132 THE KING.

or die suddenly in the throes of thyroid crisis. Butdn spite of this difficulty almost everyone would agree.that treatment should begin with the eradication-of septic foci, and with the patient’s removal to

surroundings where mental and physical strain arexeduced to a minimum, and rest can be obtained.Once these conditions are secured symptomatic- treatment would naturally be given ; a sufficiency of,sleep would be maintained by sedative drugs such asquinine hydrobromide, and the patient would receivea diet unlikely to stimulate’the already raised meta-bolism, but sufficient to meet the increased energyrequirement. So much is pretty generally accepted.Often, however, measures of this kind are inadequate,and it is then that the problem of surgical treatment- arises. During the last ten years thyroid surgery hasmade rapid strides on both sides of the Atlantic. Its

progress was assisted by the observation of D.MARINE and LENHART that small doses of iodineor potassium iodide, previously taboo in hyperthyroidconditions, produced an artificial remission of the,disease. H. S. Pi/UMMERandW.M. BOOTHBY, workingat the Mayo Clinic, then began to use iodine exten-sively in the form of Lugol’s solution as a means ofpreparing patients for operation, and found that by,so doing they were able to prevent the disastrousthyroid crisis, which in the earlier days were thecause of so many deaths at, or shortly after operation.’This discovery, coupled with a steady improvementin surgical technique-,-now makes it possible to review.the results of many hundreds of scientifically.:recorded cases treated by partial thyroidectomy, and.to consider the part which surgery should play in.treatment. CRILE, for instance, has recently reviewed’over 10,000 cases of hyperthyroidism treated surgi-cally ; a week or two ago we published3 a summary ofF. H. LAHEY’S deductions from the study of theresults of 6700 goitre operations, of which 4000 werejor Graves’s disease or toxic adenoma ; whilst in ourpresent issue appears a paper by Mr. W. H. C.ROMANIS, in which he reviews his operative results in.a smaller series of 500 consecutive cases. These threeobservers agree about the great value of surgical treat-ment. RoMANis applies the term Graves’s disease tocases in which, besides the usual signs of thyroidtoxaemia, there is definite enlargement of the heart.and definite changes in the eyes. He divides his casesinto primary and secondary, the latter being thosein which a thyroid toxaemia supervenes on a paren-chymatous goitre or toxic adenoma of many years’standing, in which type there is a particular liability Ito auricular fibrillation. This type is the one referredto by most American authors as toxic adenoma.,CRILE, LAHEY, and ROMANIS are at one about theimportance of iodine medication before operationwithout distinction between the two types, although;LAHEY says that the beneficial effects of iodine areless obvious in toxic adenoma. As regards the amountof tissue to be removed at operation, all three writers,admit a difficulty. They agree that it should usuallybe considerably more than half the gland and thatoccasionally a further portion may have to be takenaway at a second operation. CRILE and LAHEY bothrecord., a mortality of less than 1 per cent., andRoANZS a mortality of 2 per cent. LAHEY givesa separate quotation for a series of 200 cases of toxicadenomata with auricular fibrillation of which onlythree died. ROMANIS, though he does not quoteseparate figures, agrees with both other observers inemphasising the- great value of partial thyroidectomyin thyrotoxic fibrillation. All speak of rapidly bene-

2 THE LANCET, July 6th, p. 30.

ficial effects from surgery, both CRILE and ROMANISemphasising the need for removal of enough thyroidtissue if the best results are to be obtained. Whenthis is done ROMANIS considers that most patients canreturn to a normal life within six months although,especially in long-standing cases, a pulse-rate of80-90, and some exophthalmos, often persist.

