Treatment of Goitre."

Dr. Goethe Link. Simple goitre may be overlooked as the cause of important symptoms. Intrathoracic extension of the enlarged thyroid below the ring formed by the first ribs, sternum and vertebra will cause great disability and if large enough, death. The symptoms of hyperthyroidism, though common, are frequently not traced to the toxin of a goitre. Two conditions always present in toxic goitre are tachycardia and enlarged thyroid. It is doubtful if the effects of well established Graves' disease are ever entirely recov ered from. The word "cure" must be relative, including arrest of progress of the disease. Several cases of mistaken diagnosis as to hyperthyroidism were related. One patient with substernal goiter pressing on nerve supply of vocal cords, with husky voice and emaciated from hyperthyroidism, had been treated for tuberculous laryngitis. Every woman with average pulse greater than 72 should have the thyroid examined. If there is a goiter belt, Indiana is a banner state. Simple goiters often become toxic. The

heart is damaged in many cases of sim

ple goiter. The use of iodine is harmful in every form of goiter except the rare cases where there is a deficiency of thyroid secretion. Hyperthyroidism is a frequent and important complication of medical, obstetrical and surgical cases. To show the innocence of thyroidectomy in simple goiter, a case was reported and pulse record shown. Post operative distress very slight and recovery rapid. A case of operation for severe hyperthyroidism was reported in contrast. The importance of the graduated operation was emphasized by case reports.

The earlier that operation is done for hyperthyroidism, the nearer it approaches operation for simple goiter with its slight danger. The writer's experience covering 25 operations upon 20 patients was reported. All were cases of toxic goiter except two. There were 16 thyroidectomies with one death; all living patients have been benefited, though the time has been too short to pronounce a cure. Litigation was done twice in hopeless cases for a palliative measure, the

patients dying one year and six months later. The technic and cases were shown by lantern slides. The importance of skilled anesthesia was brought out, the writer preferring ether and gas oxygen. Discussion. Dr. Keene:

There have been great advances along the line of goiter. In cases of increased heart rate in the gland enlargement we have decided the secretion is stimulating to heart. Crile's conclusion in handling is unique. His method of stealing precludes possibility of reaction. Later we will know more about which cases should be operated and which not. Ductless glands are being studied very much in laboratories the world over.

Dr. Eastman: We can do surgery in pregnancy as well as not. Dr. Padgett's report shows this. Dr. Link's paper was complete. I have observed the thyroid gland in many conditions. We must mention Dr. Crile among goiter operators. Crile sets out that Basedow's disease is one in which fear is the predominating factor. We must deal with exophthalmic goiter of fright. I think we can all diagnose goiter with few symptoms. Tremor tachycardia and exophththalmos should be remembered especially. Two cases were lost partly, probably, because they were treated too long. Not a medical case. Exophthalmic goiter at one time was a simple goiter. As to anesthesia I have used ether but am getting to use a local. Two cases have had trouble with their voices afterward in general anesthetic.

cases

Dr. Oliver: Many of injury could be helped if every doctor carried some iodine and a few instruments. We can amputate any day. Never saw a case of tetanus injured in cinders. Had four deaths in first sixteen cases thyroidectomies. Simple goiter operation is not a simple thing. Polar ligation could have saved two cases. Cited case of both eyes sloughing from exophthalmic goiter. Graduation method and stealing gland are the two things I would recommend.

Dr. Dodds: Cited case of his mother who had tried everything for goiter until surgery cured the case. There are

three generations of thyroid in my family. Thyroid means surgery.

Dr. Sterne: I want to emphasize element of fear in thyroid cases. This fear is allayed in Rochester by patients unoperated seeing patients having been operated. Many of these cases are luetic. There we have a medical and surgical case confined.

Dr. Link closed the discussion.

APRIL 28, 1914.

Program: Paper, Colliculitis. Dr. P. E. McCown.

