GOITRE, EXOPHTHALMIC.
Rest in bed should be insisted upon in all cases where the disease has become established and where the pulse-rate is above 90. When this can be carried out in the open air so much the better. As soon as practicable X-ray or Radium therapy should be resorted to.
X-ray treatment has given excellent results, and should always be employed as the routine. Ilector Mackenzie's case where this treatment changed the disease into a typical one of myxcedema is strong evidence of its curative value. The applications and dosage of the rays should be always confined to an operator who has specially studied their influence in goitrous affections. The sittings of 2 or 3 times a week must be con tinued over several months. It is not yet possible to measure the relative value of this agent with Radium, which possesses the advantage of being useful in much shorter periods with longer intervals of rest between the courses. Under the rays the pulse falls, bodyweiglit increases, tremor disappears, but the exophthalmus is usually very slowly influenced.
Relapses follow in a considerable percentage of cases, and the treatment must be resumed.
lce or Leiter's tubes applied continuously over the pulsating gland may occasionally be found to reduce the heart's rapidity and other symptoms for several hours at a time.
Galvanism has been employed by the writer with advantage in mild cases and sometimes in severe ones by the use of the weak continuous current with one pole over the thyroid and the other over the spine; the sympathetic should also be galvanised, and a still weaker 5 cells (Leclanche) current sent through the brain by placing one electrode upon the closed eyelid over several layers of wetted lint and the other pole over the occiput. This treatment may be employed for /5 to 20 minutes daily at first and afterwards every 2 or 3 days for 3o minutes or more at a time; Charcot alternated the continuous with the Faradic current. There is generally a remarkable loss of cutaneous resistance, and the electrodes must be thickly padded with warm saline solution.
Drugs occasionally prove useful in the relief of the symptoms; thus 5min. doses of Tincture of Strophanthus or 15 mins. of Tincture of Digitalis assist in reducing the pulse-rate, and Bromides allay restlessness and insomnia. Belladonna is a doubtful agent, and,like Thyroid Extract, may dangerously increase the symptoms. Serum Therapy by the injection or oral adminis tration of serum from the blood of goats or sheep whose thyroid glands have been removed has proved of little or no value, and the same may be said of milk derived from such animals. The dose of Beebe's antithyroid serum should not exceed i c.c., and it is safer to begin with this dose, increasing it according to the nature of the local reaction, which is often severe.
Porter recommends the parenchymatous injections of Boiling water, 10-20 c.c., into the gland.
Operative Treatment.—After a few years of popularity the operative treatment of exophthalmic goitre has waned, chiefly owing to the success following the use of X rays. Operation is still sometimes used as a
preliminary to X-ray treatment, and is practised with greater frequency on the Continent than at home, and the results in the hands of some surgeons are very satisfactory, whilst others are much less encouraging. The real value of operation still remains to be demonstrated, but it is probable that present methods have reduced the death-rate of the disease by one-half. The first point which still requires settlement is the serious one of anmsthesia; many operators urge that local anmsthesia must invariably be resorted to. Dunhill states that he has operated on 88 cases under local anaesthesia with / death, whilst he is cognisant of 54 deaths in patients operated upon under chloroform anaesthesia during 9o9. C. II. Mayo states that he has operated on 405 cases of marked hyperthyroidism under ether preceded by atropine and morphia, with 19 deaths. In three-fourths of these one lobe was extirpated, and the great majority of them received 40 oz. Saline solution slowly by the rectum immediately after the operation. (rile believes that many deaths are due to excitement, and he urges the necessity of the patient being anxsthetised without his knowing that an operation is about to be performed, the gland being, as he puts it, " stolen away." With these very contradictory views and statistics it is obvious that there is little in the question of local versus general anesthesia. The danger of the absorption of a large amount of the fluid thyroid secretion after this has been squeezed out of the gland during the operation seems to the writer a much more serious factor in the mortality than the mere question of the form of anaesthesia, hence the great importance of drainage and frequent mopping during the stages of the operation. A long rest previous to operation is also a most important matter. Spencer and Gask recommend as the safest operative procedure division or excision of the isthmus with ligature of both superior thyroid arteries, and after a temporary improvement has occurred a partial excision of the gland may be more safely accomplished. Most operators proceed at once to remove one lobe of the gland as in ordinary simple goitre. Crile's latest technique appears to be an admirable one; he ligatures the vessels at the four poles of the gland before cutting away the gland tissue and leaves a portion of each lobe behind, after which the cut surfaces are sponged with almost boiling water to destroy the oozing secretion and check bleeding.
The operation of excision of the cervical sympathetic ganglia has been practically abandoned since thyroidectomy has been so frequently success ful. It must be remembered, though surgeons have brought down the mortality of the operation to a very low figure, in a still considerable percentage of cases the symptoms arc only ameliorated, and in a few no improvement follows, though the majority remain permanently cured. The proportion of cases successfully treated by simple ligature of the arteries without removal of gland substance is a very small one.