es which are steadily
increasing in size. Kocher considers it advisable to operate if the
patient becomes breathless on making pressure on the goitre from side
to side. The suspicion of a goitre becoming malignant is also a reason
for removing it by operation.

The operation--_thyreoidectomy_--consists in excising that portion of
the thyreoid which is causing pressure symptoms, and this usually
involves removal of one-half of the gland. The chief danger in
operations for goitre is cardiac insufficiency, as evidenced by
disturbed rhythm of the heart-beats, lowering of the blood pressure,
or dilatation of the cavities of the heart (Kocher).

It is sometimes advisable to perform the operation under local
anaesthesia. A general anaesthetic is, however, preferred in this
country. The injection of 1/6th grain of morphin and 1/120th grain of
atropin half an hour before the operation, and the administration of
ether by the open method, or by intra-tracheal insufflation, is safe
and satisfactory.

There is reason to believe that the absorption of thyreoid secretion
squeezed from the divided surfaces gives rise to a condition known as
_acute thyreodism_ during the first few hours after operation; its
symptoms are elevation of temperature, increase in the pulse-rate
(150-200), rapid respiration with dyspnoea, flushing of the face,
muscular twitchings, and mental excitement. The gentle handling of the
tumour and the employment of a drainage tube for the first forty-eight
hours diminishes this risk.

_Tetany_, as evidenced by the occurrence of cramp-like contractions of
the thumb and fingers, may supervene within a few days of the
operation if one or more of the para-thyreoids have been inadvertently
removed. It may be controlled by large doses of calcium lactate. On no
account may the whole of the thyreoid gland be removed, as this is
followed by the development of symptoms closely resembling those of
myxoedema--_operative myxoedema_ or _cachexia strumipriva_.

_Treatment of Sudden Dyspnoea._--When dyspnoea suddenly supervenes and
threatens life, it is sometimes possible to relieve the pressure on
the trachea by open division of the skin, superficial fascia, platysma
and deep fascia in the middle line of the neck, so as to relax the
tension on the goitre. If this is insufficient, the isthmus may be
divided. Should relief not follow, tracheotomy must be performed, and
a long tube or a large-sized gum-elastic catheter with a te