me access to the superior thyroid artery. This capsule is incised and gently stripped from the gland, and in so doing I lift the gland on to the surface in order to get to the upper pole where I can have the superior thyroid artery in plain view. A good plan, after clamping the artery, is to take hold of the gland just at a point where the superior thyroid artery joins and cut between. The forceps on the upper pole serves as a tractor. In the true or proper capsule there are a good many little blood vessels, so I will just use forceps to the outer side so I can peel it out of the capsule. There is a little filmy connective tissue between the false capsule and the proper capsule of the gland itself. The latter is a shiny peritoneal-like membrane. The idea in peeling the outer capsule back in this way is to keep the important structures like the recurrent laryngeal nerve and the parathyroids behind it. There are a great many small arteries between this capsule and the gland proper that must be accurately grasped and clamped. The inferior thyroid artery lies at the lower pole. The recurrent laryngeal nerve crosses it very near the gland. A good way under these circumstances is to hug the gland very closely in order to get away from the nerve. Now one little vessel is holding yet on the side. I am now up to the isthmus, and that I will divide across as a pedicle from the trachea. It is a very friable gland. No. 1 iodized catgut is used. in tying these numerous vessels.

The next step is the closing of the cut muscles transversely, and then where they were separated in the midline. The skin incision will be closed by sub-cuticular sutures.

The per cent of cures in these cases is about seventyfive, taking the good, bad, and indifferent ones as they come. Of course, many cases are being referred to the surgeon that are very far advanced, but operation should be advised early whenever a few months of careful medical supervision fails to bring relief. If these patients pass through the first thirty hours after operation without

thyroid fever, we feel sure they will get through safely. The thing to do, then, in the first thirty hours, if the patient is suffering from hyperthyroidism, is to give them large quantities of water, if they can swallow; if not, give it by the rectum, and if necessary under the skin. The only drug that is of value is atropia.

Dr. Dunklin finds the patient's pulse 135, and at the conclusion of this rather extensive operation is practically what it has been recorded before the operation; hence we feel that our effort to prevent, psychic and traumatic shock has been fairly successful.

STONE IN THE KIDNEY.

Case IV. I want to show you now the result of a very interesting case of renal calculus. This patient, fifty-three years of age, has a rather interesting history of having had "bladder trouble" for ten years. Frequent urination has been constant for five years. It got worse and she was operated on twice for urethral caruncle without result and then had an X-ray treatment with relief. At that time, in order to discover the cause of the cystitis, Dr. King X-rayed her and made this very beautiful picture, showing a large renal calculus in the left side. She had no renal colic, the reason being that the stone was too big and simply filled up the pelvis and did not give rise to colic. What she did have was an overdistended renal pelvis, cystitis and frequent urination. About ten days before she came she had for the first time great pain in the left side, tenderness, chill and high fever. The presence of the calculus caused suppuration of the left kidney and that drove her to operation, after having been in possession of the X-ray evidence of stone for two years. The operation was very difficult, because the kidney was densely adherent. I could not bring the kidney out, because it was four times as large as it should have been. There was a large pocket of pus which led into the pelvis of the kidney and formed a perinephritic abscess. There was a quantity of pus, too, in the kidney. She is still wearing the drainage tube; she

still has six or eight nocturnal urinations. I am going to cystoscope her as soon as she is able, to see if the left kidney is functionating. There is no urinary escape from the kidney abscess, and it may not be secreting any at all and may have to be removed later.

ESOPHAGEAL STRICTURE FOLLOWING TYPHOID FEVER.

Case V. Mabel B., aged 10.; Hickman, Ky. In August, 1913, this little girl had typhoid fever for five weeks. During that time she complained that nothing would go

J. M. King, showing shadow of bismuth gruel coming to a conical point at site of impervious stricture.

down easily. She cried when she took water or milk, but could take boiled custard very well. A month after her convalescence she was choked while eating chicken and has taken no solid food since. She spits up all the meat that she has tried to eat at various times, and really lives on liquids and cereals. She vomited up a melon seed last summer two weeks after attempting to eat water melon. Whenever she tries to eat much she feels choky and has to produce vomiting by putting her finger in her throat. On Christmas day she attempted to eat some turkey for the first time, and after swallowing it she felt choked and has vomited everything that she attempted to eat for four days following. Now she can only swallow water or milk with any degree of comfort.

She was sent to me by Dr. H. E. Prather, of Hickman, Ky.

The diagnosis of spasmodic stricture of the esophagus was made in Louisville two years ago after an X-ray picture was made. A bougie was passed and she was put on belladonna. The bougie was only passed three times. Under an anæsthetic I was able to get in a No. 18 (French) bougie. That was two weeks ago. She is having dilatation every other day. I will have to go at it slowly, as any rupture would lead one into the mediastinum. case is going under the anesthetic.

CHOLECYSTITIS.

The next

Case VI. Miss S., aged 18; Iron City, Ala. During the last two and one-half years she has had fifty or more attacks of cramp colic, beginning suddenly in the pit of the stomach and radiating to the right side of the upper quadrant. The spells are much harder now than in the beginning. During the past year the attacks have averaged one in a fortnight. She is nauseated, but does not always vomit. The spells confine her to bed from one to eight days; temperature in the recent attack was three degrees above normal and lasted three days. That was three weeks