. A new manual of surgery, civil and military. ebefore the surgeon is consulted. Indeed, until very recently, too long aperiod of time has intervened between the original diagnosis and the surgicaltreatment in many of these cases, and too much stress cannot be laid upon 158 SURGERY OF THE NECK the importance of an early operation in all instances in which a permanentcure is not obtained by internal treatment pursued a reasonable length oftime; provided, first, that the patient is not suffering from temporary exacer-bation of the hyperthyroidism, and, second, that the disease has not existedsuf
. A new manual of surgery, civil and military. ebefore the surgeon is consulted. Indeed, until very recently, too long aperiod of time has intervened between the original diagnosis and the surgicaltreatment in many of these cases, and too much stress cannot be laid upon 158 SURGERY OF THE NECK the importance of an early operation in all instances in which a permanentcure is not obtained by internal treatment pursued a reasonable length oftime; provided, first, that the patient is not suffering from temporary exacer-bation of the hyperthyroidism, and, second, that the disease has not existedsufficiently long to leave the circulation and the nervous system of the patientin an absolutely hopeless condition. Unless one recognizes the first of thesecontra-indieations one will lose patients who could easily bear the strainof the operation were they not also compelled to bear the additional strainof the temporary hyperthyroidism. This can be avoided by waiting untilthe temporary storm has subsided. In the vast majority of these cases one. Diffuse Toxic Adenoma of the Thyroid Gland. will find that such exacerbations have repeatedly occurred before, only tosubside again under treatment with physical, mental and emotion-rest, properdiet and internal treatment. Of course, the patient each time emerges fromsuch an attack in a worse condition than previously, consequently one showsbetter judgment by avoiding operations during an attack of acute hyperth}-roidism. This fact is most forcibly insisted upon by Kocher, Mayo and all otherclinicians who have had a large experience in the surgical treatment of thesecases, and is one that should be especially impressed on the family physician. Youthful patients. It is well to bear in mind that especially in younggirls, about the time of puberty or a little later, many goitres cause symptomswhich will justify a diagnosis of incipient exophthalmic goitre. The tremor, SURGERY OF THE NECK 159 the muscular weakness, the nervous excitability, s
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