The perfection of the modern urethrascope has revealed many interesting conditions never before seen in the living subject. It has made easy treatment to the urethra and bladder neck colliculus. Colliculitis varies from the highly inflamed and bleeding state to, in the chronic conditions, a pale, greyish, atrophic scar formation. The colliculus is described as a mound of tissue with a more or less elipticle or circular base, which rises into a pyramidal or cone shaped body, one to three-twelfths of an inch in height, with a pointed, dome shape or flattened top and is surrounded by openings of the prostatic ducts. The symptoms of this condition are illustrated by case report as follows: Married man had practiced withdrawal seven years; complained of urethral discharge, raw burning sensation in perineum and bladder neck, diminished sex power and desire. The pus proved to be sterile, thus showing non-venereal causation. Endoscopic examination showed a large, deep red, bleeding colliculus, extremely sensitive. Three applications of silver nitrate through the endoscope relieved the painful symptoms and reduced the organ to proper size and color. The belief is expressed that in addition to the foregoing symptoms, those of premature ejaculation, impotence and the other male neuroses, are not entirely due to the prostate and seminal vesicles but are the result in some instances, of colliculitis; for the colliculus is well supplied with sensory nerves, obstructs and receives the brunt of frequent voidance of urine which has a tendency to

prolong the inflammation. It behooves us, therefore, when a case presents sexual symptoms or painful symptoms referred to the bladder neck to make a careful endoscopic examination of the posterior urethra; this is specially true when the case has not responded to urethral dilations, irrigations or prostatic massages. Under treatment the galvanocautery and the Oudin high frequency current are recommended, especially in cystic conditions; bladder irrigations in the presence of pus; posterior urethral installations of silver nitrate. The best results were had by direct applications of silver nitrate through the posterior urethrascope and special emphasis is given the use of this instrument in the diagnosis and treatment of this condition. In the chronic atrophic form of this disease irrigations and dilations with sounds and Kollman dilator are recommended.

"Technique of the Wassermann Reaction," was the title of the paper read by Dr. Bernard Erdman. After discussing the Complement Fixation Test, definitions of terms frequently used were given in detail. Charts illustrated the titration of various factors. After the original method and a presentation of the underlying principles of the Wassermann reaction, the various methods of different workers at home and abroad were covered. The method of Citron 1914 and the method of Dr. William L. Moss, as found in Emerson's Clinical diagnosis, were discussed in detail. Various titrations and set-ups for titration of the antigen, Hemolysin and other factors were illustrated. Interpretation of results closed the paper, together with description of the necessary apparatus.

Discussion. Dr. Hamer: In reference to colliculitis there is little positive literature on the subject. As to treatment it varies. Chronic and acute cases demand different treatment. When cystic a puncture eradicates. Silver nitrate solution seems a popular remedy. High frequency current helps cases where papillomatous growths are found. Dilatation is necessary in these cases. Dr. Charleton: I wish to discuss Dr.

a

McCown's paper as if from the standpoint of disagreement and yet not actually so. Colliculitis as a definite conservatively determined process of disease is all that he has described it as being and requires intelligent direct and general treatment. Colliculitis as vogue or a specialists' fad, as I am afraid it is coming to be, may be greatly overemphasized and become productive of harm. Over several years I found in my own field of work touching these reddened follicles through an endoscopic tube with silver. Patches of apparent discoloration and thickening were SO treated over long periods of time. One such case with a chronic discharge and many shreds in the urine went abroad for three months and dropped all thought of his local trouble for that period. He came back entirely well. Other cases have acted likewise so that in more recent years I have begun to think that after drainage is assured by the relief of connective tissue bands (strictures) and the infective principle has been eradicated, that the less active local treatment indulged in the better. I refer to the "picking at" policy and this is what I fear from the recent emphasis laid on colliculitis. The old chronic prostatic with a scar mass instead of a gland mass for a prostate will not be cured and his sexual virility restored by applications to the veru montanum. It I will be the wise doctor who makes a strong application to the veru montanum occasionally and keeps "hands off" the rest of the time. We can't cure all cases. Dr. F. C. Potter: The Wassermann test is difficult to do. Blood serum is incubated thirty minutes before putting in ice box. This gives more serum. Have always used a colestrinized antigen. An amboceptor 1 to 3200 is preferred. The complement varies, hence it should be titrated.

