and have explained why in my article that the peristaltic action of all tubular structures and unless arrested by opiates are ever in motion. Then why should not the circular and longitudinal fibres of the appendix rid the lumen of foreign agents when they happen to get there-especially when irritation and contraction are prevented by sweet oil, and relaxation and good lubrication substituted?' I, therefore, emphasize that part of the paper that the surgical procedure would not be necessary even though it were known absolutely before an operation that foreign substances were in the appendix. The same rules govern the appendix that preside over the thirty feet of the intestinal tract; microbes may sail through, and so may foreign bodies-and they do but a blockade of constipation produces a paralysis of its structures, and, tender like an infant, it has less power of resistance than the mother intestine and, therefore, is the first to take on destructive changes. I do not claim to know the use of the appendix, but do claim that it is an ever moving tubular structure and can take care of a foreign agent which may enter it by a little assistance. You know that a little oil on an axle will remove the friction which would not only destroy it, but the whole wagon would burn if left to itself. With the appendix, it being so small a tube, it would soon strangulate under the contraction incident to the irritation of a foreign body, but by lubrication the arrested peristaltic action or the paralysis due to the inflammation is relieved and it again resumes its vermiform process."

Dr. W. G. MacDonald in the same paper of April 2, 1894, said: "That while appendicitis might in some cases yield to medical treatment, in many cases nothing but surgery could save the patient." He had known, he said, of cases in which Dr. Terry's medicines would be no more efficacious than a like quantity of water, and he has seen others in which the administration of the amount of calomel prescribed by Dr. Terry would be attended with fatal results.

"There are, it is true," said Dr. MacDonald, " many cases of appendicitis that yield to medical treatment. The physician must depend on his own judgment and experience to determine whether an operation is necessary or not. I do not agree with Dr. Terry that the surgeon's knife has been too freely used in this disease, and as far as his method of treatment is concerned, there is absolutely nothing new about it. All that is well known to every reputable

physician. I do not consider Dr. Terry a competent authority in the disease."

In reply to Dr. MacDonald, I said, in substance: "I have shown the conditions in which the treatment was not applicable, and there are other conditions in the advanced state which intelligent surgeons will recognize as not coming under the head of this treatment, so the doctor's attempted slurs that Dr. Terry's medicines would be no more efficacious than a like quantity of water' in certain cases is absurd, in view of my statement of exceptions. The cases where the doctor states injury would follow the treatment are cases in which I would not use it. Although the most recent standard work on surgery (The American) shows a mortality of twelve per cent., the truth remains that the mortality in the country is much greater. Recently I visited a village where three operations had been performed, but all had died. The methods which I used saved a professor in the same village within thirty days. As to the newness of the treatment I challenge the doctor to prove the assertion that all reputable physicians are familiar with the treatment. He must show that such treatment exists in a standard work or has been largely circulated in medical journals, and, furthermore, that such publication antedates the articles which I have written in the Medical Times, of New York, and in the Orificial Journal, of Chicago."

Dr. R. T. Morris, of New York City, connected with The PostGraduate School of Medicine and especially distinguished for his operations for appendicitis, in a letter, dated May 1, 1894, and published in the Ithaca Journal, objected to the oil treatment for appendicitis, in substance, as follows: "The sweet oil treatment of appendicitis was in common use long before we had learned to manage the disease properly, and while it is very useful in relieving symptoms, it is never of avail in the cases which are to result in troublesome complications or death. The reason why it must fail in such cases is because the bacteria which cause the disaster are out of reach of any medicament. Only about ten per cent. of appendicitis patients die in the first attack, and the knowledge of this fact tempts us to unwisely apply medical resources in many cases. Appendicitis is to-day entirely under our control, and deaths from this disease are unnecessary if the patient is where he can have the appendix removed at the first appearance of the infection. No physician can tell in advance whether any one attack is to prove fatal, or to cause chronic invalidism, or to end quickly without trouble.

"Early removal of an infected appendix means saving of time, saving of distress and saving of life. The disease is so common that we have all lost friends and acquaintances from it, sometimes under an alias of peritonitis, or obstruction of the bowels, or bilious colic."

