reaction, vascularization, and sometimes round-celled infiltration. It is important to note that usually but a small part of the gland is involved, and, unless the examiner is persistent, the affected portion may be overlooked. These never show much gland-proliferation, and never papillary formation. This fact accounts for the absence of eye-symptoms.

Goiters which exist for a long time are not innocent unless they have become calcified. Unless they do this, while they may not become toxic or undergo malignancy, they may have a deleterious effect on the heart muscle. How much we may do toward preventing these changes by operation is dependent on how much of the offending portion of the gland we may be able to remove.

CASE 13.-This patient, aged 55, had three children and no miscarriages, and passed the menopause two years ago. For several years prior to passing the menopause the menstrual flow was irregular and excessive. She had had a goiter for thirty years. It grew slowly until four years ago, but since that time it has not grown. Since the menopause she has had nervous spells and palpitation. The goiter seems sensitive at times and seems to disturb her respiration. Her sleep has been somewhat disturbed. There is a moderate, fine tremor. The thyroid isthmus shows a mass as large as a goose egg (Fig. 11), and a smaller nodule in the upper pole of the right lobe. The section showed glandular proliferation. (Fig. 12.) The pulse is 86. The nodule was removed. The disturbance to respiration seemed the only certain indication. The removal of the nodule resulted in the prompt and complete subsidence of all complaints. It seems fair to assume, therefore, that the part removed was exerting a mild intoxication. This assumption is substantiated by the evidence of proliferation as seen on microscopic examination.

CASE 14.-A woman, aged 36. She has had enlarged thyroid for many years. She was never conscious of any disturbance from it. A year ago she became nervous and trembly. The pulse is 100, and she has a marked tremor. She has lost a little weight, but feels weak out of proportion to the amount of weight lost.

A right lobectomy was done. She left the hospital on the fifth day with a pulse of 80. She was completely relieved of

all her symptoms. The specimen showed a cyst as large as a small apple in the lower pole. (Fig. 13.) The section showed cellular activity and increase of colloid. (Fig. 14.)

CASE 15.-A woman, aged 53. She had one child twentyfive years ago, and passed the menopause five years ago. She first noticed her goiter eighteen years ago. A year ago she had pain in it for the first time. She has quite a difficulty in going to sleep. She is exceedingly nervous, and worries a great deal though, according to her own statement, she has nothing to worry about. She has night-sweats and has lost considerable weight. The pulse is 96, and there is marked tremor of the hands. There is a well circumscribed tumor, the size of a small apple, in the isthmus. The tumor was removed. (Fig. 15.) On section it proved to be a fetal adenoma. (Fig. 16.) The pulse dropped to 66 before she left the hospital, and her other symptoms were relieved. The tumor contains several cavities filled with straw-colored fluid. The remainder is whitish-pink and granular. On section this is seen to be adenoid tissue.

V. Atypical. In this group those cases may be placed which, because of their course or form, depart widely from the usual. One may observe them many months, even years, before a definite diagnosis is possible. They may present the general symptoms of the neurotic. The one dependable clew is that they lose weight, regain it, and lose it again. A typical neurotic does not do this. The toxic cases likewise, when placed in bed, often show a high morning pulse with a lower one in the evening, though at no time is the pulse high enough to designate it as tachycardia. For instance if a patient with a pulse of 80 at a number of examinations, be placed in bed, the nurse may find 90 to 95 in the morning hours before it is time for the doctor to make his rounds. If, in addition to this, there is tremor the diagnosis is strongly presumptive. Often in such cases a thyroid enlargement or eyesigns may reward the astute observer for his pains. Operation does these patients no good, but they recover unless a too doting family too thoroughly convert them to the joys of invalidism. This type is

often operated on, and reoperated on without noteworthy results. Every thing about them is defective, and one cannot make a plus by taking yet more away from a minus. In these cases, more than in any other type, one must study the state of the patient before she becomes sick. In these cases it is well to consider carefully the family history. The life history of the mother may presage the subsequent history of the daughter with greater accuracy than we are able to do by the application of the fine points of our art.

