tion when it occurs as a concomitant of some other disease. We almost never think of operating on a growing girl for hyperthyroidism. In addition to the sex-stimulation of the gland at this period there is the high school course in which she carries her books home and burns the midnight oil. Some misfortune, death of a parent or financial reverses, may necessitate leaving off the high school course and taking a highpressure wage-earning position. Now, the added burden of responsibility not infrequently is quickly followed by symptoms of acute hyperthyroidism. In a medical way—and I think they are all medical cases in the beginning-the best results follow where the surgeon and internist are associated in the treatment. These patients in my experience have nearly all recovered, following proper care without operation. The subject, as has been dwelt upon in both papers, shows an unsatisfactory state in the medical mind, and it will probably continue to remain so until we learn more about the causation of hyperthyroidism. We no longer think of one cause alone. There are many causes that will cause the gland to become more active and the symptoms will continue until relieved by medicine or surgery.

Our pathologist finds many changes in the specimens submitted to him. Of especial interest is the constantly increasing numbers of malignant and tuberculous thyroids he reports as experience broadens.

DR. H. B. SWEETSER (Minneapolis, Minn.): There are two or three points I would like to emphasize.

First-In the very acute cases of hyperthyroidism what plan of treatment is most likely to succeed? In our experience even ligation of the vessels has failed, and we have come to depend on absolute rest in a darkened room, an absence of noise and fuss, and no one allowed in contact with the patient except the attendant nurse. Under this plan many of these patients improve to a point where they may be safely operated on.

Second-As regards anesthesia: We prefer general with ether. We can work more expeditiously, and there is less strain both on the patient and the operator. This may be because we have not developed the best technic for local anesthesia.

Third-Concerning technic: We no longer restrict ourselves to removal of one lobe and the isthmus. The cosmetic results were poor, and patients would return with recurrent symptoms and hypertrophy of the opposite lobe. We now remove the isthmus and parts of both lobes, and tie both

superior poles. In this way there is no danger of interfering with the recurrent laryngeal nerve, the cosmetic result is better, and the probability of relapse very much diminished.

DR. HERTZLER (closing on his part): The gain in weight strikes me as a good index of the value of any treatment. Some of these patients take on weight if they are simply put to bed and not treated at all, but if this happened when you were doing anything for them you would be convinced that the therapeutic measure was of value.

DR. MACLEAN (closing on his part): I was glad to hear Dr. Judd mention the difference between ligation in the true exophthalmic and those of the thyroxtic type. There seems to be a distinct difference in these two types of cases, and we are just beginning to find out about it. I think we owe a great deal to the work done at Rochester along that line.

Speaking of metabolism: The one patient who died following injections of boiling water was a very severe case, and one of the marked symptoms was the great amount of food she could consume. If her metabolic index could have been taken it would doubtless have been very high. We have not as yet been able to carry out this line of work.

As regards experiments: These can be used only as a guide to a certain extent. They do not always apply clinically. We have done some experimental work that is not yet sufficiently complete to be reported, but we have found that dogs can live if one parathyroid is saved. It is difficult to do that in the dog, but we have run across a few cases where one parathyroid was distinct from the thyroid and have removed all the thyroid and all the parathyroids except this one, and the dog has lived and apparently had no symptoms from the operation. No definite report can be given on this work yet.

As regards tubercular infection in the thyroid: We have not observed any cases with definite tuberculosis, probably on account of our cases being more limited in number. I am consultant at a tuberculosis sanitarium, and have seen only two cases of exophthalmic goiter at this institution. I think one of the patients was there on account of the obscurity of the symptoms rather than that a definite diagnosis had been made, although the other patient had positive tuberculosis of the lungs and symptoms of hyperthyroidism associated with it. Whether there was tuberculosis of the gland was not known, because no operation had been done.

With the permission of the chairman I would like to show a few slides that I brought with me.

