phied glands, or rarely in non-hypertrophied thyroids, the cysts being either single or multiple, being due to mucoid or colloid degeneration, and containing a fluid sometimes clear and thin, sometimes viscid, and often coffee-ground in character; and fibrous goiter, a fibrous induration which is apt to arise in old bronchoceles, and which may pass into a calcareous condition. Parenchymatous goiter is enlargement of the whole gland. By the term malignant goiter we mean malignant disease of the thyroid gland, either sarcoma or carcinoma.

The symptoms are-congestion of the head and neck from enlargement of veins; occasionally cerebral symptoms (anemia, syncope, even convulsions) from pressure on carotids; irritation of recurrent laryngeal nerve (causing spasm of the glottis or laryngeal paralysis); compression of the trachea (dyspnea). Rapidly-growing goiters are often fatal; slowgrowing goiters are rarely fatal. A goiter moves up and down as the patient swallows. A malignant goiter grows rapidly, becomes adherent, infiltrates, and quickly produces metastasis. Both sarcoma and carcinoma produce metastasis by way of the venous system.

Treatment.-Iodid of potassium and arsenic internally have been advised; ointment of red oxid of mercury locally is advocated by some writers. The local use of iodin benefits many cases. The administration of thyroid extract may do much good. Cystic goiters may be aspirated and injected with a solution of iodin. Electrolysis may benefit a soft goiter, the negative pole being pushed into the growth, the positive pole being applied to its surface. In considering the propriety of operation remember that a goiter which begins at puberty may pass away. We should operate on every non-malignant goiter which is increasing rapidly in size, and on every goiter which causes much respiratory trouble, but should not operate simply for deformity (Bergeat). If enucleation or extirpation is performed, do not give ether or chloroform. These agents greatly increase bleeding, and are dangerous. Do the operation without any anesthetic or with the aid of local anesthesia (cocain, eucain, or Schleich's fluid). It is a great advantage to have the patient conscious, because by asking him to speak during the operation the surgeon can tell if the recurrent laryngeal nerve is being touched. In most cases intraglandular enucleation is performed, in some cases extraglandular enucleation, in other cases these two methods are combined (Bergeat). Ligation of the thyroid arteries has been recommended. Enucleation, if pos

sible, is the desirable operation. It may easily be employed for the removal of a single colloidal or cystic area (Socin). Thyroidectomy or extirpation is employed when enucleation is impossible. The entire thyroid is not removed; a portion of the gland is left behind, otherwise myxedema will arise (Kocher). Unilateral extirpation is the usual method. In sarcoma or cancer of the thyroid extirpation may be attempted. The operation will occasionally prolong life,

but it will rarely effect a cure.

Exophthalmic Goiter (Graves's Disease; Basedow's Disease; Pulsating Goiter).—In a typical case there are rapid pulse, protrusion of the eyeballs, and enlargement of the thyroid gland; but any one of these conditions may be absent. The enlargement may be unilateral, but is usually bilateral. A systolic bruit is usually audible over the thyroid region. Von Graefe's sign may be present; this consists of retraction of the eyelids, and inability of the lids to follow the eyes in looking down. The lids in some cases cannot be completely closed, and when the eyeball is suddenly turned up the lid and brow may fail to act together. In some cases the lids pulsate, in some ocular palsies exist, in others photophobia or nystagmus. Patients may suffer from neuralgia, colic, choreic movements, tremor, flushes of heat, and gastric crises. Dyspnea often exists, and albuminuria and polyuria are not uncommon. Hemoptysis, hematemesis, or mental disturbance is sometimes noted.

Exophthalmic goiter may arise after emotional excitement or depression, during pregnancy, or during the existence of locomotor ataxia, paresis, epilepsy, neurasthenia, hysteria, and other nervous troubles. Cohen considers it to be a vasomotor ataxia. Its real cause is uncertain; but is probably the action upon the sympathetic system of some poisonous product of thyroid action.

Treatment. Thyroid extract more often does harm than good. Electricity is said to be of benefit. Most cases are treated by improving the general health, and employing digitalis. Thymus extract has been used by some. Extirpation of the cervical ganglion of the sympathetic, and division of the nerve below the ganglion, have been employed with benefit (Jaboulay). Ligation of the thyroid arteries may do good. Incomplete removal is the operation commonly employed in severe cases; it has cured eighty per cent. of the cases operated upon. In some cases thyroid intoxication follows operation. In other cases very rapid growth follows incomplete removal, and the operation seems actually to have

done harm. Sudden death occasionally follows the operation of thyroidectomy. The removal of an exophthalmic goiter is difficult; the capsule and blood-vessels rupture from slight force, and the use of ether and chloroform is very dangerous. All cases should not be operated upon; in fact, only those cases should be operated upon in which medical treatment has proved futile, or in which there is profound toxemia or excessive dyspnea. If the operation is performed, neither ether nor chloroform should be given, as either of these agents will greatly increase bleeding and prove dangerous. Operation is to be done under local anesthesia (eucain, cocain, or Schleich's fluid).

XXXIII. DISEASES AND INJURIES OF THE

LYMPHATICS.