In another group, fortunately small, an exact diagnosis may never be possible. The small, hard thyroid, possibly existent for many years, may be palpated if it is sought for. The patient may be a confirmed neurotic, presenting a complete picture of neurosis. Often, if one searches the past history, he may receive a clew. True neurotics are congenitally introspective and selfish. If, in the absence of such a history, the general symptoms of an indefinite neurosis develop the possibility of an endocrine disarrangement must be kept in mind.

CASE 16.-Mr. M., aged 52, has always had good health until five weeks ago. Without known cause he began to feel worn out, and had palpitation of the heart. The palpitation is made worse by excitement rather than by exertion. His sleep has been much disturbed by nervousness.

When he entered the hospital he had a pulse of 106; temperature, 100°, respiration, 30. The lungs and abdomen were negative. The apex was outside of the midline, and the heartbeat was diffuse. The right border was near the midline of the sternum. The mitral sounds were somewhat muffled, but there were no murmurs. The leucocyte count was 9,000.

Because of the persistent low temperature and the heartfindings a probable diagnosis of endocarditis was made. The significance of an apprehensive nervousness was entirely overlooked. Rest in bed for several months was attended by general improvement. He returned in two months in much the same condition as on his first entrance. He had at this time Kocher and Stellwag signs, rendering the diagnosis easy. A month later the right lobe of the thyroid was found

to be enlarged. The enlargement remained for six weeks, and then gradually disappeared. The disappearance, on the contrary, was attended by greater nervousness, which increased to actual mental disturbance at times. He subsequently improved and returned home, where he had a rather sudden exacerbation and died.

In approaching the study of the therapeutics of goiter it is helpful to have observed cases untreated in order to obtain a knowledge of the life history of the disease. If one has not had this opportunity it may be obtained in a measure by reading the earlier literature. The young man is too apt to assume that whatever good follows his efforts must have come because of such efforts, and, if disaster is averted, it must be because of his efforts.

It should be ever kept in mind that the general tendency is toward recovery and that many recover spontaneously. Recovery may be expedited by judicious operations. The time for operation must be carefully selected, and the operation chosen must be commensurate with the resistance of the patient. Above all, the operator must always hold the fact before himself that his operations must be without mortality, lest his therapeutic endeavors prove a greater menace than the disease.

Just what operation shall be done is a matter of judgment. In pulsating goiters preliminary ligation is useful. In large rapidly developing goiters improvement follows as it often does from mere rest in bed. In the small extremely toxic variety I do not believe ligation does any good at all. If one lobe is predominantly enlarged or if there is a circumscribed nodule, extirpation of this portion is usually sufficient. uniformly enlarged goiters a wedge may be taken from each lobe if the condition of the patient is first class; otherwise it is well to take two bites at it.

FOR DISCUSSION SEE PAGE 101

In

THE SURGICAL TREATMENT OF EXOPHTHALMIC AND THYREOTOXIC GOITER, WITH SPECIAL REFERENCE TO BILATERAL RESECTION

NEIL JOHN MACLEAN, M.D., M.R.C.S. (Eng.), F.A.C.S.

WINNIPEG, MANITOBA

There is no subject in the category of medicine about which there is so much diversity of opinion between internist and surgeon, as there is in the treatinent of exophthalmic goiter. There is, moreover, no uniformity in procedure, as to operative indications and operative technic, among surgeons themselves. The whole subject seems to be in a chaotic state, and this, no doubt, is due to the fact that the actual etiology of the disease is still unknown.

McCarrison1 says "there is no definite proof that the cures effected by surgical means (that is, by hemithyroidectomy alone, or with ligature of arteries) are more lasting than those effected by medical means." He has done excellent work on diseases of the thyroid, and has pointed out the importance of searching for focal infections; but, without minimizing the importance of these infective foci as etiological factors of obscure diseases, how often one finds that, even after all are removed, these cases are not cured, and, conversely, it is seldom that one finds exophthalmic goiter associated with extreme oral sepsis, infected gallbladders and appendices, or profound intestinal stasis.