SURGICAL.-11, after treatment with iodine or with thyroid extract, no effect is produced, then operation becomes ad visable.
Three months considered ample time for the exhibition of drugs, when, failing improvement, operation becomes advis able. Pressure on the trachea causing dyspncea, and on the recurrent causing hoarseness, indicate early operation. John B. Roberts (Amer. Lancet, Feb., '95).
The surgical treatment of bronchocele has for many years been a subject of great interest, and to Kocher, Socin, and the Swiss surgeons much credit is due for the gradual development of success ful methods of operation. As above in dicated, it is more especially in the cystic forms that nowadays there is need to operate. Several methods have been suggested, the earlier being either in cision of the cyst (Beck) or puncture, followed by injection of iodine.
Referring to treatment by puncture and injection of iron, the substitution of rubber for metal cannuIse recommended on the third or fourth day, so as to do away with the risk of irritating the walls of the goitre. Thorton (Lancet, Feb. 18, '88).
Goitre the size of a hen's egg reduced to that of a small nut in nine months with one hundred injections of 5-per-cent. iodoformed ether. Terrier (Le Progres Med., Dec. 1, '88).
Interstitial injection of pure tincture of iodine is the most efficacious and least dangerous of all methods of treat ment for ordinary cystic goitre. Schwartz (Revue Ceti. de Clin. et de Therap., Mar. 23, '89).
Following directions given for the use of tincture-of-iodine injections: 1. Be sure that the needle is in the body of the tumor before injecting. 2. Avoid, as far as possible, the veins distributed in the cellular tissue over the tumor.
The syringe must be aseptic; it must be plunged slowly, but without hesita tion, into the gland. The syringe must then be taken off to see that no blood flows from the needle. This precaution is necessary to avoid injecting into a vein. Inject very slowly; 8 minims is enough for the first injection. If this is well borne (i.e., only slight pain with little swelling is caused), 15 minims can be used next time. One should wait a few seconds after making the injection before removing the cannula; only one injection to be made at a sitting, and an interval of four or five days to elapse before the next. There is considerable
radiating pain for a short time after the injection, also a metallic taste in the mouth for a few hours. Tincture of iodine is the best substance for injection. Terrillon (Bull. Gen. de ThGrap., Sept. 30, '89).
Case in which a goitre had diminished one-third after injection of tincture of iodine twice a week for four months. The last injection was followed by con vulsions and death, due probably to thrombosis. Sixteen cases of death after parenchymatous injections collected. Heymann (Med. News, Nov. 23, '89).
Four cases of cystic goitre successfully treated by evacuation and injection of a few drops of chromic acid in an "acid carrier." E. Noakes (Lancet, June 21, '90).
Iodine injections should not be used on account of the danger connected with them, and on account of the periglandu lar adhesions which they cause. These adhesions afford especial difficulties in the event of a surgical operation be coming necessary. G. Naumann (Cen tralb. f. Chir., July 9, '92).
Injections of iodine are only efficacious in recent parenchymatous goitres, but in these they are of great value. Brunet (Archives Clin. de Bordeaux, Feb., '95).
These methods are often followed by reaccumulation of fluid or haemorrhage into the the cysts, and extirpation of the cyst as first suggested by Juillard and Kottman, now as modified by Socin into his method of enucleation, gives excel lent results both in the case of cysts and in that of nodular parenchymatous growths.
In this country, Shepherd, following Socin's method, has had singularly good results in enucleating both cystic and nodular colloid growths. In the cystic forms he taps the cyst and evacuates some of the contents, and then the cyst wall can be peeled off from the gland tissue with the fingers or the raspatory much as an adherent ovarian cyst is peeled off from its surrounding struct ures. Should a vessel come to view, it is tied. Thus the operation is made one that is almost entirely external to the neck. It is remarkable how rapidly healing takes place after these opera tions, even when a huge cyst has been removed.