So striking a consensus of opinion from American andEnglish sources cannot fail to impress those who aredoubtful about the part surgery should play in thetreatment of hyperthyroidism. For what are thealternatives ? There is the wait-and-see policy, which,from the nature of the disease, will often justify itself;and there is local treatment of the gland with radiumor X rays. Both these methods yield a high pro-portion of partial and complete cures, but it is doubt-ful whether in primary Graves’s disease the risks ofthese more conservative measures are not greaterthan the risks of operation, whilst in the secondarytype operation is certainly the treatment of choice,and should be done before auricular fibrillation hashad time to develop. In the absence of a true curethe objections to surgery, or to any other treatmentwhich aims at partially destroying the thyroid gland,are mainly theoretical. These objections are thatexophthalmic goitre is due to an unknown stimulusaffecting the whole gland, so that however much isremoved the stimulus to the remaining portionremains, and a low-grade form of the disease is likelyto persist or recur; that there is no accurate way ofestimating the amount of gland which should beresected in each case ; and finally, that removal of thegreater part of a gland so important as the thyroid isunsound as a means of re-establishing its normalphysiological action. The problem, of course, is somuch an individual one in every case that it is difficultto dogmatise. From a consideration of the results ofthyroid surgery for the last few years, it does, how-ever, seem that if medical measures fail, partial andsufficient thyroidectomy by experienced thyroidsurgeons offers the sufferer from Graves’s disease herbest chance of certain and speedy recovery to theextent of being able to live a normal life.

THE KING.THE clear and detailed bulletins which have been

issued during the week have alike informed andreassured the public in regard to the health of theKing. It being known that there was a residualabscess communicating with the surface by an

oblique sinus increasingly difficult to keep patent,steps were taken to accurately localise the abscessby a radiological examination after the injectionof lipiodol. Stereoscopic pictures were taken atBuckingham Palace and these were closely examinedand their implications discussed by Sir Stanley Hewett,Sir Hugh Rigby, Mr. Wilfred Trotter, Mr. Martyn,and Lord Dawson on Tuesday, July 9th. After afurther consultation the next -day the nature of theoperation was agreed upon. This operation wasperformed by Sir Hugh Rigby and Mr. Wilfred Trotter,after which the following bulletin was issued on

July 15th. ’

The operation on His Majesty the King has been performed.Portions of two ribs were removed, in order that the

circumscribed abscess, li in. across, should be directlydrained and treated. "

The condition of His Majesty is satisfactory.STANLEY HEWETT. FRANCIS E. SHIPWAY.HUGH M. RIGBY. DAWSON OF PENN.WILFRED TROTTER.

.

ij" As His Majesty has now acquired a high degree ofgeneral immunity, there is every prospect that theabscess cavity will steadily progress towards healing.

133THE TRAFFIC IN DANGEROUS DRUGS.

Annotations.

SEAMEN’S HOSPITAL SOCIETY.

"XI’ quid nhnla."

THE week has seen another milestone passed in Ithe adventurous career of the Seamen’s HospitalSociety, for on Monday last the Duke and Duchess of York declared open the new pathological labora- Itories built to the design of Sir Edwin Cooper,which are to serve the needs not only of the Seamen’sHospital itself but of the whole neighbourhood inwhich it lies. Another building opened at the sametime was the nurses’ home, situated within the gardensof the Royal Hospital School, which is to provide aseparate room for each of the 130 nurses who staffthe " Dreadnought " itself and its local extensions.The capital cost of both buildings has been fully metout of the fund raised by Viscount Devonport, in1915 and after, as a lasting memorial to the work ofthe mercantile marine, and there is a small balancefor maintenance. Not as large certainly as some ofthe optimists on the staff would like. Responding atthe banquet to the toast of the laboratories proposedby Lord Devonport himself, the dean, Mr. PercivalCole, spoke of their double function in supplying theknown needs of the moment and in organising researchto meet the unknown needs of the future ; andProf. R. T. Hewlett, who was in the chair, picturedthe endowment of research scholarships as the nextobjective in view. The scheme has in fact come tofruition at an opportune time. Even in their previousdomicile the laboratories, under the joint direction ofProf. Hewlett and Dr. Arthur Davies, had served thehealth departments of five London boroughs and theneighbouring poor-law hospitals. The new unit isfit to play an integral part in any new organisation ofa local health service if only for the remarkablefaith shown by the promoters of a great fund inallotting it to the development of pathology ratherthan to the provision of beds or clinics. Sir JohnRose Bradford, in giving eloquent expression at thebanquet to this feeling, was but echoing what was nodoubt in the minds of many of his listeners, and hisremarks were endorsed by the Member of Parliamentfor Greenwich who, while disclaiming knowledge ofpathology or of the sea, said he knew something ofhuman values at the Seamen’s Hospital. It mustnot be assumed by those who do not know all thefacts that the " Dreadnought " is now nothing morenor less than a school of pathology. Since 1901 when,according to Prof. Hewlett, the palaeolithic period inthe Society’s history came to an end, the hospitalsfor sick and injured merchant seamen under theauspices of the Society have increased remarkably insize and number ; there are now 627 beds in theseven establishments, including the sanatorium atBramshott and the hospital at Marseilles. The pointis rather that pathological research has always beena tradition in the Society-was it not at Greenwichthat one of the first cases of acromegaly was

described ?-and that this tradition is now assuredfull scope in its further development.

