the tumor be a carcinoma, there will likely follow the infection of those lymph-glands in nearest relation to the neoplasm.

EVIL EFFECTS OF GOITRE.-In this country, though goitre may grow to a large size, it is not common for patients to suffer any inconvenience other than that which results from the unsightly appearance of the tumor; hence life is not seriously imperilled by the disease. Occasionally, however, there are exceptional instances in which unpleasant and even troublesome symptoms are developed. Among these may be mentioned alteration of voice or a slight aphonia in consequence of pressure by the tumor on the recurrent laryngeal nerve. An irritating cough may also exist, and when no evidence of pulmonary trouble is present it must be referred to pressure upon the pneumogastric nerve. Dyspnoea when present results usually from pressure upon the trachea. It has been observed that when this pressure is long continued, particularly in cases of vascular goitre, some of the rings of the trachea gradually disappear, leaving only a membranous tube, which may collapse and cause the sudden death of the patient.

Hiecough and diaphragmatic spasms have also occurred when the enlargement of the gland extended laterally, in consequence of pressure on the phrenic nerve. In addition to the above phenomena there is often experienced in goitre severe neuralgic pains on the side of the neck, in the ear, and over the back of the head, and indeed in the course of any of the branches of the cervical plexus of nerves.

Occasionally I have seen a red blush of the integument on the side of the neck, answering to the largest portion of tumor, accompanied by increased heat, doubtless from the growth encroaching on the sympathetic nerve.

TREATMENT. The treatment of goitre may be divided into constitutional and local. Too often the management of the disease is conducted in an empirical manner, every variety being subjected to the same routine of remedies. No greater mistake can be made. To attain any satisfactory success it is absolutely necessary that a correct diagnosis of the composition of the tumor shall be known. In follicular and in fibrous goitre much may be anticipated from constitutional and local measures. Those remedies which possess the property of inducing retrograde changes of structure and their subsequent absorption are the ones to be selected for administration, and among these iodine and its combinations rank highest. The compound solution of iodine, the iodide of potash, and the iodide of iron, all have their therapeutical adaptiveness. The earlier treatment is commenced the more hopeful will be the prognosis. If the patient is in all other respects in good health, and especially is somewhat fleshy or given to obesity, the compound solution of iodine should of preference be selected. At first the dose should be small, in order to test the tolerance of the stomach, not exceeding five or six drops three times a day, taken in some sweetened water, orange syrup, or curaçoa, and always about one hour after meals. Every two or three days the dose may be increased one or two drops until eighteen or twenty are taken, beyond which it is not desirable to go. It is in these forms of goitre that the burned sponge (spongia usta) was at one time very generally used as an internal remedy, half a drachm to a drachm being taken twice or thrice daily. As the virtue of the article was due to the iodine it contained, it must necessarily be inferior to the solution of the same substance.

In addition to the constitutional treatment the local use of alterative ointments will be indicated, the best of these being iodoform, iodide of lead, and iodide of mercury. Iodoform will be found most efficient employed in the following formula:

ziss;

R. Iodoform,
Benzoated lard, 3j.

This ointment is to be rubbed into the goitre for fifteen or twenty minutes

morning and evening, after which a piece of lint smeared with the same should be laid over the tumor, covered with oiled silk, and retained in position by a strip of muslin. If the officinal iodide-of-lead ointment be used, it will be desirable to lessen its strength by the addition of a little simple cerate, as it is liable to cause severe irritation of the skin when thoroughly applied, thus neutralizing in a great measure the value of the application. Whatever unguent is selected, the application will be best made before an open fire.

There are several natural waters which can at the same time with the other treatment be taken with advantage, their efficiency being due to the iodine which they contain. The most valuable of these are Adelheid's Quelle and Wildegger. A glass of either can be drank morning and evening. If after two or three months' continuous treatment under the plan described no impression is made on the disease, or in the event of the iodine acting unpleas antly by causing symptoms of iodism, the iodide of potash should be substituted, administering three times a day from five to twenty grains of the salt dissolved in water and syrup, and well diluted.

