Association there is an editorial giving a summary of the work that has been done on the prevention of goiter. It is a vital question, not only to me but to every one of you. What are you going to do about it? Hold that question in mind.

In Ohio, that is, around Cleveland, we cannot carry out the prophylactic treatment for various reasons, and among them I may mention politics, Christian Science, and so on. But in six other cities and villages in that neighborhood they are carrying this treatment out as a public health measure. I do not know for sure, but I have heard that there are one or two towns in Michigan that are carrying out this preventive treatment of goiter. I believe Bay City is one of the cities in which they are carrying it out. They are very much interested in it as a public health measure in Grand Rapids. This simply shows what they are hoping to do in Michigan.

In 1918 Professor Fraenkel of Zurich, Switzerland, received our letter, requesting him to start the prevention of goiter in Switzerland. He started in the public schools there and his first survey in many of the schools showed that 100 per cent of the girls and boys had goiters. On an average throughout the whole cantons of Zurich, Berne, and so on, 87 per cent of the school children had goiter. We thought we had a terrific endemic of goiter when we had 60 per cent; they had 87 per cent of boys and girls in these cantons with goiter in 1918. They carried out prevention, using the same amount of iodin by a different method. They gave each child five milligrams of iodin put up in a nice preparation. It is the iodin that does the work. On Monday morning the children were given iodin. That is the first they had in the school systems in these cantons.

In January, 1922, the incidence of goiter in the cantons mentioned in 1917 was 87 per cent. In January, 1922, it was 23 per cent. They gave smaller amounts of iodin gradually, and they never had a single case of iodid rash, and with the tremendous decrease in goiter, they had not a single case of goiter developing. Incidentally they had 3 per cent of cases of goiter which represents about the number of adenomas we found which means congenital goiter.

As a practical measure, it is just as easy to prevent goiter among pregnant women as it is in adolescent goiter. But that problem is up to the medical profession. We are carrying it out in maternity hospitals, and a great many of the practicing physicians in Cleveland are doing it. We can sum it up in this way: if every expectant mother in this endemic goiter district can have her thyroid gland kept

saturated with iodin, she would not develop goiter, and the child's thyroid would be normal.

When it comes to the presention of adolescent goiter as a public health measure, it can best be carried out through the public schools. We have an organization. the treatment can be given by the teachers, and a very important factor is educating the boys and girls so that whenever they go out of school they will continue to take care of their thyroid glands. If each one of us here would simply go home and tell the school board members about the importance of this prophylactic treatment, and can prove to them its value, and that we can prevent every one of these goiters in boys and girls for a maximum of five cents per girl per year, great good will have been accomplished. In a recent talk with Dr. Marine, he says that every expectant mother, when she learns the truth that goiter is the easiest thing in the world to prevent, in five years from now a symposium on goiter would sound like ancient history.

DISCUSSION OF THE SYMPOSIUM ON GOITER

(Papers of Dr. Louis B. Wilson, Charles L. Mix, George W. Crile, Wilbur O. Upson and O. P. Kimball.) DR. ANGUS MCLEAN, Detroit: I think the members of the Michigan State Medical Society are remarkably fortunate today in having heard this symposium on goiter and its treatment, medical and surgical, by the X-ray and radium. We have had the pathology summed up in an admirable manner by Dr. Wilson; we have had the view. point of the internist by Dr. Mix, and the surgical aspects presented by a master.

Eighteen years ago we had a symposium on this subject before this Society which was gotten up by Dr. Dock, now of St. Louis. The internists then did not take as favorable a view of how to cure hyperthyroidism as they do today.

The subject was likewise discussed recently in St. Louis at a meeting of the American Medical Association. The internists years ago were not quite so highly scientific as are those with us today. Goiter was beautifully compared to appendicitis, and the position that was taken with regard to appendicitis twenty years ago. We all know that you can have appendicitis, and that you can have an abscess and peritonitis. If the appendix or abscess is dealt with surgically the patient is likely to get well, but if the abscess is left alone it is likely to do great damage and may result in the death of the patient.

With regard to the method of operation, Dr. Crile discussed this subject before our Society two years ago with Dr. Bartlett of St. Louis, and recommended leaving a part of the thyroid, and leaving the wound wide open to allow the secretions or toxins to escape, instead of closing the wound. It is undoubtedly an advantageous thing to leave the wound open, thus establishing free drainage.

