trouble is confined to the one side, and that two kidneys are in existence.

If in the course of the operation we have located a pyelonephrosis, and we are content to treat the disturbance by drainage alone, we should satisfy ourselves that the ureter does not contain a calculus which has been the original cause of the trouble in the kidney.

To attempt to discuss all phases of the treatment of suppurative inflammation of the kidneys would be quite out of the limits of a paper of this character, but I am convinced in having examined many specimens of urine in cases of slight alteration of the normal urinary flow, that there are quite a few of these which are the result of a very mild grade of pyelitis; that many of these are promptly cured by timely administration of urinary antiseptics, especially if these are backed by a judicious tonic course of treatment.

Report of Cases of Surgery of the Thyroid Body By JOHN CHADWICK OLIVER, M. D., Cincinnati

Diseases of the thyroid body calling for surgical intervention are by no means common in this locality, nor does there seem to be any portion of the United States in which goiter is an endemic condition. Certain parts of England (Derbyshire) and of Switzerland (Cantons of Berne and Fribourg) seem to possess the conditions most favorable to the production of this disease. Careful investigation of the local conditions fails to reveal any clear and distinct cause for this unusual prevalence of the disease.

Berry (Diseases of the Thyroid Gland, page 71) says, "Summing up, there can be no doubt that climatic and atmospheric conditions have little or no share in the causation of goiter. That want of air and sunshine has absolutely nothing whatever to do with it is equally certain. Habits, such as carrying weights on the head, violent exercise and

the like, play but a secondary part in the production of the disease. That heredity is the cause of goiter is extremely doubtful. Intermarriage has certainly no share in its causation."

"That there exists some definite relation between endemic goiter and some poison in the soil upon which it is found is tolerably clear, and there can be no doubt that in the vast majority of cases drinking-water is the vehicle by means of which that poison obtains access to the body. Such water is usually, if not always, derived from calcareous soils, but it is probable that the goiter-produced poison is not a salt of lime or magnesia. It has not yet been proved satisfactorily that any salt of iron is the essential constituent. The same may be said of microorganisms.

What little personal observations I have been able to make convince me that in this country at least, locality, social station, heredity and age are not important factors in the etiology of the disease.

From a surgical standpoint the chronic affections of the thyroid calling for possible surgical intervention are fourparenchymatous goiter, cysts, exophthalmic goiter and malignant diseases of the thyroid. I have had no personal experience in the surgical treatment of the exophthalmic variety. The cases reported below have some points of unusual interest and are therefore worthy of being placed upon record.

Case I Eva S., aged 12, had been afflicted with an enlargement of the right side of the thyroid body for seven years. She was referred to me by Dr Robe, of Peebles.

The superior thyroid artery passed in an oblique manner from above, downward and inward over the mass. Palpation of the enlargement conveyed the impression that the growth was cystic. A curved incision was made, beginning in the median line, going down to the upper part of the sternum, then curving to the right and up to the top of the tumor. The muscles were divided and turned back. The

cystic character of the growth was now very apparent. Further investigation disclosed the fact that there was but one large cyst. This was rapidly enucleated after the superior thyroid artery had been tied. Ligature of this vessel was necessary in order to prepare a safe approach to the gland. After enucleation the tissue of the thyroid was brought together by sutures (catgut). The muscles were sutured and the external wound closed tightly with a subcuticular silkworm-gut suture.

This patient had an enlarged heart with an inconstant murmur, but there was no exophthalmos. Union took place by primary intention, and the patient returned to her home much improved in appearance. There were no unpleasant complications in this case beyond a pretty smart hemorrhage during the enucleation of the cyst.

Case II: Mrs. P. was a fleshy, short, thick-necked woman, aged 28, with an enlargement of the left lobe of the thyroid gland extending from the sternum to the angle of the jaw. This had been present for ten years. The patient attributed the condition to an attack of scarlet fever she had had shortly before this. She had been treated for three months by an osteopath, who had religiously rubbed her neck each day. The growth seemed to grow away from the trachea and there were no symptoms of pressure upon that viscus, although her voice had become somewhat strident. She complained more of the deformity than of the pressure. She had no exophthalmos or irregular heart action. Her general condition was excellent. The dangers of operation were fully explained to her, but this did not deter her from desiring its removal. In this case the bulk of the tumor seemed to be cystic.

