BOOK REVIEWS

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book to press, and to judge whether or not he has succeeded in his endeavor, rather than compare merely size and other points of contrast with the other books upon the same subjects.

The volume in question at this time, is stated by its author, to be, not an exhaustive treatise upon pulmonary tuberculosis, but a manual, a handbook, with many case histories, intended to be of value to those who have not the time to give to the more elaborate consideration of this disease.

Following a chapter on Anatomy and Physiology, we are given a brief history of Tuberculosis, bringing the attention of the reader to the point where Pathology and Bacteriology may be logically studied. Diagnosis is very carefully outlined, as possibly the most important chapter, the author quoting Hamman, "Mistakes are due far more commonly to carelessness than to the difficulty of diagnostic methods." The chapter on Prognosis considers that the nature of the reaction of the patient early shows what may be expected, either a strong resistance which is likely to overcome the invasion, or a lack of resistance which can have but one end, and that the first year of the disease indicates the final result.

The ideas of Dr. Otis upon treatment may perhaps be judged by his quoting at the beginning of this chapter, Dr. Oliver Wendell Holmes, to the effect that it was his belief that the food swallowed and the air breathed were more important than other agents and would be so proven. All methods are considered in detail, both as to the disease in general and as to special symptoms, not forgetting the matter of prophylaxis. A final chapter gives case histories illustrating various phases of the disease, in addition to those in the chapters preceding bearing upon certain points in diagnosis, prognosis, and treatment.

It would appear that the author had attained his object in the production of a medical book helpful to all who read it, and a worthy member of the "Case Book Series" as published by W. M. Leonard, Boston, Massachusetts.-H. R. Reynolds, Surg. U. S. P. H. S.

NEW AND NON-OFFICIAL REMEDIES

During April the following articles have been accepted by the Council on Pharmacy and Chemistry for inclusion in New and Non-official Remedies: Armour & Co.:

Suprarenalin Solution-Armour. The Diarsenol Co.:

Silver Diarsenol.

Silver Diarsenol 0.05 Gm. Ampules. Silver Diarsenol 0.1 Gm. Ampules. Silver Diarsenol 0.15 Gm. Ampules. Silver Diarsenol 0.2 Gm. Ampules.

Silver Diarsenol 0.25 Gr. Ampules. Hynson, Westcott & Dunning:

Mercurochrome-220-Soluble.

During May the following articles have been accepted by the Council on Pharmacy and Chemistry for inclusion in New and Non-Official Remedies: The Gilliland Laboratories:

Acne Mixed Vaccine-Gilliland. Hoffman-La Roche Chemical Works: Pituglandol.

Lederle Antitoxin Laboratories:

Cholera Vaccine (Prophylactic)-Lederle.
Plague Vaccine (Prophylactic)-Lederle.
H. A. Metz Laboratories:
Silver Salvarsan.

Silver Salvarsan 0.05 Gm. Ampules.
Silver Salvarsan 0.1 Gm. Ampules.
Silver Salvarsan 0.15 Gm. Ampules.
Silver Salvarsan 0.2 Gm. Ampules.
Silver Salvarsan 0.25 Gm. Ampules.
Silver Salvarsan 0.3 Gm. Ampules.
Seydel Manufacturing Co.:

Guaiacol Benzoate-Seydel.

VOL. XI

No. 8

so that we cannot find from a test of the body that the patient has only one-half of one kidney. In the child, the thyroid should have at least onethird of its active cells to give off secretion during the period of growth. The thyroid is rarely destroyed by operation. More commonly the changes taking place through loss of the thyroid are due to disease, such as thyroiditis, an inflammation which gives little evidence of its existence until later in life, but changes occur which are finally identified through loss of the

that it may function throughout life. The child may be born without a thyroid, but it looks like any other child at birth because up to that time it has had an opportunity to secure the necessary hormone from the thyroid of the mother. The child born without a thyroid remains a dwarf, of animal type, with dry skin, dry hair, with failure of growth physically and mentally. But that child can be made to grow by giving it the chemistry that is created by the gland. All the world is run on the basis of chemistry. In the same way each animal cell has its chemical action, and now we have reduced the secretion of several of the structures of the body to a chemical condition so that they can be synthetically produced.

The thyroid is a gland which, because of its subcutaneous location, we know a little more about than we do about the pancreas or the adrenals. We see its enlargements. In the case of the girl as she comes to puberty, in the mother in the course of pregnancy, the thyroid is a little larger; in menstruation even a little more work is thrust upon it. Its normal action is chemical, and only a little material is necessary in order to stimulate activity. A part of any one gland is apparently enough to furnish the necessary amount of secretion, but production of this necessary amount may make the gland overwork. One-half of the thyroid does good work. Onehalf of one kidney will permit enough filtration

*Presented at the Sixty-Ninth Annual Session, Iowa State Medical Society, Des Moines, May 12, 13, 14, 1920.

the thymus is also furnishing its chemical secretion as a stimulus.