In reply to the above criticism, I stated in substance: “Unquestionably the knife can save cases in the suppurative stage of appendicitis when you are called in late, and it is here that the skill of the surgeon can, in the majority of cases, save life. If citizens throughout the country will do just a little thinking for themselves, it is my opinion that the suppurative stage of appendicitis will seldom, if ever, be reached, and the surgeon's skill in this almost specialty will be only exceptionally seen. Look into the physiology of your lives, and after you have gained the information that every organ has its peculiar function and that the system demands the regularity of an excellent timekeeper is order to preserve health to the body, that the most necessary part of the structure is the diurnal attention to the intestinal tract, and finally if the peristaltic or ever-moving tube which conducts the refuse of the body as well as the microbes which are now considered one of the causes of appendicitis-along the thirty feet of intestinal tract, is suspended, the difficulty which causes the appendicitis will be seen to begin in the сосит. It is a bag-like affair located in most cases in such a pendant position that obstruction in the cæcum means strangulation and death of the infantile intestinal protuberance unless relief begins early. If such be the condition, which is the more rational, a good cathartic or a knife? It is not good reasoning to apply in the meantime hot fomentations with oil for its relaxing effects, and if it be good on the outside, is it not reasonable, theoretically, that muscular fibres will suspend contraction if taken internally ?"

In concluding this paper, it has been my aim to impress one thought, at least, in regard to the stages applicable for the oil treatment, and I will emphasize it now. It is applicable for every symptom which leads eventually to appendicitis, including the inflammatory stage up to the suppurative, and I believe if this rule of limitation be taken as a guide, the suppurative stage will seldom, if ever, be reached, and the surgeon's knife and the fear of the people in regard to appendicitis will be a thing of the past.

DISCUSSION.

DR. LEE: Dr. Terry is one of my personal friends, and always tells what he believes to be true. Now, as to the application of oil internally and externally to the irreducible hernia, it seems to me that any physician or surgeon who would allow a patient to go over night with irreducible hernia would be almost criminally culpable. We know that the mortality in operations is higher than in some other procedures with remedies, but when some accident has happened to the loop of the intestine, the surgeon has only one thing to do, and that is to operate, and if, on opening the sac, he finds a ruptured intestine with pus and fæces in the sac, he must do his best to save the patient, but if the operation had been performed a few hours after the obstruction formed all this would not have happened.

As to the treatment of appendicitis, I think that surgeons are now agreed that many operations have been done which might have been avoided; the operations were done too early. I do not know that the oil does any good or harm, but I do know that if we will give the patients the indicated remedies and let them lie quietly, they will, four out of five, recover without an operation.

MYXEDEMA IN ITS RELATION TO THYROI-
DECTOMY.

BY S. B. PARSONS, M.D., ST. Louis, Mo.

THE history of surgery contains no record of two diseases that in any manner assume the definite relationship that myxedema does to thyroidectomy.

It is a question of great importance in all its bearings whether it pertains to the patient or the surgeon. It is a question which every surgeon should consider thoroughly before an attempt is made to relieve his patient of a goitrous tumor by removal of the enlarged gland. It is a question so intricate in its details, so profound, so far-reaching, so inextricably mingled with the far-away future, as to cause us to halt in forming a line of treatment which includes total ablation. It is not alone the question of removing an ugly deformity that should demand our thoughts, nor whether the operation will or will not be a bloody one; but that which is paramount to this is, will there be brought about by the operation a change in the system that leads to a worse condition than the original disease, is a more vital point that should claim our attention before operative measures are instituted. Myxoedema is a peculiar disease, unlike anything else in the catalogue of human ailments. Nothing approaches it in its pathological status, nothing resembles it in any manner except dropsy, and in this complaint the likeness is only in the general external aspect.

My attention was drawn to this subject twelve years ago, at which time I performed my first and second thyroidectomies. The entire gland was removed in both cases, one being a married female, 28 years old, and the other a married male, 41 years of age. The length of time between the operations was eight months. The woman died in two years and four months, and the man three years and seven months after being operated upon, both presenting nearly the same train of symptoms from first to last. Death, in the case