DR. FRANK R. STARKEY, Detroit: Dr. Crile spoke of removing a portion of the thyroid gland, just enough, but not too much. That is the thing I cannot quite understand, and I would like to have Dr. Crile, or some other surgeon, tell me how he arrives at that assumption. It is a fact that a great many cases of thyroid enlargement or goiter will vastly improve under iodin administration. It is also a fact that the gland enlarges under certain physiological conditions, like pregnancy and during menstruation, and also in the presence of infection. I had a patient recently that impressed that point unon me strongly. The patient was a young woman with a large goiter. She was asked to come

to me for the treatment of this gotier, although she had been previously under the observation of an internist or a surgeon. I looked at her throat and saw enormously enlarged tonsils. I sent her to a throat specialist, who removed he rtonsils, and in three weeks her goiter was two-thirds gone. In three months it was entirely gone. She received no other treatment except a little iodid of iron. I am sure you have all seen cases of that kind.

So far as metabolism is concerned, I look at that as a part of the technic of laboratories, and something which people have gone crazy over. It is of no legitimate value except in a limited number of cases. It is of no value as a routine measure.

DR. HUGH CABOT, Ann Arbor: The thing that strikes me in the discussion this afternoon is that most of us have come a long way to hear this symposium and to listen to the different viewpoints that were brought out. Most of us have been brought up under the tutelage of great physicians and great surgeons. I have been amazed to see here that a great internist and a great surgeon have given us precisely the same views, almost in the same words, and I did not suppose it was possible. I believe it is one of the greatest revelations and revolutions that has taken place in medicine, on account of the harmony that exists between the views of the internist and those of the surgeon.

I am not able to come to the defense of the X-ray as much as I would like to do. I wish I knew or that anybody else knew precisely what happened when you turn an engine of destruction loose upon an unfortunate patient. I was told long ago, and I have continued to believe it, that the first principle in the practice of medicine is that we shall do the patient no harm. I do not know that I am not going to do a patient some harm by turning loose a force which I know will destroy tissue, and I am not quite sure what tissues you will destroy, as there are various things that lie in the neighborhood. I am one of those terribly biased creatures who have struggled and sweat in trying to get out thyroids after they have been X-rayed, and personally, I don't want them X-rayed.

DR. W. J. CASSIDY, Detroit: We operate today in the average general hospital, and patients get well in spite of the hospital and not because of the hospital. Patients are given preliminary doses of morphine or some other drug, and then what happens? They are asleep. They are taken down the middle of the hall, lying flat on tables, with pans and dishes dropping in all directions, and You have done very soon they are wide awake. You have the thing you have tried not to do. given the patient something to quiet him, but instead you have stirred him all up and have produced an effect on him that you tried not to do. Success does not lie so much in the perfection of surgical technic, in the use of the X-ray and radium, but it must come from a better management of patients in hospitals and better working of the operative groups in the hospitals rather than So far from advancement in technical measures. as any one measure of treatment is concerned, goiter must be put on the same basis as the treatYou cannot advocate ment of any other disease. If you dogmatic treatment for any one disease. are satisfied that X-ray or radium should be used, do not hesitate to use it. If patients need surgery, give them surgery, or if you think they need surgery, X-ray and medicine, give them all in combination.

DR. M. A. MORTENSEN, Battle Creek: I should like to voice what has been said this afternoon and to emphasize the point that I think we have reached the time when the surgeon and internist will get closer together in the management of not only cases of hyperthyroidism, but other types of diseases, where both are necessary to come to proper conclusions as to diagnosis and treatment.

easy.

The diagnosis of hyperthyroidism is not always Many times it requires a longer period of study and careful observation, and even then we are not certain as to the diagnosis.

We have heard about basal metabolism, about the Goetsch test, and a study of the heart, and so

on, as factors in coming to a conclusion as to the diagnosis, and what should be done. I want to emphasize the importance of studying the circulatory system in all cases of hyperthyroidism, and particularly in the type of border-line cases. think it is important for us to bear in mind in the great percentage of cases of hyperthyroidism that we have a high pulse pressure; that is, we get a systolic pressure higher than the average for the age of the patient, and we get a decidedly lower diastolic pressure in these cases, and that many times will be a guiding factor as to the presence of hyperthyroidism and, at the same time, we should study the pulse as related to exercise and its response to the same. Take a patient with circulatory asthenia, as a rule his pulse will not be increased so materially from exercise in moderate amount as a patient that has hyperthyroidism, so that we have factors there that will be of benefit to us in coming to a conclusion. Furthermore, I wish to say that we forget the surgeon has his field and the internist has his field.