Dr. Langdon: The past ten years constitute an epoch in the history of syphilis that is unparalleled in the study of any other disease. The principle upon which the Wassermann reaction is founded is scientifically accurate, but our trouble lies in the execution of the test.

We are agreed as to the specificity and reliability of the reaction, but much is to be said of the technique. Much discussion has centered in the antigen. There are dozens each having its own following. The two in most common use are the alcoholic extracts and thacetone insoluble extracts of human and animal tissues. The complement deviation test for syphilis is not an absolute thing. It is influenced by treatment and by the stage of the disease. The Wassermann test is the best we have for the diagnosis of certain cases of syphilis. It should be used in controlling treatment. The laboratory man can report only the reaction in an unknown blood. The physician must interpret it.

Dr. Earp: Asked for information regarding the fallibility or infallibility of the Wassermann test.

Dr. Brayton: There has not been enough of the Wassermann in our society. Sixty-five per cent. of our clinic patients have syphilis. The Wassermann will enable us to make a proper reparation. But we must be conservative.

Dr. Cregor. In colliculitis we must not forget prevention. When in that kind of practice I learned to refuse treatment to those to whom I felt sure would not carry out all instructions. The Wassermann must be used as an aid.

NEWS ITEMS.

Dr. Frank Mann, formerly an assistant to Dr. Gatch at the University Medical School, has accepted a position with the Mayo's at Rochester, Minn.

Dr. Frank Brayton, formerly an interne at the City Hospital, has an office with Dr. A. W. Brayton, 330 Newton Claypool.

Governor Ralston has appointed Dr. J. L. Freeland to succeed Dr. J. R. Hicks, of Covington, as a member of the State Board of Health. Dr. Hicks has gone to California to practice medicine. Dr. Freeland formerly was superintendent of the Indianapolis City Hospital. He is a Democrat. He was appointed to the

superintendency of the City Hospital by Mayor Shank, a Republican, and resigned about a year before Shank left office. Dr. Freeland was succeeded at the hospital by Dr. John W. Sluss. Dr. Freeland's appointment is for the remainder of the term of Dr. Hicks, which would have expired May 1, 1915. The remuneration of members of the State Board of Health is $10 a day for each day actually consumed in the course of the State's business, and necessary expenses. Other members of the board are: T. Henry Davis, Richmond, president; Dr. James S. Boyers, Decatur, vice-president; Dr. H. H. Sutton, Aurora, and Dr. John N. Hurty, State health commissioner and secretary of the board.

Dr.

Dr. Joseph Rilus Eastman, of Indianapolis, has been invited to read a paper in a symposium on Cleft Palate at the Clinical Congress of Surgeons in London in July. Sir Arbuthnot Lane, Johan Ulrich of Copenhagen, Judd, of Rochester, Minn., Brophy, of Chicago, G. V. I. Brown, of Milwaukee, Percy Legge, of King's College Hospital and Professor Kieth, of the Royal College of Surgeons, will take part in the symposium.

Dr. A. C. Shipp, assistant of Dr. Alburger at the University Medical School, has accepted the professorship of pathology in the medical department of the University of Arkansas, at Little Rock.

Dr. Charles L. Rea, of Falmouth, Ind., died April 7.

Dr. Francis M. Carr, age 83, who has been established as a physician at New Market, Stark county, since 1855, and actively engaged in his profession until eight years ago, died March 18.

