treatment of cases of toxic adenoma; iodin hyperthyroidism is a frequent sequel of the injudicious use of iodin in adenomatous goiters. Cases of adenomatous goiter complicated by exophthalmic goiter are not uncommon, and we have even had cases of both types of goiter, each complicated by hyperthyroidism. Such conditions are necessarily confusing and complicate the indication for the use of iodin.

In the majority of our cases of exophthalmic goiter we are now giving 10 drops of Lugol's solution three times a day before meals for three days, and then 40 or even 50 drops a day for one or two days before operation. Following operation, 10 drops is given in 500 cc. of normal saline solution by proctoclysis, while 40 or 50 drops is given by mouth for twenty-four hours. The iodin may be diluted freely in water. It is often necessary to divide the dosage and to encourage or persuade the patient to swallow and retain the iodin.

Naturally iodin does not decrease the risk of cardiac or renal failure in cases of long standing in which there has already been severe damage to these organs. Especially encouraging, however, are the excellent results. obtained in children with hyperthyroidism. During the past year we have had 12 such patients all of whom had only the mildest reaction after being thoroughly iodinized.

An interesting field for further inquiry is revealed by a pathologic study of glands removed following the use of iodin. It was with great surprise and chagrin that I studied the first few specimens removed. A clini

cal diagnosis had been made of exophthalmic goiter and the patient had been treated for that disease, but on microscopic examination the glands appeared to be largely composed of colloid. Further study and observation led to the conclusion that a transitory change occurs, the gland tending to assume a more natural appearance, and colloid replacing areas of hyperplasia. Consequently, one might assume that, in time, a clinical cure might be effected by the use of iodin. In our experience, however, a tolerance for iodin is developed after some weeks, and the drug loses its efficacy.

CONCLUSIONS

The problem of goiter is now one of national rather than of regional interest.

Goiter is increasing and is becoming an important economic as well as a social problem.

The treatment of colloid goiter by iodin in order to be effective must be begun before the development of adenomas. Treatment must not be sporadic, but should be continued from the age of ten to the age of twenty years.

There has been a great reduction in mortality following goiter operations. In the series of cases reported here covering one year's work, 171 operations on the thyroid were performed with no deaths.

Important factors in the reduction of mortality have been the prompt diagnosis of cases of hyperthyroidism; the perfection of operative teamwork; the development of preoperative and postoperative regimes; the use of

iodin in exophthalmic goiter; the improved methods of anesthesia; and the use of the metabolic rate.

The use of iodin has eliminated the necessity of ligation in 90 per cent of the cases of exophthalmic goiter.

Crises may be prevented or aborted. To be effective, iodin must be administered in large amounts.

Iodin causes a morphologic change in the gland, colloid replacing areas of hyperplasia.

coating over the nasal mucous membrane, and thus preventing contact of the pollen grains with the membrane.

DRUG TREATMENT

A few patients seem to obtain considerable relief from large doses of calcium chloride, aspirin, quinine, etc. However, large and frequently repeated doses of powerful drugs, such as aspirin and quinine are undoubtedly harmful, and furthermore, they will prove disappointing in the hands of the great majority of hay-fever sufferers.

VACCINE TREATMENT

Vaccine treatment during the attack of typical seasonal hay-fever has been recommended by Scheppegrell and others, but the use of vaccines seems to me to be illogical and unnecessary.

Bernton (3) has well said:

The use of bacterial vaccines has from time to time been included in the treatment of hay-fever. Vaccine therapy in chronic disorders is based on the assumption that the bacteria responsible for the infection

have become immune to the tissues of the host. As the result of retarded growth, little bacterial substance is liberated to stimulate the production of immune bodies, therefore, vaccines supposedly supply the deficiency. It is difficult to reconcile this view with the conditions which obtain in uncomplicated hay-fever. This disease, according to the preponderance of evidence, is an expression of protein intoxication. The rôle which bacteria play is seemingly unimportant. The paroxysms of sneezing and the constant rhinorrhea tend to dislodge the bacteria and wash away their toxins.

