SURGERY OF THE THYROID GLAND.

1091 toxin being possibly of placental origin as suggested by Willson. The haemorrhage may be apparent, the blood escaping under the edge of the placenta or through the cervix into the vagina, or it may be concealed, the blood accumulating in the retro-peritoneal space and infiltrating the muscle fibres, thus causing uterine atony, or it may rupture into the amniotic sac. The haemorrhages which are small at first coalesce and extend to the tubes, ovaries, and out into the broad ligaments. Bloody nuld may be found in the peritoneal cavity probably coming from small fissures in the surface of the uterus. In a typical case the onset is sudden and violent, the severity of the symptoms depending on the degree of the separation. The patient who is in the last three weeks of pregnancy complains of a sudden abdominal pain of a colicky nature and soon shows signs of acute anaemia, followed by shock. A bloody vaginal discharge may or may not appear. On examination the uterus is found to be larger than usual, very tender, and of a peculiar wooden consistency. No placenta can be felt per vaginam. Treatment consists in emptying the uterus as soon as possible by forceps, version or Caesarean section, stopping the haemorrhage, and combating the anaemia. In some cases hysterectomy may be required. The prognosis is very grave, the maternal mortality being about 60 per cent. and the foetal mortality about 90 per cent. Cases which survive require the utmost care and attention. SURGERY OF THE THYROID GLAND. IN the April number of the B1’itish JOlLrnal of Szcrgeo°y Mr. James Berry gives an account of a series of 500 operations for goitre, with special reference to the afterresults. The youngest patients were five girls of 14 years of age, who had parenchymatous goitres. Operations on children under puberty were only undertaken when urgent, for in the young there is danger of interfering with growth and normal development. The oldest patients were seven males between 70 and 75 The two commonest forms of goitre years of age. were the non-encapsuled adenoparen137 cases, and the encapsuled cystic adenomatous, 109 cases. Seventy-nine operations were for true exophthalmic goitre as distinguished from " false" exophthalmic goitre. In the latter there is tachycardia, tremor, &c., without exophthalmos, mostly with unilateral goitre. Sometimes true exophthalmic goitre develops in a patient who has previously had an ordinary goitre for a more or less long period. Twelve cases of malignant disease were operated on, these being selected from a large number of cases Of the cases of malignant disease which were seen. operated on, two were sarcomata, one undetermined, The and the others carcinomata of various types. indications for operation were chiefly dyspnoea (274), discomfort and deformity (99), and exophthalmic goitre (79). Tracheotomy was never performed for innocent goitre, and is considered to be much more dangerous than thyroidectomy. But when dyspnoea is urgent a long tracheotomy tube, such as Koenig’s, should be at hand. With bilateral goitre and severe dyspnoea it is often dangerous to rely on a unilateral operation. If only one lobe is removed, the other may bend the trachea to the opposite side and increase the dyspnoea. An important practical point is that often it is not the most obvious and prominent part of the goitre which is the cause of the dyspnoea. The real offending part is not unlikely to be the opposite lobe lying more deeply, perhaps wholly unsuspected, behind the sternum. An X ray examination is often useful in showing which part of the trachea, appearing as a band of light, is most deflected. In the young with bilateral goitres it is usually the least prominent lobe which causes the dyspnoea. The lower the situation of a goitre, the more liable it is to produce dyspnoea. Discussing the methods of operating, the writer remarks that he has never performed total removal of the gland and that he considers it unjustifiable and never necessary even for malignant disease. He rarely performs total removal of even one lobe. A portion of gland is nearly always

operated on chymatous,

left

hilus, or "dangerous area," for various being to safeguard the recurrent laryngeal nerve. Seven patients died from operation : two of them had simple goitre and succumbed some days later to pneumonia ; three had exophthalmic goitre and died from cardiac failure; two had malignant goitre. Recurrent laryngeal nerve paralysis is known to have at the reasons, one

occurred three times. It is sometimes unavoidable in tumours. The nerve lies in front of the groove between the trachea and oesophagus. It may be pulled forward with the gland when operating and is most likely to be injured at a level a little below that of the lower border of the pharynx. An important table given is that showing the late results in 406 cases. The patients with simple goitre are nearly all well and in much better health than before operation. Of the 78 patients with exophthalmic goitre 53 are practically well, 18 much improved, 1 improved, 2 not improved, 1 worse, and 3 died. All were operated on before Dec. 31st, 1919, and 24 of them in 1913. Complete cure in this disease, with no trace of the previous symptoms remaining, is rare. Often a considerable amount of exophthalmos remains in patients who consider themselves otherwise well, and they may have palpitation on exertion. The operations are considered to be much more dangerous than most operations for simple goitre. The patients are often quite unsuitable for operation when brought to the surgeon. In some ligation of one or both superior thyroid arteries will give great relief. The condition of the myocardium is a very important factor in prognosis. Relapse may occur after a long period of good health. Of the 12 patients operated on for malignant goitres, 5 are living and well after periods of 1 to 7i years. One is fairly well but with recurrence 1 years after operation. Four have died from recurrence within a year, and 2 died from the operation. There has been no marked myxoedema in any of the author’s cases. In a few, chiefly of extensive bilateral removals, there have been slight transient symptoms of thyroid insufficiency and the patients have benefited from taking thyroid extract. Tetany has never been seen by the author to follow operation for goitre, though he has operated 1338 times, and he is sceptical as to the separate function of the parathyroids. We have closely followed Mr. Berry’s own account of his experience, which adds a new and useful chapter to the literature on the practice and principles of this branch of surgery.

large, deep-seated

THE

ROYAL SOCIETY

EXHIBITS.

THE annual conversazione of the Royal Society was held at Burlington House, London, on May llth, when Fellow demonstrated to Fellow such portions of new and original work as lent themselves readily to isolated treatment, the interest centring round the light thrown upon natural law rather than upon its application to human need. Medicine as the most highly specialised of sciences was consequently little represented. Mr. J. E. Barnard showed how certain animal tissues reveal marked differentiation of structure when illumiThe image nated by means of ultra-violet light. obtained is a fluorescent one and the resulting colours or tints depend on differences of chemical constitution. Apart from the biological interest of the method the image so formed is of considerable value for testing the optical qualities of microscopic objectives as the object so illuminated is a perfectly self-luminous one. Dr. Leonard Hill exhibited a recording kata-thermometer. This instrument gives a continuous record of the cooling power of the environment exerted on the surface of the bulb of the kata-thermometer, which is automatically kept at skin temperature. Introduced into the bulb of the "kata," which is filled with alcohol, is a coil of wire with a large temperature coefficient of resistance. This coil forms one arm of a Wheatstone bridge, which is balanced when the coil is at a temperature of 36’5" C. An automatic device is used by which the current sent through the coil varies according to atmospheric conditions, so that the coil is kept at 36050 C. The ammeter placed