Boinet has proposed the mixture of iodine with the food as a very satisfactory mode of introducing the drug into the system; and I suppose that it was on the strength of this suggestion that Michaud, with a view to protect the gar rison of Étiennes against the prevailing goitre, ordered iodine to be baked in the soldiers' bread. In cases of goitre associated with a pale, anæmic state of the system it will often be found necessary to alternate, for a time, the remedies already directed with iodide of iron and cod-liver oil.

In follicular and fibrous goitres which prove rebellious to the plan of treatment detailed a resort may be had to injections. From eight to twenty drops of the tincture of iodine should be introduced deep into the substance of the gland by the hypodermic syringe. This procedure can be repeated every three or four days, selecting at each operation a different section of the gland, at the same time carefully watching the effect produced. Any marked elevation of temperature, local or general, accompanied by pain or stiffness of the neck, is the signal for suspending temporarily this form of medication. The favorable signs following injections are the shrinking and increasing hardness of the tumor; and so long as these processes continue progressive no repetition of injections will be necessary.

Electrolysis constitutes another therapeutic resource, applicable not only to the treatment of follicular and fibrous, but also to the vascular, goitre. This agent has been favorably employed by Chvostek of Vienna, and to some extent in this country by Baird and others. The current used by Chvostek was one from a Siemens battery of thirteen elements and strong enough to cause a moderate degree of burning. The time consumed at each sitting is not to exceed five minutes, during which the points of application must be frequently changed.

In vascular goitre, iodine, either internally or locally, effects little good. Ergot is to be preferred. From ten to twenty drops of the fluid extract should be given internally three times a day, with injections of the same amount and used in the same general manner as has been directed for the iodine.

Recently I have been using injections of carbolic acid in vascular goitre, and thus far with the most promising results. Four or five drops of a solution of the crystals of the acid dissolved in glycerin, using no more of the latter than will be barely sufficient to liquefy the crystals, should be deposited by means of the hypodermic syringe deep into different portions of the gland at intervals of four or five days. On the withdrawal of the instrument the puneture can be covered with a strip of rubber adhesive plaster. The acid when thus employed causes the tumor to shrink and become hard.

Gelatinous and cystic goitres are quite intractable to constitutional remedies. They require to be attacked locally. Bonnet has tried caustic potash and chloride of zinc. The applications were made over the front wall of the tumor, and in some instances to the inner surface of the sac. The results were not of a kind to make the method a popular one. Iodine and alcohol have also been thrown into the parenchyma of the gland, and with a like unsatisfactory effect. Setons have had numerous trials. The method is an old one, having been used by Celsus, and revived from time to time by Quadi of Naples, Hutchinson, Kennedy, and Stanton. The object in using the seton is to develop in the tumor a destructive inflammation and suppuration. Any one who has witnessed a case of acute suppuration in the thyroid gland will not be anxious to repeat the experience. The purulent products are profuse, highly offensive, and tax severely the powers of the general system; and to these disadvantages may be added the risks of sloughing, hemorrhage, and septic poisoning.

The treatment which promises most in gelatinous and cystic goitre is either that practised by Gosselin or that by Morrell Mackenzie of London. The plan of Gosselin is to make a very small incision in the skin over the front of the tumor, in order to lessen the resistance to the introduction of a small trocar and canula, through the latter of which, after evacuating the cyst and washing it out with tepid water, he injects the tincture of iodine (f3j). This injection is allowed to remain about five minutes. Should its discharge be followed by a flow of blood, a second and even a third injection is made before withdrawing the canula. This operation does not materially differ from that practised by V. Dumreicher, except that this practitioner emptied the cyst with an aspirator previous to washing out the sac and injecting the iodine. The method of Mackenzie, however, has succeeded so well in practice that it is to be preferred both for efficiency and safety. In this plan perchloride of iron is substituted for iodine. One part of the iron is mixed with four parts of water, and after partially emptying the cyst with a trocar and canula at its most dependent part the fluid (faj-fzij) is thrown into the sac by a syringe. The canula is now plugged with a stopper that the injection may be retained. After three days the stopper is removed and the contents of the sac are allowed to flow out. In case the discharge proves to be bloody or serous, the injection is repeated; if, on the contrary, it exhibits signs of pus the iron solution is withheld, but the canula is permitted to remain, that free drainage may be maintained until the goitre has been destroyed by suppuration. During the presence of the instrument the affected part of the neck is covered by a flaxseed-meal poultice.