Dr. Cabot stated that the X-ray was a dangerous thing. Others may think the knife is a dangerous thing, and should be wielded with just as great caution as the X-ray. Anyone who has had experience in the management of cases of hyperthyroidism treated by surgeons without success, knows that they constitute a difficult problem. I have had a few cases that have been very difficult to manage because of having had surgery without results. I am sure the surgeon has no more desire to treat a patient who has had surgery applied to the thyroid than he does a gland or patient who has received X-ray treatment. Both of them are not as easy as in the beginning, and consequently must try and use extreme judgment in our conclusions as to the patient's condition and as to the steps that are to be taken to relieve the patient of suffering.

we

DR. M. W. CLIFT, Flint: was rather in hopes Dr. Case would be here to say something regarding the X-ray feature of this discussion. I was glad to hear a defense of the X-ray. However, I think there is too much confidence displayed at the present time in regard to the benefit of X-ray treatment in certain types of hyperthyroidism, but I do not think we should dismiss it absolutely from the field of therapeutics. Only recently in the Berliner Klinische Wochenschrift, an article appeared which gave the statistics of 300 cases of goiter treated by means of the roentgen ray. The conclusions reached were very much the same as regards results from the use of the X-ray as from surgery. Aside from that, according to these statistics, there was no greater frequency of recurrence following the use of the roentgen ray than from surgery.

As to the remote dangers of raying the thyroid, I think it must be open to question as to the effect of the ray on tissue. It is only necessary to refer to the work that has been done at various times in the Memorial Hospital in New York, in which the effect on various types of embryonic tissue and on other types of tissues have been pretty well demonstrated.

For a long time most of our surgical friends have been worrying about what the X-ray would do. It is only necessary to call attention to the fact that we have been raying cases for a great many years; we have rayed them through all sorts of difficul ties, and yet outside of the unfortunate cases of burns, the remote effects of the roentgen ray are not very well established, and certainly have not produced any tangible thing we can base an opinion on.

As to the treatment with the X-ray, it seems to me it has now about the same status as surgery. I do not wish to be understood as advocating the use of X-ray to the exclusion of surgery. We all agree that there are certain types of cases that are poor surgical risks. These cases I believe are good X-ray cases. Our experience has been extremely satisfactory, controlled with the basal metabolism and following out Dr. Crile's regime following and before X-ray treatment. It strikes me, it is just as necessary to prepare patients for the X-ray, as

tains three grams, put in a convenient place, so that different girls come along with sanitary drinking cups and fill the cups with water, and the teacher puts a teaspoonful of this sodium iodid solution in the water and makes them drink it. The teacher watches these girls very carefully and knows that they take it. That is an important part. We have called attention to the danger of too much iodin.

The next question is with reference to potassium iodid. Dr. Slean issued some reprints last year in which he advocated the use of sodium iodid in common table salts. A company is putting out that salt now, a so-called new salt. I saw a sample recently which was marked N. M. an dour Detroit chemists were induced to give their opinion regarding it. As iodin is such a hygroscopic salt, it will probably run out and go down to the bot. tom, and you will have iodin in about the last quarter of an inch in the bottom. Some time or other a child who is nervous will get quite a dose of iodin and the rest of the people will not be getting any. You do not have any control over that. I would prefer seeing a method carried out where I can give a definite small amount.

As to the method they are using in Switzerland at present, the Goiter Commission has recommended that to the government, so that next year they will carry that out throughout all Switzerland as a public nealth measure. Each child gets five milligrams the first thing Monday morning.

Some one spoke about functional disease. Every normal girl goes through the period of puberty, and we see thousands of cases of pregnancy. These are two periods in a girl and woman's life when the function of the thyroid is whipped up. In that sense it is a functional disease, but these are normal functions, and the real difficulty at this time happens to be while there is an increase in function. There is also a lack of iodin in the thyroid.