I am convinced, however, that there is a small group of seasonal hay-fever cases, that are not sensitive to any

pollen, animal epidermal or food protein, but are due primarily to bacterial infection, and probably bacterial sensitization. In this type of case, proper autogenous vaccine therapy is of course indicated.

The bacterial seasonal hay-fever case may be differentiated from the typical pollen hay-fever case by the following criteria: In the bacterial case, eye symptoms are usually absent. The symptoms are not usually limited to the period of pollination of any particular plant or plants. Bacterial cases frequently occur in the changeable weather of early spring or late fall. The nasal secretion is usually thick, and yellowish or greenish in color. Symptoms of bacterial hay-fever are usually worse on damp, rainy days. The cases give negative ophthalmic, cutaneous and intradermal tests with pollens. They also fail to react to food or animal epidermal proteins.

In the typical pollen hay-fever case, on the other hand, eye symptoms are usually present. The symptoms are usually limited to the period of pollination of some particular plant or plants. The nasal secretion is usually a thin, clear watery one. Symptoms of pollen hay-fever are usually worse on dry, sunny, dusty days. The cases give positive ophthalmic, cutaneous or intradermal tests with pollens.

CLIMATIC TREATMENT

The typical fall hay-fever season, in this part of the country, is from about the middle of August (August 10 to 20) until the first frost, which coincides with the period of pollination of ragweed, to which pollen practically all of these cases are dominantly sensitive. Thus, fall hay-fever patients may

obtain complete relief from symptoms by going, at this season of the year, to Europe or Northern Canada, where there is no ragweed. More or less complete relief from symptoms may also be obtained by going to places where there is very little ragweed, such as Bethlehem in the White Mountains of New Hampshire, or the seashore, where there is practically no ragweed pollen in the air except when there is a land breeze. This annual running away from hay-fever, however, is possible for only relatively few hay

fever victims.

SPECIFIC TREATMENT

It seems to be the consensus of opinion that the co-seasonal or specific pollen treatment of fall hay-fever is of little or no value. In support of this contention, I will quote the following from the literature:

Walker (4) has said.

On comparing the results from duringthe-season treatment, with the results from pre-seasonal treatment, it is evident that for late hay-fever, by far the best results are obtained from pre-seasonal treatment, and it is questionable whether during-theseason treatment is even worth giving, when it is taken into consideration, that there are localities to which patients may go, where ragweed does not exist.

Also in another article (5) Walker states under the treatment of fall hay

fever that

A third method of treatment consists of four or five injections of minute amounts of pollen extract after the hay-fever has set in. This method of treatment is hazardous at best, since it introduces measured amounts of pollen into the system of the patient at the same time that unknown quantities are being inhaled from the air, and is hardly worth trying with hay-fever from ragweed.

If the patient applies for treatment during an attack of hay-fever, the pollen extracts are usually ineffective, and a vaccine should be used, these being injected at intervals of one or two days, until the

severity of the attack subsides.

An abstract (6) appearing in the Journal of the American Medical Association of an article by Miller states that "Some patients seek relief only when an attack is on them, and with these, the use of pollen extracts is of no benefit." Miller recommends instead the intramuscular injection of a nasal secretion filtrate, as a new treatment for hay-fever during the attack. As a matter of fact, in using a nasal secretion filtrate, he is really using a specific pollen extract.

My opinion regarding the value of co-seasonal or specific pollen treatment of fall hay-fever, is so contrary to those expressed above, that I feel it is worth while to go into some detail on this subject. Co-seasonal treatment of fall hay-fever has given extremely gratifying results in my hands. In a previous paper (7) I mentioned briefly co-seasonal treatment, reporting a case of late spring or summer hayfever, and also one of the fall type, successfully treated by this method.

When I first started to treat these cases during season, I followed the method of Walker, of giving pollen injections only every five to seven days. This method gave either no