She was operated upon March 1, 1902, at Christ's Hospital. An incision was made reaching from the angle of the jaw down along the inner edge of the sternomastoid muscle, curving at the base of the neck so as to reach the median line just above the sternum. It was then continued along the median line for an inch and a half. When the capsule proper of the gland was reached a knife was plunged into the organ and exit given to several ounces of

blood-stained, grumous fluid. This did not materially diminish the size of the mass and the finger introduced into the cavity showed a very considerable mass of thyroid tissue present. In view of this an excision of the lateral half of the thyroid was made. The wound was sutured tightly with a subcuticular suture of silkworm-gut. The patient sat up on the second day and went home on the ninth, the stitch being removed on the sixth day.

Case III: Miss S. R., aged 43, had noticed an enlargement on the right side of her neck for 18 years. She was not absolutely sure but that it might have been there longer. During this period the patient had tried iodin, arsenic, thyroid tablets and all medical suggestions coming from any source, but absolutely without benefit to the condition. She consulted me with the idea of having the mass removed. In this case there were slight pressure symptoms, but, as in the previous case, the main complaint was of the deformity. She was fully enlightened as to the character and seriousness of the operation. She chose to run those risks in order to be rid of the deformity...

On September 28, 1901, a crescentic incision, with the concavity upward, was made over the mass. After the infrahyoid muscles had been divided a search was made for the superior thyroid artery in its usual locality. It was not found at the outer upper angle, but was very unexpectedly ruptured at the inner upper angle. Investigation showed that the superior thyroid artery came from the left carotid, passed across the trachea and entered the gland in the situation mentioned above. The superior thyroid vein was tied separately. The capsule of the gland was readily reached by blunt dissection. It was now seen that the goiter was composed of two masses, one on top of the other. In attempting to isolate the upper mass the inferior thyroid artery was ruptured at the inner lower angle of the gland. All visible venous channels were ligated and the upper of the two masses was thus liberated. As the finger was carried around the mass another artery was ruptured deep down near the outer lower portion of the mass. This vessel could not be picked up readily so pressure was used for its

temporary control. When the mass could be brought up into the wound it became apparent that the anterior mass was the left lobe of the thyroid displaced to the right of the trachea. This explained the curious distribution of the arteries. The isthmus, instead of running across in front of the trachea, ran anteroposteriorly from the superimposed left half of the thyroid to the subjacent right half. The isthmus was now divided and the left half of the gland removed. We had already ruptured the inferior thyroid artery going to the remaining right half of the gland but had not as yet secured the vessel. The bulk of the right half seriously interfered with the clamping of this vessel. It now developed that the remaining right half of the gland was cystic and evacuation of the contents of this cyst permitted the ready control of the inferior thyroid artery. The interior of the cyst was curetted and the remaining portion of thyroid tissue whipped together with catgut sutures.

The operation was an exceedingly severe one and the loss of blood was very great, yet the patient rallied quickly from the shock and made a very excellent recovery.

This case is, I believe, unique, in that both lobes of the thyroid gland were on one side of the neck. A personal correspondence with Mr Berry corroborates the above statement so far as his investigation goes. This was one of the most embarrassing operations it is possible to imagine because of the fact that the blood-vessels were apparently all misplaced. One could not by any known means have suspected the condition that was found, and hence the troubles described above arose in the course of the operation.

Case IV: Mr W., aged 44, was referred to me by Dr J. M. Withrow because of extreme dyspnea associated with an enlarged thyroid. When first seen by me the patient was scarcely able to breathe. Each breath gave rise to a high-pitched tubular sound, indicating extreme pressure upon the trachea. The history of the case and the physical character of the growth made it apparent that we were dealing with a malignant growth of the thyroid. In view of