PURGING BEFORE AND AFTER ABDOMINAL

SECTION

HENRY T. BYFORD, M.D., F.A.C.S.

CHICAGO, ILLINOIS

A few years ago the drift of surgery, as a result of the introduction of anesthesia and the adoption of antisepsis, was toward the development of technic and the perfection of methods. Coincidentally, much attention was given to the elaboration of the preparatory and after-treatment. Many things were recommended and more or less extensively employed for the purpose of fortifying the patient for the operative ordeal, and of neutralizing the untoward effects. As surgical technic improved and methods were perfected these measures were found, one after another, to be no longer necessary, and were eliminated; and the preparatory and after-treatment assumed a simplified, more or less routine character.

One of the routine measures which have survived is pre-operative and postoperative purgation; yet there are those who are now seeking to give this attempted imitation of a simple process of nature its coup-de-grace. They not only declare it unnecessary, but attempt to prove by arguments and experimentation that it is harmful in its effects. I shall try to avoid prolixity and irrelevance by restricting my remarks to purgation in cases of intra-abdominal surgery in which the opening of the peritoneal cavity makes the condition of the intestinal canal a matter of considerable importance.

Let us take up first the subject of preparatory purging. But before we can discuss it intelligently we must define what we wish to do by it, and how we do it. I suppose that the main purpose is to cleanse the bowels of any gas or feces that might interfere with the attainment of the best results from our operative work. Another purpose is to have a comparatively empty colon in cases in which it may be desirable to keep our patient constipated for two or three days after the operation. The main argument against such purgation is that it seldom cleanses the bowels, and more often increases than diminishes the abdominal distention; and such really seems to be the case in many instances. An examination of the way in which it is ordinarily carried out in practice will show why. When a plumber cleans out a sewer he does not put dirt into it at the same time, because he knows better. But when the average surgeon prescribes a laxative to clear out the bowels, he allows food to be taken a short time before the laxative is given, and allows, or orders, more to be taken before the laxative has quit working. The result is that, instead of cleansing the bowels, the laxative merely moves everything onward. It expels old fecal matter and gas along with the digestive secretions and ferments while the stomach is delivering food into the duodenum. This food not only does not find the normal secretions for its digestion, but it is rushed onward too fast for digestion, and arrives in the colon as food for bacteria rather than for the patient. Not only this, but more food is usually given before the intestines have recovered from their fatigue sufficiently to take care of it. As a consequence they become distended, whether they have been so previously or not. If such is the ordinary preparatory purging and I think it is—then it does not require much argument and experimentation to condemn it.

This might be said to conclude the argument from the objector's standpoint, but it does not touch upon the merits of the question. The question is whether a laxative can be given so as to accomplish what we give it for, and, if so, how? I think it can, if what I shall call the four R's are observed, namely, the right laxative, in the right dose, at the right time, and under the right conditions. To begin with the last R mentioned, the surgeon or somebody should prescribe the conditions under which the desired results of the laxative may be secured. The material for the renewed formation of gas should be kept out of the alimentary canal; the last food that the patient takes before taking the laxative should have time to leave the duodenum, and be absorbed before the rapid peristalsis connected with purgation begins. After the purgation has ceased, none but easily digested food in properly regulated quantities should be given, such for instance as the quickly absorbable forms of sugar, meat extracts, or nutritive wines, or, if the patient is very weak, predigested food, until the upper intestines have sufficiently recovered from their fatigue to assume normal function, which may be before, or not until after, the operation, according to the requirements of the case.

But the fact that such severe restriction of the diet is required constitutes an indication for limiting our attempt at securing collapsed or partially collapsed intestines to the cases in which they are not already sufficiently collapsed, and in which the conditions of the operation require it.

The timing of the laxative must be such that any residual gas which may be left will have a chance to be absorbed. Thus, for a forenoon operation the laxative will have to be given early on the day before or, in some cases, the night before that. For an afternoon operation it will ordinarily be required the night