignorant of this relationship. Certain remedies and toxins have been known to cause goitre; pilocarpin has been known to produce this effect. A. STENGEL calls attention to the frequent occurrence of this condition during the course of certain anemias and particularly that of chlorosis.

Whatever the etiology, be it microbic infection, high altitude, an over-nitrogenous diet, heredity, or water overladen with lime salts, the fact of its being a menace to human life in all cases should provoke more attention than this disease has from the general practitioner. The mere outward manifestations of swelling and deformity should not be our criterion for treatment; we should recognize in the small goitre, the possibility of malignant change, of its greater susceptibility to treatment, of the pressure upon important nerve trunks and blood-vessels, and of cystic degeneration accompanied by its results. Not infreqnently deaths occur from small goitres, and what should make this last point more impressive is that we do not know the cause of death in these cases. The simple fact of size is not our guide-some small goitres produce profound disturbance, while others may be of enormous size and do but little harm. This depends much upon the character of the growth and the pressure made by it. I have had two or three cases in which the growth would only be recognized by palpation, and yet they complained bitterly.

BOUFFLEUR, of Chicago, says, "The comparative frequent occurrence of sudden death in patients afflicted with goitre of even small size gives additional emphasis to the indication for regular, systematic medical and surgical treatment in all cases.'

Malignancy is often the result of a simple benign growth in the gland, and of the malignant class VIRCHOW states none is so prevalent as the round-celled sarcoma.

It is unnecessary to say anything in general upon the diagnosis, as the symptoms are usually so plain that they are unmistakable. I only wish to call attention to the fact that many cases of benign goitre may possibly be mistaken for Graves' disease. I refer to that hard, fibrous enlargement which rests heavily upon some important nerve trunk and produces through pressure such allied symptoms as nervous tremors, palpitation and rapid pulse. It would be but natural to think that these symptoms were produced by some interference with the cervical sympathetic, and I would be inclined to think that probably some of the cases that have recently been operated

upon for Graves' disease with such flattering results may have been simple goitres producing pressure.

The classification of the disease as I give it is largely an anatomical one used chiefly for convenience as a reference to treatment: (1) Parenchymatous enlargement;

(2) Cystic enlargement;

(3) Vascular or pulsating enlargement.

From the first class our patients are mainly derived, at least in Detroit. I say "at least in Detroit" because by referring to the "American Text-Book of Surgery" we find that the cystic enlargement is most common. This, certainly, is not true here.

Parenchymatous goitre consists in not only a hypertrophy, but a hyperplasia as well of all of the glandular tissue, the follicles of which are filled with a colloid or gelatinous material. In the process of enlargement, any one of the different tissues or structures of the gland may outgrow the others, and we would according to circumstances have (1) the hard, uneven and unyielding fibrous type, which, according to my observation, has been quite generally unilateral, or (2) the soft and rapidly growing colloid goitre which is, I believe, more commonly bilateral.

I have thought it probable that it was from this last mentioned variety that the cystic goitre is developed. This, however, is only conjectural on my part. In parenchymatous goitre we usually find the whole gland involved and its surface smooth and regular. The colloid variety of this class I believe is often best treated by electricity; either by cataphoresis or by electrolysis on the belief that it best stimulates absorption. I remember a case I had some three or four years ago which I had treated in the usual way with little success when I determined to try cataphoresis. I applied the negative electrode which had first been saturated with a strong solution of iodide of potash to the tumor and the other to the back of the neck. I turned on the current until the patient complained considerably of pain. The application was of about ten minutes' duration. I asked the patient to call again in three or four days, but I did not see her for over a year, when she said she was afraid to come at the stated time as the last sitting had burned her so much, but to her surprise the tumor then began to decrease, and in a few weeks disappeared entirely. I believe this due entirely to the stimulation of the current and not to cathodal diffusion, as some believe. Undoubtedly electrolysis practiced by the insertion of a needle deep into the substance of the gland is often of great benefit. But in the longer standing enlargements, in which the knotty fibroid growth has taken the place of the colloid, we must not expect such rapid transformation as in the case above, and yet it is in this class of enlargements that I believe it to be particularly serviceable, for we cannot hope for much good to come from internal medication. It is here where operative interference is often found necessary.

Iodin and its compounds have probably enjoyed a larger patronage than any remedy yet known. How it brings about a cure in many cases is yet a mystery; whether the cure is wrought by feeding the whole glandular system, or whether the drug enters into combination with the thyroid secretion direct, remains to be demonstrated. BAUMAN and Roos isolated what they call the active principle of