Formerly it was thought that in overworking glands the thymus might be associated with exophthalmic goiter, for a thymus sometimes is found in such cases. More commonly, however, it is not found, or only a vestige of it is found. We have the late Dr. Theodore Kocher to thank for calling attention to the indications, not only for operation, but for the prevention of the loss or injury of the parathyroids, causing tetany.

Dr. Crile believes that iodin deficiency in certain regions of the country has much to do with the development of thyroid over-growth in its tremendous struggle to get the one thing that it needs for normal function. Iodin is present in the gland, as was shown by Baumann, in 1895. Iodin, however, is not essential to the activity of the gland, but does help to activate it more quickly.

In some cases of exophthalmic goiter iodin cannot be found. There is an excessive secretion, without iodin. The gland is slightly larger, is harder, and under the microscope shows more cells. In parts of Canada, parts of Pennsylvania, and regions scattered through the mountainous districts of the West there are many goiter cases. Greenfield, of England, in six cases reported on in 1893, showed that in exophthalmic goiter there is an excess of cells, hyperplasia, and hypertrophy of the cells. Adenoma is the term applied to this condition in most any gland body. We

have adenoma of the breast; displaced adenomatous material from the interior of the uterus gives rise to adenoma of the uterus mixed in with the muscle cells. In the thyroid we find adenoma, the kind to which Dr. Plummer has called our attention. If the right stimulus can be applied, the thyroid is constantly ready for growth. In its structure a single layer of columnar cells surrounds the alveoli, and as the thyroid becomes larger with an accumulation of colloid it shows these little drops of colloid passing through the cells into the alveolus. The bulk of the material is given off at the base of the cell into the circulation. The thyroid does not deliver its secretion through the lymphatic system, but there are lymph spaces all through the gland. It delivers through its own venous system.

The thyroid affects metabolism. This was first demonstrated by Magnus-Levy in 1895, whose test showed that persons with exophthalmic goiter were burning more oxygen, and that there was more rapid exchange of the gases of the body than in other persons, unless the latter had fever or some such condition. A few years ago DuBois collected about twenty-six cases from the literature and his studies indicated that the thyroid in its overworked condition causes a more rapid exchange of gases, and that these people were eating ravenously, but by testing the air they took in it was found that they were taking more oxygen out of it, and by testing the expired air it was found they were putting into it more carbon dioxid.

Persons who have myxedema, having lost the thyroid gland, have a temperature of 94, 95 or 96 degrees Fahrenheit, according to the effect produced by loss of the thyroid gland.

Dr. Kendall, of our Clinic, put in seven years of time in an effort to reduce the thyroid gland to its chemical constituents, and finally, in 1914, on Christmas day, he was able to make the final analysis and reduce the thyroid gland to its chemical state. It is true we cannot transplant organs from animal to man because of the blood's incompatability. We cannot make the tissue of a lower animal grow in man and remain a working structure, and we should not transfer blood . from one individual to another unless the bloods are tested. We have, then, generated by these glands, a chemical action that we need. We need carbohydrates and proteins, but each thing is supplied to the type of tissue in the body which needs it, the circulation carrying it and the cells picking it up. The thyroid has to do with the activity. If the thyroid is removed the individual begins to get cold, there is great increase

in weight, he is sluggish mentally and physically; ask him questions and you get delayed answer or perhaps no answer at all; he will look at you stupidly just like the cretin born without a gland.

Dr. Plummer, having analyzed the thyroid, has been able to determine how much thyroid secretion there is in the body, which amounts to 7 mg., and how much there is in the gland, which also amounts to about 7 mg. If 7 mg. is injected into an individual with a temperature of 95 degrees Fahrenheit, dull, stupid, heavy weight, with fat pads over the shoulders, in three days you would not know him-the fat is disappearing, the edema is fading, the appearance of the face is changed. In eleven days, testing the metabolism and the burning every day, he is found to be normal. The effect slowly disappears after that time in about ten days, when he is examined daily. So not only do we know that increase of thyroid secretion increases the metabolism in the body, but after the thyroid is lost we now know for the first time how much thyroid secretion is required to keep up the work and for how many days between doses the case will remain normal. If thyroid tablets are given to patients with myxedema, most of them are able to absorb them. But those who cannot absorb them must have thyroxin hypodermically. Something goes wrong with these people with goiters in the ability of the intestinal cells to pick out the right chemicals with which to carry on their work. Then come the changes and retention of the colloids and changed secretion. The colloids can be made to disappear by giving thyroxin. If 7 mg. of Kendall's thyroxin is injected into large soft, rather smooth goiters of young people, perhaps seven times the normal size of the gland, the secretion will be reduced and in ten days the goiter will have gone down one-half.

