patient on Bulgarian bacillus tablets (Galactenzyme) for a prolonged period.

This line of treatment is strongly recommended and, by following it out, any and every doctor will have better results this summer than he has ever had before-that is certain.

It is too often forgotten that disease has its origin in the bowel tract; and it is surprising how many diseases, aside from those we are wont to look upon as purely intestinal, are the better handled by giving preliminary attention to the local bowel irregularity.

Slee's Glycerinated Vaccine Virus (Small-Pox Vaccine).—Our plans for serving our many doctor-friends with their biologic needs are working out beautifully.

After months of preparation we are now in position to supply the above, which we believe implicitly is at least "a bit better" than the best vaccine produced in any other laboratory the world over.

It is prepared and packaged at the Slee Laboratories under exactly the right conditions to assure a pure and potent vaccine. Everything involved is sterile and every precaution is taken to guard against contamination from beginning to end.

The laboratories themselves are miles removed from the smoke and dirt and the other contaminating influences of the city. Only young heifers in "the pink of condition" are utilized as the source of this vaccine; they are pastured and stabled out in the country and are rigidly inspected by the resident veterinarians at frequent intervals to make sure they are fit.

In charge is Dr. Richard Slee, the originator of the glycerinated vaccine, which now is used universally, and who is admitted, by all scientific people, to be an expert in this special field of work. There is probably no man living who has had more to do with the actual production of vaccine than he; his practical experience extends over a period of seventeen years. Under such supervision is this vaccine prepared -an ample guarantee for our doctor-friends that it is trustworthy.

If used properly it produces an absolutely typical "take," without pus-infection, which is the bugbear of the doctor as well as the patient.

Small-pox vaccine, as produced by Dr. Richard Slee, has been accepted as the standard for years by the government, who use it extensively-this is still another guarantee, and a strong one, that it is reliable.

This Glycerinated Vaccine Virus is prepared under Government License No. 6, granted after formal inspection by the authorities, as provided by law. The Slee Laboratory was one of the first to receive its license, as will be noted by the number assigned.

It is put up in glass capillary tubes of standard size, with all the necessary accessories, such as a scarifying needle, expression bulb, etc.

The price per package of ten tubes is $1.50;; per package of five, 75c. All orders will be filled promptly on the day they are received and delivery thereon prepaid when cash payment is enclosed. Emergncy orders received by wire will be rushed out by the first carrier.

Ask your druggist to stock this vaccine, thus guarding against delay in getting it when wanted.

Full directions for using, and precautions to be observed by the operator in vaccinating, are given on each package. Sole distributors, The Abbott Alkaloidal Company, Chicago.

A Common Form of Toxemia of Pregnancy -S. H. Blodgett (Medical Record, Jan. 13), from a study of over 1000 pregnant women in the Maternity Department of the Massachusetts Homeopathic Hospital for the past two years, concludes that many cases of vomiting of pregnancy are of pancreatic origin, as shown by acetonuria, diaceturia and a decided sore spot on deep pressure over the head of the pancreas. These patients, he claims, are relieved by the administration of 20 to 60 grains daily of sodium bicarbonate in abundance of water, which may be flavored with tea or lemon juice.

VOLUME XXXII

NUMBER 2

An enlarged thyroid-whatever the type should be of vastly greater interest to the general practitioner than it appears to be. Unfortunately, too many of us are prone to take refuge in the excuses so often repeated by the laity that medical treatment of goitre is well nigh useless; that its surgery is terribly dangerous and will leave the patient with a horrible skin disease or devoid of voice or intelligence. On the other hand, let us see how the old line insurance companies regard a goitrous applicant. If the goitre has not increased in size for five years; has not degenerated; is not substernal nor exophthalmic; and if the applicant is less than thirty-five years of age then and then only he may receive insurance, but always for the highest priced form of insurance extending over a limited number of years.

The enormous experience of the insurance companies must force us to believe that their statistics are correct; and if they decide so adversely against these people as acceptable risks, should we not awaken to the necessity of doing our best for them?

Again, our "oldest timers"-the Mexicans are very prone to goitres. Whether nationality or environment does this, we do not know. If environment be responsible, will the next generation of Americans in this region prove so goitrous as the Mexicans?

As yet, we know of no sure prevention. The subject is enormous; the real investigators few; and the lines of research lead far afield. Final conclu

sions will probably be reached by elimination rather than by positive findings.

Confusion arises from several sources "The pathology of the thyroid cannot be understood without a thorough knowledge of its physiology." This we do not know. Again, as yet "clinical and anatomic forms of goitre are impossible to harmonize-for instance, the vascularity of the gland-of great clinical importance is quite secondary, pathologically." For these reasons, nearly every scientist delving into the mysteries of the thyroid, gives us a different classification of its tumors. They distinguish, however, a diffuse and a nodular goitre.

The diffuse enlargements may be due to—

(1) Increase of all the elements-a genuine hypertrophy of the gland; or (2) Enlargement, due to increase in number and size of the epithelial cells (parenchymatous goitre); or

(3) Increased size of the follicles, due to increased colloid content (diffuse colloid goitre); or

(4) If in one of the already mentioned forms--(the hypertrophic, parenchymatous, or the colloid) the vascular changes are prominent-we have the diffuse vascular goitre.

(5) The diffuse fibrous goitre is usually the result of infiammation and subsequent connective tissue increase in one of the three forms first given.

The nodular goitre is one in which only a circumscribed area of the thyroid becomes diseased, but with charac

teristics within that restricted area which may be either hypertrophic, parenchymatous, colloid, vascular, or fibrous in type. These nodular goitres are prone to degenerate. To add to the confusion, there may be more than one type of pathological change in the same goitre, hence the numerous classifications.

