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and is able to do most of her house work that she formerly did before her illness began. She has attacks of tachycardia and weakness at times, due to a partly degenerated heart muscle-permanent damage that had been done by a delayed operation. The eye symptoms have nearly disappeared. I believe she will continue to improve over her present condition.

The examination of the blood in exophthalmic goiter is also a guide to the gravity of the case when operation is considered. Kocher reports careful examination in fifty-eight cases in which he found the number of lymphocites increased while the polynuclear forms were diminished. The total number of leucocytes were normal or rather low. The number of lymphocytes were at times absolutely increased, but more often the increase is a relative one. The increase is proportional to the degree of the disease, and if there is no increase of lymphocytes the case is an especially serious one. He found only in very early, undeveloped cases, and in those of long standing which have improved, do we find lymphocytosis absent. These findings have been confirmed by our pathologists at the hospital.

Many cases of goiter get well without or with treatment, and as Mayo very tersely says, it is perfectly justifiable for physicians to institute treatment on any line, plan or system which they believe proper. The mistake in the past has been to persist in the belief that some particular drug or treatment would eventually be successful in spite of the downward progress of the patient, thus withholding surgical aid until of necessity, the surgical mortality represents, also, in part, what should properly be medical.

I have had no experience with serums or milks. The published reports of serum treatment by Rogers and Beebe are still uncertain. In forty-two cases where they used the cytolitic serum, they report 43 per cent. of the cases cured, 33 per cent. unimproved, and 10 per cent. dead. Organotheraphy may yet be perfected to great efficacy.

Both Mayo and Kocher report a percentage of less than 3 per cent. in exophthalmic goiters, with 83 per cent. reported

cures and all the cases that survive the operation have been much improved.

There is no doubt that the prognosis of exophthalmic goiter has improved the past few years since it has been placed on a safe and sound basis. Kocher, in a foreign journal for March last, states that there are fully one thousand cases on record now of operative treatment of exophthalmic goiter, including three hundred and seventy-six cases from the Kocher clinic, 76 per cent. of the patients being cured. In the latter group, the exophthalmus has subsided in three-fourths of the cases, depending more on its duration than its degree. He discusses the twenty cases in which the operation failed to cure, showing that recurrence of the goiter was responsible for this in some of the cases. In others secondary lesions of the other organs were responsible, and in the remainder there was a tendency to neurasthenic-hysteric manifestations erroneously ascribed to the exophthalmic goiter itself, but they should be considered separately, and the fact born in mind that a neurotic tendency influences the onset, and degree, and the course of the exophthalmic goiter. He compares the almost inevitable improvement and the constant cure when the operation has been properly done with the uncertain results of internal treatment, everything speaking in favor of the former.

In preparing advanced cases for operation, rest and hygiene and internal treatment is important. The internal administration of extract belladonna and quinine, with quiet surroundings, have seemed to place the patient in better condition for operation. The X-ray shows marked improvement in most cases, but it does not last long. The Kochers and Mayo, in advanced cases, ligate one or more vessels of supply (under cocaine) according to the case, reserving the extirpation of the gland for a later period.

Ether was used in all of our cases. In six cases it was necessary to discontinue it after the collar incision was made, except to give a few drops at intervals during the operation as required; the open drop methor being used, and is given in the room where the operation is done. The region of operation is prepared while the ether is being given. The patient is

placed in the reversed trendelinburg position, with a pad under the shoulders to throw the head back. The size of the pad under the shoulders must be regulated so as not to interfere with respiration. Morphinae sulphat grs. 1-6 and atropine sulphat grs. 1-120 is given hypodermically, one-half hour before the patient is brought to the operating room. In so doing, less ether is required and helps to keep the trachea free from


A symmetrical transverse curved incision is made after the manner of Kocher, extending from the outer border of one sterno-mastoid to the outer border of the other, according to the position of the goiter. Goiters of any size or position can be readily approached and removed with this incision. The skin and platysma are divided. They expose the anterior jugulars and the muscles covering the gland, namely, the sterno-hyoid and thyroid and sterno-mastoids and omohyoid. The muscles are now separated, and if a good exposure of the gland is not obtained, a high transverse incision of the muscles is made on one or both sides, as required.

