that surgical interference will not cure and can never repair such degenerations; and finally, that the time comes when the surgeon refuses to operate because these degenerations are SO marked that the patient cannot withstand the shock of radical treatment.

What, then, should the internist do? A good working rule is to treat the case medically for three months. If no improvement, refer to the surgeon. Medical treatment of exophthalmic goitre never produces the brilliant results found after operative interference, but should the patient be willing to persist in its use and should improvement warrant, it should always be tried. Many are incapable of persevering in the restrictions essential to control this disease, and these must go to the surgeon before it is too late.

In the medical treatment, above all things, enjoin rest, physical and mental, both during acute stages, and also when recovery seems complete.

Diet must be controlled just as carefully and persistently as we would in a case of diabetes. Indiscretions in diet are frequently followed by just as severe exacerbations in one of these dis

eases as in the other.

We must impress upon the patient the absolute necessity of avoiding all meats excepting a little poultry. He may eat vegetables, excepting beans and peas; raw fruits, excepting bananas, apples and berries. The basis of the diet, however, should be buttermilk or some of the fermented milks.

Some drugs aid. Sodium phosphate, 1⁄2 dram with meals, is highly recommended. A course of calomel about once a week is of marked benefit.

Tonics, fresh air and careful attention to the numerous symptoms as they arise, are always in order.

Serum of thyroidectomized animals has a distinct influence on the symptoms, unfortunately but little effect on

during the time the serum is given.

The cytolytic serum of Beebe still has its firm supporters, although the profession at large tends to believe that the results obtained are due rather to the associated general treatment than to any particular efficacy of the serum.

Another factor which must be recognized as of paramount importance is the mental attitude of these patients. For some unknown reason, their nervous system is constantly on high tension. Anxiety, fright or excitement of any kind is likely to produce an acute exacerbation of the disease.

Acute hyperthyroidism so frequently following thyroidectomy in Graves' disease is explained on this basis by Crile. As the result of a brilliant series of experiments, Crile concludes that this condition may be prevented by excluding the psychic factor, prior to and during operations. seem tenable, the internist must bring all his powers of suggestive therapeutics into play while dealing with this disease. But in spite of all that the internist can do, a large majority of cases of hyperthyroidism rightfully belong to the surgeon before it is too

As his conclusions

late.

Remember that the surgical border line of safety in the best of these cases is but slight. Every effort should be used to help the surgeon in his work. Let him have the patient before the degeneration of other organs is so far advanced that he returns to you a patient invalided for life-not because the operation has not removed the cause, but because the operation cannot repair the damage already done to the other organs.

In order to conserve that which remains uninjured, the post operative patient should invariably undergo a prolonged rest cure-with the treatment almost as rigid as already outlined.

Providing this class of cases has been operated upon before secondary changes

have taken place in the vascular and nervous systems, there are perhaps no such brilliant results attained elsewhere in surgery. Rapid recovery of perfect health is the rule. It behooves us, then, to constantly bear this

fact in mind-these cases can be cured -perhaps medically-nearly always surgically, if taken in time.

Whatever the type of goitre it should be cured. Nowhere in the field of medicine is the delay more insidiously dangerous and unwarrantable. First educate the public that this disease can be cured, then cure them-medically if possible, and surgically if necessarybut cure them, and help prove to the world that another disease has succumbed to science.

Mrs. M. R.-Age 48; married at 26; housewife; has had four children; menstruated at 14-28-day type; five-days' duration; moderate amount; menopause occurring eighteen months ago.

Always in good health until four years ago, when she contracted a severe cold; sick for three months following this, having high fever with considerable cough. This continued almost constantly until about two years ago, when some difficulty in swallowing occurred, with profuse regurgitation of about four ounces of foulsmelling and tasting fluid, whenever patient stooped over. Was obliged to sit upright at night in sleeping.

Tests for an esophageal diverticulum proved negative. A skiagraph taken did not clearly demonstrate anything definite in the chest, and a tentative diagnosis of bronchiectasis was made and the vaccines recommended. This gave negative results. In June of 1911 Dr. J. N. Hall saw the case, and diagnosed an old empyema, and further study of the skiagram substantiated in part this diagnosis. Operation was then recommended, but was refused. In November, 1911, patient became bedridden and sudden profuse pulmonary hemorrhage occurred, the regurgitation of fluid still continuing.