In gelatinous goitre, when the tumor is multilocular, after tapping and before injecting, I introduce through the canula a plunger, and by pushing it in different directions through the interior of the tumor break up the separating walls of the cysts, and thus open a way for the better diffusion of the injecting material. The plan of Mackenzie, destroying as it does the tumor by a slow chronic form of suppuration, and at the same time draining away the pus as it forms, greatly lessens the risk which might otherwise arise from diffused suppuration, bleeding, or sloughing. At the Copenhagen Congress, Mackenzie stated that he had by the method described treated 193 cases of goitre with only 2 fatal cases, the latter being those of a fibro-cystic form.

In making a comparison between the relative safety of perchloride of iron and of iodine as injections in goitre, the great superiority of the former over the latter is well brought out in the cases collected and analyzed by Schwalbe, 106 in number, for the cure of which iodine was used, death following in 5 cases and diffused suppuration in 22 cases.

When all measures fail to control the growth of a goitre, and the life of the patient is jeopardized from the effects of pressure, the case ceases to be

a medical one and must be relegated to the domain of surgery. Fortunately, the necessity for operation rarely occurs. It may be remarked, in closing this article, that the excision of the gland has been followed in several instances by evils greater than those for which the operation was performed. The experiments of Zesas and Horsley on lower animals, and the observations of Kocher after the removal of the thyroid in man, place the question of extirpation of goitre among the unsettled problems of surgery.

SIMPLE LYMPHANGITIS.

BY SAMUEL C. BUSEY, M. D.

ANATOMY AND PHYSIOLOGY.-The pathological relations of the absorbent system are important, because of their direct connection with the morbid processes and structural changes taking place in a variety of diseases; therefore, before discussing the subject of lymphangitis, a brief reference to the anatomy and physiology of the lymphatic system is necessary.

The lymphatic system consists of large and capillary vessels, interstitial spaces or juice-tracks, lacteals, follicles, and glands. The serous cavities are also considered lymph-chambers, and the loose cellular tissue is a vast chambered lymphatic sac communicating with lymphatic vessels. The larger vessels are divided into two classes-the superficial, which in the subcutaneous tissue accompany the veins, while in the solid viscera they lie under the capsule, and in the tubular viscera under the serous membrane; and the deepseated vessels, which accompany the deep-seated blood-vessels, ramify through the interior of the organ in the solid viscera, and emerge at the hilus; while in the tubular viscera they lie in the submucosa, and by free anastomosis form plexuses. There is no communication between these two sets of vessels, except in the solid viscera and in the glands which may be common to both sets. Between the vessels of each set there is, however, a free anastomosis, by which large-meshed plexuses are formed. In consequence of these peculiar arrangements each set may be separately diseased, and inflammation may spread rapidly from vessel to vessel of the same set.

The lymph-capillaries are arranged in networks which lie in the meshes of the plexuses of the blood-capillaries, from which they are separated by intervening tissue-elements. Their walls consist of a single layer of endothelium resting upon elastic tissue. In their continuity they are sinuous, and are provided with an incomplete valvular arrangement.

The large vessels have three coats, not unlike the coats of the veins, and are provided with numerous valves. These valves are the more abundant in the superficial vessels, and the intervals between them grow gradually less as they approach the glands.

The whole lymph vascular system terminates either in the right or left thoracic duct.

The origin of the lymphatics has not been definitely settled. It has been demonstrated that lymph circulates in the connective-tissue interstices, and it seems to have been established that these spaces are lymph reservoirs, discharging through lymph-capillaries. It is admitted that the capillaries commence either in closely-meshed networks or lacunar spaces. Plexuses of lymphatic capillaries, corresponding with the distribution of the blood-capillaries, lie under the endothelium of the serous membranes, and are in open communication with the serous cavities through the stomata. The stomata vera are either the openings of lymph-channels communicating directly with lymph-capillaries, or discontinuities between the cells of the surface, leading