I had intended to give you a real story of the prevention of goiter in animals at Sheridan, Wyoming, and through the valley of the Pemberton Meadows in the Province of Columbia. A most interesting article we can read will be found in the New York Medical Journal of March 15 of this year. Dr. Marine and I got in touch with some of the leaders of the grangers and the agricultural men in British Columbia in 1918, and this article in the New York Medical Journal gives a summary which amounts to this: They could not raise pigs, calves and lambs and even their chickens. Roosters could not grow after a year old on account of goiter. These grangers give sows three drops of tincture of iodin once a week. The sheep got iodin in the water, and the remarkable thing is that since the grangers have started using iodin they are raising so much young stock that they cannot raise pigs to feed them. They have not had a single case of goiter. In other words, they have obliterated goiter in their domestic animals where they can take care of them by that simple method. This method is carried out through the whole valley of the Pemberton Meadows.

If any of you should go back home and see that the school board or the health authorities are interested, I will be very glad to write down the details of my experience and tell them how to start. Furthermore, if the school board and health authorities so desire, I will pay my own expenses and tell them how to do it.

DR. CHARLES L. MIX, Chicago, (closing the discussion): I do not know that I have much to say except to come to my own defense. Are you sure, Dr. Wilson, I said dorsal gland? We agreed it was the cervical gland. I am glad to know that part is straightened out.

There was one thing I had thought might be added, that simple goiter occurs, for the most part, in girls in the preportion of four to one, whereas exophthalmic goiter does not. It occurs pretty nearly equally among the two sexes. It shows a fundamental difference between the two.

I should like to throw a monkey wrench of my own into this discussion. Why is it, if hyperplasia as a compensatory hyperthrophy in the quest for iodin, the same gland subsequently becomes senile because it pours too much thyroxin in the system? That is a poser, and while it does not bear on the

same proposition perhaps, yet it does seem it is physiologically the case. At any rate, it is hard to explain the proposition on any other basis. We can easily understand how thyroxin intoxication can go over to the stage of myxedema, but how thyroid deficiency with compensatory hypertrophy should subsequently become a hyperthyroidism case is a little difficult to figure out.

There was one other point I thought ought to be mentioned, and that is this, that prophylaxis is never going to prevent exophthalmic goiter; it may to some extent insofar as it overcomes fatal adenoma and lessens the incidence, but it will not prevent it. We will have cases of thyroids which have gone wrong.

In regard to the circulation, something was said about the very important fact that the systolic pressure is high, while the diastolic pressure is low. That is very true, but that is what the problem is. If you are accustomed to looking at a patient and noticing this throbbing, you do not need to get out your manometer to figure it out. I think in the majority of cases we can pick out these throbbing, pulsating cases, and without taking blood pressure you know before you do it, it will be 170 and about 60 or 70, with a pulse pressure of 100. You will notice also that as these cases improve throbbing disappears; the two pressures get together. These patients fluctuate; the throbbing will fluctuate. Some days there will be a great deal of throbbing, while on other days there will not be so much. Evidently the dosage put into the system varies from time to time, from hour to hour, so that the intensity of the intoxication varies.

I was glad to hear about Dr. Kendall's experience in regard to thyroxin because, as I stated, I believe that there is more than one form of intoxication. I have come to the conclusion that one form of toxin would explain all of the cases, and that we have merely varying degrees of susceptibility on the part of certain organs to dffierent organisms.

I also think-and I believe you will agree with me-that Dr. Wilson ought to be a clinician instead of a pathologist. I think he ought to give us some of his observations in regard to the sternocleidomastoid and other muscles and set us right. I am glad to be set right in regard to what he said about Muller's muscle. The explanation of the hyperemia in the post orbital region is a more sensible explanation than any effect upon the cervical sympathetic, particularly when you try to dissect it out.

BRAIN ABSCESS OF OTITIC ORIGIN

MAX MINOR PEET, M. D.
ANN ARBOR, MICH.

A brain abscess is the result of a circumscribed purulent encephalitis. The suppurative process is always subsequent to a more or less localized inflammation of the brain, due to the introduction and multiplication of pyogenic micro-organisms.

The usual etiological factors are otitis media, frontal sinusitis, ethmoiditis, trauma and septicemia. Of these, otitis media with mastoiditis is by far the most frequent, over half of the cases being due to this cause. The brain abscess develops about four times as frequently in patients with chronic otitis media as in those with acute middle ear infections. No age is absolutely immune, although probably not more than one per cent occur under five years of age. Between ten and eleven per cent occur from the fifth to the tenth year, while the second decade has an incidence of over thirty-seven per cent.