Operation at this time was accepted, and resection of one rib was made, with patient in sitting posture, under ether anaesthesia, Dr. Ham. A pocket of foul-smelling pus foul-smelling pus was opened, and drainage introduced, followed by the use of the hyperemic suction cup. Relief was quite marked at once, bleeding from mouth having ceased,

and patient able to lie down. Later the drainage tract. was explored with the Nitze cystoscope, and an opening discovered leading into a bronchus, from which was discharging a thick muco-purulent material. After about five weeks the tract became so small that little discharge was found on the dressings, and the patient commenced complaining of increase in cough and expectoration, with rise in temperature.

The original incision was enlarged and larger drainage tubes introduced, with steady improvement. The patient has had since this last operation two definite attacks of bronchitis, but since the first operation the patient has had no hemorrhage, nor has she had, on stooping, the annoying regurgitation of foul-smelling matter into the mouth. She is now able to pick up objects on the floor with no difficulty, and she is also able to lie flat upon the pillow.

612 Empire Building.

The diagnosis of delayed union and non-union of fracture of the neck of the femur is usually not a very difficult problem. The surgeon who is unlucky enough to have a case, where one or the other of the above conditions obtains, has the problem of diagnosis solved before he cares to admit it.

The symptoms are more or less shortening, advancement of the trochanter above Nelaton's line, unnatural mobility and some crepitus, and tendency to outward rotation. A skiagraph is indispensable, if obtainable, when the diagnosis is doubtful.

The causes of delay and non-union

seem to be too numerous to enumerate. The following may be mentioned as the chief causes: Improper reduction, causing a too wide separation of the fragments; imperfect or inadequate retention apparatus, failing to retain the fragments in place, after proper adjustment. Shreds of periosteum, muscles, tendons or fascia between fragments. Fragilitas ossium, which is usually due to osteoporosis. Charcot's degeneration; chalkiness, due to lack of animal matter; rickets; osteomalacia; diseases like syphilis, septicemia, pyemia, marasmus, pernicious anemia, advanced tuberculosis, scurvy, inanition, deficient innervation and blood supply. Inflammation of bone and loss of substance as a consequence, atrophic resorption of the ends of the bones, which appear as the eroded ends of the carbon points in an are light in the skiagram. The infectious diseases running a chronic course. Restlessness and

disobedience of the patient, and too early use of the fractured limb, before consolidation has taken place sufficiently.

Management of delayed union and non-union of the femoral neck. The first thing to engage our attention in non-union of the femoral neck is the shortening that exists and how to overcome it. The patient has already been confined to his bed for a longer

The

or shorter time, and it is usually not desirable, on account of his general health, to so confine him to bed more than is absolutely necessary. operative treatment of transfixing the fragments with a drill to be left in situ for some two or three weeks, is no doubt the best operative procedure. The patients, as a rule, are not willing to submit to operative treatment, and in delayed union and non-union there is not much prospect that union will take place in the limited time that the drill will be tolerated in the tissues. We have to look for something that will keep the fragments in position as much as possible, and when we have accomplished this, there will practically be no shortening.

The plaster of paris spica, extending down over the limb to the ankle first, then to the knee to admit of motion in the knee, is used more than any other ambulatory splint, to maintain fragments in position and prevent shortening.

The drawback to the plaster dressing is that it is almost impossible to get it snug enough to keep up the extension without compressing the cir

One

buckle is fastened to the belt in front of the groin, and a strap lined with sheepskin is sewed on the belt behind opposite the gluteal fold. A slit is cut in this strap where it passes under the tuberosity of the ischium, so as to form.

C

Side view showing reenforcement with steel brace.