Lymphangitis is inflammation of lymphatic vessels. Reticular lymphangitis, which is inflammation of lymphatic radicals, is seen in some circumscribed inflammations of the skin. It is apt to attack the hands, causing redness and swelling, fading at the point of initial trouble while it spreads at the periphery; it is caused by micro-organisms derived from decomposing animal matter (Rosenbach). Erysipelas also causes it (see Erysipelas). Tubular lymphangitis, which is due to the entry into the lymphatic ducts of virulent microorganisms or toxic materials, is seen in dissecting-wounds, septic wounds, snake-bites, etc. It is announced by edema and by minute, hard, red streaks running from the wound up the extremity. Suppuration may occur.

Infective lymphadenitis, or inflammation of the glands, may follow lymphangitis or may be due to the deposition of infective material, the lymph-vessels not being inflamed. In septic lymphadenitis there are pain, tenderness, and swelling; in severe cases there are chill and septic fever. Suppuration may arise. The treatment is to drain and asepticize the wound, to apply iodin, blue ointment, or ichthyol over the glands and vessels, and to employ rest and compression. Internally, milk punch, quinin, and nourishing diet are required. If the glands do not rapidly diminish in size after disinfection of a wound, and if they are in an accessible region, extirpate them. If suppuration of the glands occurs, incise and drain.

Acute lymphadenitis, or acute inflammation of the lymphatic glands, may be due to tubercle, syphilis, glanders, cold, or traumatism. Suppuration may or may not occur.

In in

flammatory lymphadenitis there are pain, heat, and nodular swelling. In severe cases there is fever. The treatment is to asepticize any area of infection, place the glands at rest, apply cold and lead-water and laudanum, or inject into the gland every day 5 minims of a 3 per cent. solution of carbolic acid to prevent suppuration. If the glands do not rapidly shrink, extirpate them. If pus forms, evacuate, drain, and asepticize.

Chronic lymphadenitis is almost invariably syphilitic or tubercular. It requires constitutional treatment and the local use of ichthyol, iodin, or blue ointment. If these remedies are not rapidly successful, tubercular glands should be removed, but syphilitic glands will rarely require such radical treatment.

Lymphangiectasis (varicose lymphatics), or dilatation of the lymphatic vessels, is due to obstruction. It results, as a rule, from chronic lymphangitis or the pressure of a tumor, and is most usually situated in the pubic, the inguinal, or the scrotal regions, or on the inner side of the thigh. There are two forms: the varicose, in which the vessels have a tortuous outline, like varicose veins, but are covered only by surface-epithelium; and lymphatic warts (lymphangioma circumscriptum), in which wart-like masses spring up, these masses being covered with epithelium and filled with lymph. In most cases of lymphangiectasis there is considerable hard edema. Rupture of the dilated vessel causes a flow of lymph (lymphorrhea).

Lymphangioma is an advanced stage of lymphangiectasis (page 226). The treatment in mild cases is to pierce each vesicle with the negative pole of a galvanic battery and pass a current. In severe cases destroy the mass with the Paquelin cautery or excise it with a knife or with scissors.

Elephantiasis.—True elephantiasis (elephantiasis Arabum) is chronic hypertrophy of the skin and subcutaneous tissues following upon a lymphangiectasis produced by a nematode worm (the filaria sanguinis hominis). Spurious elephantiasis is hypertrophy of the skin and subcutaneous tissue due to chronic inflammation (in a leg which possesses an ancient ulcer, or in the scrotum of a man with urinary fistula). The treatment is massage and bandaging, sometimes ligation of the artery of supply, extirpation, or amputation.

Malignant Lymphoma, or Hodgkin's Disease.— (See page 221.)

XXXIV. BANDAGES.

A bandage is a fibrous material which is rolled up and is then employed to retain dressings, applications, or appliances to a part, to make pressure, or to correct deformity. It may be composed of plain gauze, of gauze infiltrated with plasterof-Paris or soaked in silicate of sodium, of gauze wet with corrosive-sublimate solution, of flannel, of calico, or of unbleached muslin. Unbleached muslin, which is the best material for general use, is washed to remove the sizing, is torn into strips, and the edges are stripped of selvage. One end is folded to the extent of six inches, this is folded upon itself again and again until a firm center is formed, and over this center the bandage is rolled. In a well-rolled bandage the center cannot be pushed out of the roll. A roller bandage is divided into the initial end, which is within the roll, the body or rolled part, and the terminal end, which is free. In applying a bandage the outer surface of the terminal end is first laid upon the part.

A cylindrical part of the body may be covered by a circular bandage, each turn exactly covering the previous turns. A conical part may be covered by a spiral bandage, each turn ascending a little higher than the previous turn. As each turn of a spiral bandage is tight at its upper and loose at its lower edge, the reverse was devised to correct this inequality; hence a conical part should be covered by a spiral reversed bandage. To make a reverse hold the roller in the right hand, start the bandage obliquely upward (do not have more than six inches of slack), place the thumb across the fresh turn, fold the bandage down without traction, and do not make traction until the turn has been carried well around the limb. A projecting point is covered with figure-of-8 turns. The groin, shoulder, breast, or axilla can be covered by figure-of-8 turns, each succeeding turn ascending and covering two-thirds of the previous turn and forming a figure like "the leaves on an ear of corn." Such a figure is called a "spica." In bandaging an extremity the peripheral turns should be tighter than the turns nearer the body. Never apply a tight bandage to the leg or the arm without including the foot or the hand. In firm dressings leave the ends of the fingers exposed, and use them as an index of the condition of the circulation in the part.

Spiral Reversed Bandage of the Upper Extremity. -To apply this form of bandage use a roller two and a half inches wide and eight yards long. Take a circular turn