Dr. Harvey W. Sigmond, of Crawfordsville, received a telegram April 15, informing him of the death of his brother, Dr. R. H. Sigmond, of Durango, Mexico. Dr. Sigmond died of uremic poison. The message was sent by the American consul at that place. Dr. Sigmond attended Wabash college with the class of

1897, but left Wabash in 1895 to attend the University of Virginia, from which institution he was graduated in medicine in 1899. He had been practicing medicine in Mexico since his graduation. He was born at Grand Lake, Ark.

Dr. J. Y. Hitt, aged 82, the oldest physician and surgeon in Greensburg, died in his apartments in the Annex hotel April 14. He was a native of Jefferson county, Kentucky, but had lived in Greensburg for fifty-five years. At one time he practiced in Indianapolis. During the Civil war he was surgeon for the Seventeenth Indiana regiment and later for Wilder's brigade. For thirty years he was physician for the Big Four Railroad Company.

The engagement is announced of Miss Helen S. Shingler and Dr. Colin V. Dunbar. Dr. Dunbar graduated from the Indiana Medical College in 1906.

Dr. M. M. Carrick, of Dallas, Tex., who is conducting a sanitary survey of twenty American cities, declared April 4 at the Claypool hotel that Indianapolis is one of the cleanest and most sanitary cities in the United States, if not in the world. He praised the State and asserted that the State board of health, under the direction of Dr. J. N. Hurty, is doing efficient service and that the entire country is beginning to be attracted by the administration of the Indiana health officials. Dr. Carrick has been investigating the public health administration of many American cities, and is closing his researches in Indianapolis.

The home of Dr. and Mrs. N. D. Woodard was the scene of a pretty wedding April 14, the bride being their daughter, Miss Grace Woodard, and the bridegroom Myron Curtis Cosler, son of Mr. and Mrs. O. D. Cosler.

Dr. William F. Batman, of Ladoga, a graduate of Jefferson Medical College, class of 1880, and one of our leading physicians and contributors to the Journal, has been nominated by the Demo

cratic party of Montgomery county for county auditor in a convention of 153 delegates. He writes the Journal that his election is commended and that if elected he will give up his practice and devote himself to the office. Thirty-seven years of general practice should at least entitle him to do a consultation practice. Dr. Batman has a large view of public duty and will no doubt bring as much credit to his county as its auditor as he has brought as a physician. Success to him and congratulations in advance to the county.

medical man in town. He refered me to Dr. Torrence. I found him at home looking happy with his three children, third wife and third mother-in-law sitting about him. He was a Scotch doctor and had been 29 years "on the job” at that particular post. He had a native assistant, a small hospital, several nurses and as many patients as he could handle. He entertained us kindly and the next day he and his American wife, accompanied us over to Nazareth and spent two days showing us the country. The Doctor could do this for he had walked, ridden and driven over almost every bit of it many a time day and night. It was touching to see the devotion of the people of that section to their Doctor. At Nabulus, ancient Sechem, a fanatical Mohammedan town where it is not safe for a Christian to go out alone, I found Dr. Clark, working away where he had been since he and I were students together at St. Bartholomews at London, 1881. At Assiut, up the Nile, I found my old friend and schoolmate, Dr. L. M. Henry, who is doing noble work and has been there for 22 years. He had some interesting pioneer experiences in Egypt when he used to count himself fortunate if he found a bag of onions to sleep on, onions and bed bugs being incompatible. He commenced on foot, then rode a donkey, a horse, a carriage and now an automobile. There are many others like these. E. S. M.

Patrick O'Rourke, an Irishman, had the misfortune one day of falling from the second story of a house just being completed. Mike Flaherty, the foreman, saw him fall and immediately called an ambulance, which in due course of time arrived. The surgeon gave one glance toward the still form and said, "he's dead."

Pat, who was coming to, heard him and, rising to a sitting posture, replied, "You're a liar; I ain't."

Mike was standing close by and took hold of Pat, gently saying, "Lay down, Pat, the doctor knows better."—Med. Standard.