To overcome these objections and shortcomings of the plaster cast, the writer has substituted a heavy sole leather belt of the very best material, closely moulded to the pelvis, extending up even with the crests of the ilia, downward over the great trochanter for 10 to 12 centimeters in front, on outside and behind. The front part of the belt should not be lower than the arch of the pubis. The belt is made in the following way: Take a piece of paper and cut out a pattern for the belt, after which the sole leather is shaped. This is soaked in water for 24 hours. It is then applied very accurately. A plaster spica is applied over the sole leather very tightly, extending half way down the thigh. This spica is to remain on until the belt is perfectly dry, which takes from three to five days. The belt is then taken off and lined with sheepskin, tanned on one side, wool to the surface of the body. Then three buckles and straps are sewed on the ends of the belt, so that it can be buckled tight to the body. One diagonal strap is placed over the ends of the belt, to prevent

Front view showing diagonal and split ischium strap.

a socket for the tuberosity, on which much pressure is brought, as it is this strap that prevents the belt from slipping up. The belt having been accurately moulded around and over the trochanter, as long as the belt is kept from slipping upward, the trochanter cannot advance upward, and the fragments are maintained in apposition favorable for union. The jarring that they receive from walking and using the limb, is conducive toward repair. Another action that the belt has is that of crowding the fragments aganst one another, as suggested by Sir Astley Cooper, who says that the fragments must be pressed against one another to facilitate union. The belt might be improved after it is finished by taking a cast of the trochanter with plaster on the inside of the belt, and making a pad after the cast and sewing this on to the belt in the exact place. A malleable inverted Y-shaped steel brace is riveted to the outside of the belt over the trochanter to maintain its shape, to prevent the perspiration from changing its shape by softening it.

Report of a Case. On July 13, 1910, the writer was requested by Dr. Cuneo to confirm a diagnosis that he had made of impacted fracture at the base of the femoral neck. The patient was a Greek, 21 years old, and gave the following history: Some three weeks before he had jumped off a street car in the middle of the block, and fell on the left hip. When he got up he found that he had practically lost the use of his left limb, but managed to hobble home, some three blocks away. A surgeon was called, and during the three weeks prior to seeing Dr. Cuneo he had five different surgeons, and spent two weeks in the hospital, where he was X-rayed. They all told him that it was only a bruise, and that he would be all right. When the writer saw him in consultation, there was eversion of the limb, with inability of active inversion, some crepitus, distension and bulging of the capsule, and one cm. shortening. He did not take the doctor's advice to have it set at once, but waited four days, till the fragments had unlocked, and the tissue surrounding the fracture had stretched, so at the time of setting there was 3 cm. shortening. Dr. Cuneo reduced the fracture, put on Buck's extension, with sandbags at the side of the limb, under the trochanter, so as to bring the fragments on the same level.

On examination at the end of seven weeks, there was no provisional callus thrown out, the fragments grated like rocks upon one another. It was evident that we were not going to have union in any reasonable time, if at all. We attributed the lack of union in part to lack of nourishment, confirmed by the patient's appearance. At the time of setting the fracture, instructions were, a generous diet with three quarts of milk a day and ten per cent of lime water in his drinking water.

This was not heeded for economic reasons. The patient was kept in bed for two more weeks, when a plaster spica was put on, extending below the knee, which he wore a couple of weeks. It did not maintain the desired extension, and edema of the foot and leg necessitated its removal.

At the writer's suggestion, a sole leather belt was improvised, as described, was put on and the patient instructed to use his limb with the aid of a crutch and cane. He was seen by Dr. Cuneo from time to time, till the latter part of March, 1911, nine months after the accident. When we examined the break there was no union yet, crepitus could be heard when he worked the rotator muscles. At this time there was inflammation and some distention of the capsule, some provisional callus was present; the digital fossa was partially obliterated by the callus. He suffered pain in the joint on walking, and claimed that he was as bad off as he ever was. Measurement of limb showed shortening 11⁄2 cm., apparent shortening much more on account of tilting of the pelvis. He was advised to use it less and have patience. He got disgusted and went to bed for 25 days. From this we probably have learned a lesson, that when a patient. gets inflammation of a delayed union, the fragments should be kept in absolute rest for a month or more, to give the delayed union a chance to consolidate. When he started to walk again with the aid of crutch and cane, he found the limb in a short time strong enough to walk on, without a cane, and he has been using it ever since. The shortening is 11⁄2 cm., which is neutralized by curvature of spine, so he has only a slight limp. We attribute the small amount of shortening and favorable termination of the case to a certain extent to the pelvic belt.