RETROPHARYNGEAL ABSCESS IN INFANTSAND CHILDREN.

ALTHOUGH retropharyngeal abscess is not common,its recognition is important owing to the risks attend-ing spontaneous rupture. According to Greenwaldand Messeloffl the majority of cases occur during thefirst year of life, and it is just at this time that anadequate examination of the throat is difficult.Inspiratory and expiratory stridor, aggravated by

1 Greenwald, H. M., and Messeloff, C. R. : Amer. Jour.Med. Sci., June, 1929, p. 767.

the horizontal position, is, of course, the outstandingsymptom, but diagnosis should usually be possiblebefore it becomes the presenting symptom. Aprevious history of acute nasopharyngitis is the rule,and in any case in which this is followed by restlessnessand unilateral enlargement of the cervical glands,the question of a retropharyngeal abscess should arise..Owing to difficulty in swallowing, mucus collects inthe throat and causes the rattling and stertorousbreathing so often heard in the later stages. Asnoring, gurgling respiration during sleep is, in fact,one of the most constant symptoms. Further, theyounger the patient and the more rapid the courseof events, the more pronounced are these findingsTorticollis is nearly always found, and its presenceshould suggest retropharyngeal abscess before any-thing else. As Greenwald and Messeloff point out,the examiner must have a clear conception of a normalthroat in infants and children in order to determine,from his brief glance, whether or not there are patho-logical changes. Even then inspection of the throatin infants is rarely conclusive, and should be followedin all suspicious cases by palpation with the finger.In older children, difficulty is encountered in theexamination because of trismus. The pushing forwardof one faucial pillar is an outstanding sign found oninspection and one that may easily be overlooked.Slight oedema of the soft palate may also be seen insome cases. The mucosa covering the swelling is atfirst red, and later, when there is suppuration, theredness fades and the pharyngeal wall becomes paleand somewhat yellowish, feeling elastic and boggyto the finger. Once an abscess has formed, surgicalmeasures and evacuation of the pus are obviouslyindicated, but in the stage of lymphadenitis, beforetrue suppuration, great harm may be done by incision,because generalised sepsis may follow. In Greenwaldand Messeloff’s opinion, the best results are obtainedunder light ether anaesthesia, unless the child isdesperately ill; the outlook as a rule is excellent.

THE TRAFFIC IN DANGEROUS DRUGS.

THE third annual report made by the BritishGovernment to the League of Nations respecting thetraffic in opium and other dangerous drugs is nowavailable. It would appear that while the admiiaistra-tion of the Dangerous Drugs Acts, 1920 to 1925,seems to have given effect to the principles impliedin The Hague and Geneva Conventions, and to havegreatly restricted illicit procedures in Great Britain,there is abundant evidence of vigorous illicit commerceelsewhere. Reports of seizures have during 1928been received from the colonies and the Dominions,in particular India and Canada, from the UnitedStates, as well as (through the Secretariat of theLeague) from other countries, notably Egypt andChina.

’ The total amount of morphine and its saltsmanufactured in Great Britain, by the two Edinburgh, firms licensed for the purpose, was 69,021 ounces, aL further reduction on the previous year. Likewise thes amount exported from Great Britain, 49,824 ounces,l was greatly less than obtained only a few years ago.

Of this exported morphine, 7058 ounces went toAsiatic Countries and 2749 ounces found their way toChina, an increase of 1831 ounces over the previousyear. The exports of British morphine to Africa,America and Australasia also show an increase overthe figures for 1927, while the consignments to

, European countries showed a considerable decrease.. Of heroin (diacetyl morphine) 10,794 ounces weremanufactured in Great Britain, of which 6038 ouncesJ were exported. It is interesting to note that Indianl opium is now almost entirely employed in this country.

for pharmaceutical purposes to the exclusion ofT Persian and Turkish opium, which latter were formerly_ regarded as the more appropriate sources of thealkaioids. It is also to be noted that in addition to

.

the import of raw opium 9647 ounces of crude morphine