The overworking gland was first described by a Frenchman, Parre, nearly one hundred forty years ago. Many years later it was described by Graves of England as Graves' disease. Later on Basedow also described the condition; therefore the Germans called it Basedow's disease. Then we have pseudo-exophthalmic goiter to which all sorts of appellations have been applied to indicate that the patient had symptoms of exophthalmic goiter so far as the rapidity of pulse, nervousness, loss of weight, excessive metabolism, and so forth were concerned, and yet it was not a true case of exophthalmic goiter. In this country very little has been written on this condition, and yet it represents nearly one-fifth of all the cases of exophthalmic goiter in this or any other country; as a rule this type of goiter

is not quite so dangerous although it appears to be worse. For instance, a patient may have had a goiter for about fourteen years and five months before symptoms due to the degeneration of the adenomatous material begin. At the end of about nineteen years on an average from the time of the development of the goiter, at the age of fortyeight years, the patient comes to the surgeon for relief with the history that the symptoms have been increasing for about five years.

The adenomas are subject to all types of degeneration. It is only the solid forms that can give adenoma with hyperthyroidism. There may be sagging of the lower lid, but this symptom may occur in chronic serious heart conditions, nephritis, syphilis, and so forth. Since 1911 we have separated these cases from the exophthalmic goiters, and during that period about 20 per cent of all the cases observed have been called toxic adenoma, or adenoma with hyperthyroidism.

What, then, is there about the degenerating adenomas that can produce a toxic condition of the body? Mitochondria was brought out by Bensley years ago in working on the thyroid of the oppossum. Recently Goetsch has been working on the thyroid of man and has shown that in these adenomas there is a mitochondria of the single cell. The condition of mitochondria has been studied by a good many observers. It is the most difficult work in the laboratory, for it takes many days to work out the stains of the single cell. It is good to work on until you have proved the condition, but not easy like showing the work in hyperthyroidism where you merely have to demonstrate hypertrophy and hyperplasia of the cell. In the case of mitochondria, we do not know whether it represents cell proliferation or activity, but we have taken it for granted that it is but an over-active cell in the adenoma, indicating cell activity.

On an average, patients with exophthalmic goiter come for treatment between the ages of thirty-one and thirty-six. The history is that they have had a goiter for three months, when in 50 per cent of cases exophthalmos develops, and in 90 per cent within two years. The patient with adenoma with hyperthyroidism has also rapid heart, trembling, weakness, myocarditis, irregular pulse, and, in the later stages, marked heart fibrillation which is almost a heart block. In exophthalmic goiter the same symptoms occur only very late. In the early stages the pulse runs rapidly. In the exophthalmic goiter case, it may run to 180, but in cases of degeneration of the gland it is often too rapid, weak and irregular to be counted easily.

Referring to iodin: Marine believes that iodin has much to do with the function of the gland. In a study of many of these cases we find that the iodin content of the adenoma may be way down or way up, that it does not follow the rule found in the hypertrophy and hyperplasia of exophthalmic goiter in which the iodin content is very low. And yet these patients have hyperthyroidism.

These cases are both medical and surgical. There is no question but that some goiters get better spontaneously, and that many simple goiters in the young disappear. I have had a number of patients come to me to have something done to get rid of the exophthalmos, the only symptom of the exophthalmic goiter remaining. Up to the time of Graves and Basedow hyperthyroidism was attributed to diseases of the nervous system and the central nervous system was believed to be at fault. Medical men resisted the idea that any surgical work done on the thyroid would benefit the patient. Kocher believed this until he had observed a few experimental cases and especially the pseudo-hyperthyroid cases, although at that time we did not know the cause of hyperthyroidism.

In

Innervation of the gland is through the sympathetic system. Jaboulay and Jonnesco advocated removal of the sympathetic ganglia, superior and middle. I studied the question in connection with epilepsy and goiter. Sometimes removal will help, but it has no permanent benefit, it does not do away with the exophthalmic goiter, and exophthalmos remains about the same. 50 per cent of cases one does not get sufficient benefit to warrant the operation. The operation is advisable in a few cases associated with paring the outer canthus of the eyes and suturing it to cover the eyeball. I have seen several people totally blind from exophthalmic goiter, with the eyes open, ulcerated, eroded, and with loss of the cornea.

Operation For the patient in whom the adenoma is beginning to grow and cause some pressure, operation should be advised because many of this group of patients at forty-eight will have serious hyperthyroidism.

We advise operation in exophthalmic goiter. If it is right to operate at all, it is right to operate early. early. There should be no mortality in the early stages; it is only in those cases in which the operation is done after complications that death occurs. It is just as right to operate early in these cases as it is to operate on gall-stones early, not waiting until the common duct and pancreas are involved. The patient should be told that at this