After the capsule is exposed the superior thyroid artery and vein are located and well separated from the muscle and tied and divided. This ligating prevents much of the occurrence of hemorrhage when the capsule is opened. The gland is well separated from the surrounding tissue. The capsule is now split and dissected or brushed back with dry gauze, and gradually pushed back and the capsule preserved. Here you may encounter the bands which stretch from the neighboring tissue to the gland and contain the accessory veins. These are clamped and divided. The vessels are well developed in large goiters and the vascular exophthalmic type. Each bleeding point should be securely clamped as you go along. The goiter is dislocated by lifting forward with the finger and elevating the upper and lower holes. The inferior thyroid is seen to enter the gland well down near its attachment to the trachea. To expose it the tumor is pushed to the opposite side. In tieing it care must be taken to avoid the recurrent largeal nerve, which ascends behind it. This artery, if seen, is many times found and ligated out in the dissection. By keeping

within the capsule and clamping in a line parallel with the nerve, you are less liable to injure it. By preserving the posterior capsule you are ordinarily safely away from the parathyroids. Their removal, as well as injury, from clamping, should be guarded against, as in either case tetany may result.

The capsule having been well pushed back, the isthmus and pyramidal lobe, if present, remains to be isolated and divided. If the isthmus is to be removed, the communicating veins. between the two sides are tied and divided and the isthmus can be separated from the trachea with blunt dissection without any great bleeding, leaving a stump which protects the recurrent lanyngeal. This is then closed with lock stitch of catgut.

The remaining lobe is examined and if not diseased is allowed to remain. The bleeding points are securely ligatured and wound carefully sponged and inspected for bleeding points. If it has been necessary to cut across the upper attachment of muscles, they are now sutured in position again with continuous catgut and the muscles in the midline brought together.

All exophthalmic cases we drain from two to four days. Nearly all the other cases are drained for one day only. Normal salt solution per rectum is started as soon as the patient is put to bed, especially in exophthalmic cases. Three to four quarts are given the first day and continued for three or four days if required. If the salt solution is given slowly it is usually retained. It must be given subcutaneously if the patient expels it. Morphine is given hypodermically for pain or restlessness and atropine sulphate for sweating. A rise in temperature and pulse may occur for the first two or three days, when it usually subsides and the patient is out of bed and home in a week.

The platysma is well sutured with cutaneous catgut to prevent a wide scar, and a subcuticular catgut is used in skin. Enucleations of goiter recommended by Porta, and brought into general use by Professor Socin, is indicated where there are well defined colloid nodules scattered through both halves of the gland, or where a single nodule exists, causing pressure

atrophy of the gland, which would ultimately destroy its usefulness. The condition of the gland present at the time of operation is a guide as to what surgical procedure to perform.

A nodular, hard goiter, of rapid growth, should be removed early, as it suggests malignancy. Malignant disease of the thyroid gland is rather rare. It is said to be found more often in the goiterous gland than the normal gland. It is but rarely seen at a period when it is suitable for operation, and the result of operations are most unsatisfactory.

During the past three years we have operated on one hundred and twenty-five thyroids, with one death. This was an exophthalmic case far advanced in the disease, and possibly a mistake was made here in not doing a preliminary ligating of the superior thyroids. Forty-two of these were of the exophthalmic type. The remaining operations represented cysts, colloids, adenomatous and parenchymatous, one a tumor of the pyramidal lobe, and one fetal adenoma of an accessory thyroid. The results of operation have been most satisfactory, and the rapid improvement in all the cases has been very gratifying.

One of our operative cases of colloid goiter in a man aged 56 years, who had pronounced evidence of hyperthyroidism, and who came late for operation, died six months after, owing to lesion in the heart and kidneys brought on by his goiter. He was bed-ridden when brought to the hospital, but he improved rapidly after operation, and was soon looking after his business, that of an upholsterer. Overwork and too close attention to business after operation overtaxed an already diseased heart, his death being directly due to changes produced in the heart muscle and kidneys by a delayed operation.

The results in the exophthalmic cases have been most satisfactory, having improved in all their symptoms, and many of them cured. A large percentage of these cases have been done in the past year and a half, and the favorable reports received from these patients is sufficient to encourage the belief that a permanent cure will result in a large percentage of these cases.

The only complication we have had following operation was a mild case of tetany in an exophthalmic case which lasted

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