The symptoms, for which relief is sought, are manifold. At first sight it would seem that the immense enlargements so frequently found in diffuse goitres would soon kill; but so long as the goitre shows approximately the same enlargement in all directions, the mechanical interference is slight, excepting in one way-cerebral congestion with its associated vertigo, and headache. This may be due to two factors constant pressure on the great vessels of the neck, or to the constant variation in the amount of blood in the goitre, so that the circulation cannot adapt itself to constantly varying pressure conditions.

Nodular goitres, on the other hand, tend to produce marked effects upon surrounding parts. Depending upon the direction of the pressure, we may have interference with the pneumogastric, phrenic or the recurrent laryngeal nerves; local interference with the circulation or the production of various types of "goitre hearts"; or distortion of the trachea and larynx, the oesophagus and pharynx (which at times have been erroneously diagnosed as asthma, aneurism and carcinoma).

Another great type-the exophthalmic goitre is a functional derangement most frequently associated with diffuse goitres; occasionally with nodular goitres, and rarely when no enlargement of the gland is demonstrable. The tendency for the goitrous is in two directions-into the hands of the surgeon or into the hands of the quack. And yet, over one-half of these cases can and should be cured by the internist.

In passing it might be well to state that it is by no means a rare event for a goitre to disappear without any treatment-apparently without any change in the mode of living of the host.

Medical treatment of simple goitres is divided into dietetic, hygienic and medicinal.

Diet: Change the drinking water. The patient should drink plenty of good water-which should be imported if necessary. if necessary. A vegetable diet is important. In addition, a careful regulation of the bowels must be insisted upon.

Hygiene Plenty of sleep; plenty of fresh air; avoidance of mental and physical excitement or exhaustion,in other words-the simple life.

Medication: The time-honored local

applications of iodine are of value. A mistake, frequently made, is to use the tincture of iodine, which irritates. It is far better to use a bland iodine ointment, which must be discontinued as soon as there is the least sign of local irritation.

Electricity, either faradic or galvanic, applied locally, often acts well, principally by diminishing vascularity. X-rays have been used frequentlysometimes with excellent results-more often with failures. In using the treatment, it must be borne in mind that the skin of the goitrous is very susceptible to the X-ray burns

Internally: Thyroid extract, 3-6 grains per day, should be given. Remember, however, that this is a potent drug and the first symptoms of overdosage must be noted. Many of these simple goitre cases are anaemic, nerv

ous

or depressed-which conditions should be corrected as soon as possible by tonics-the basis of which should usually be iron-preferably in the form of syrup of the iodide.

Complete cures are frequent by following this outline. But our efforts

must not cease—for upon return to bad environment, bad drinking water, continued excitement or a meat diet, a relapse is only too frequent. The patient must be constantly guided and guarded for months, perhaps years.

The next step, should our efforts be unsuccessful, is operative. We should first resort to the legitimate injection treatment—although the quack's refuge. Usually some form of iodine is used for this purpose. My own preference, advocated years ago by Dr. Gunn, is to inject 111⁄2 drams of a 5% c. p. carbolic acid solution in distilled water. Inject once a week and in successive lobes if the condition be diffuse, otherwise only in the diseased portions. About a dozen injections will usually suffice. Inject deeply into the gland with the patient reclining. Watch the urine for carbolic acid poisoning. I have never seen ill results from its use.

In the use of other injections I have had no experience-excepting once. That case had been injected by a colleague with iodine. A few minutes after the administration, there was a diffuse swelling of the entire neckclosely resembling a cellulitis.

As phyxia was threatening from rapidly developing oedema of the glottis. Intubation was about to be resorted to. The swelling of the glottis soon subsided, however. The massive swelling of the neck continued for two days, then rapidly disappeared without further symptoms.

Radical operations for simple goitres have definite indications; the results are good, and the mortality, in the hands of the experienced, not more than one per cent.

All simple goitres, undergoing fibrous, calcareous, hemorrhagic, colloid or cystic degenerations, should be operated upon at once. If pressure symptoms are marked, or if abnormally situated; or if growing rapidly; or if sensitive to pressure; or if nodular in a person over forty years of age-any

such goitre should be referred to the surgeon. Occasionally, also, a goitre should be removed for cosmetic reasons only.

Exophthalmic goitre (or as Mayo better terms it, hyperthyroidism) is easily recognized when typical. Hundreds of cases are atypical. The prominent symptoms of which the patient complains may be seemingly in no way related to hypersecretion of the gland. No disease give us so many signs of a generalized toxaemia.

Not an organ nor a physiological function of the body escapes being disordered at some time during its course. Such being the case, should we be surprised when our patient seeks the advice of the quack after his disease has been repeatedly diagnosed erroneously from a transitory prominent symptom and the underlying cause is not recognized?

One case, under my care, will illustrate. A physician of undoubted ability referred a case of amenorrhoea of unknown origin. Careful physical examination would have revealed a slight tremor, pulse of 110, and thyroid enlargement. Two weeks after a partial thyroidectomy, the patient menstruated for the first time in seven months. Now-three years after the operation

the patient is still perfectly well. In other words, amenorrhoea-a minor symptom sometimes present in hyperthyroidism-became of paramount importance to the patient, and unconsciously her anxiety reflected itself upon the physician's better judgment when diagnosis was in mind.

In considering the treatment of exophthalmic goitre, we must bear in mind several factors-that medical treatment must be persisted in for months or years if a satisfactory outcome is to be expected; that in spite of such treatment sudden relapses are common; that degenerations and functional derangements of other organs are constantly progressing when such