CLINICAL SYNDROMES 363 



Prognosis 



The prognosis is more favorable in children than in adults; some 

 recover completely whilst in others slight struma and exophthalmos 

 remain. It is better in the female than the male, because the physi- 

 cal exertion of the former is never as great and more readily 

 controlled. The social position is of considerable importance, by which we 

 mean a patient with private means is not compelled to return to his 

 work too soon, and there is usually, in consequence, less mental anxiety. 

 Apart from the above considerations the prognosis depends upon (1) the 

 mode of onset, (2) the severity of the symptoms, (3) the duration of the 

 disease, and (4) the amount of damage already suffered by the circulatory 

 system. Symptoms of grave omen are progressive emaciation, much pros- 

 tration, great tachycardia, anorexia, continued vomiting, severe diarrhea, 

 dyspnea and severe muscular tremor. 



In any case, however, a guarded prognosis must necessarily be given. 

 While there is a general belief among physicians that patients with exoph- 

 thalmic goiter never recover and yet never die, except following surgical 

 operations, it would be much nearer the mark to say that few recover 

 and some die. A relatively complete return to health is not rare, so that 

 the patient may be able to resume his work or domestic duties : but such a 

 patient is not perfectly well and, in my experience, always reveals some 

 evidence of the disease, as nervousness, a slight increase of the pulse 

 rate and exophthalmos. Indeed, some degree of exophthalmos is the most 

 constant residual sign even in those cases treated surgically. Further, 

 modern laboratory methods have shown that the metabolic rate will also 

 show a persistent level above the normal even in cases which otherwise 

 show marked subjective improvement. 



There can be no doubt that cases which early submit to operative 

 treatment show a more marked and more complete recovery than is evi- 

 denced in those who postpone surgery indefinitely and try one after the 

 other of the various medical procedures. 



C. H. Mayo (h) believes that surgery, aided by medical treatment, cures 

 exophthalmic goiter in seventy per cent of cases; or, in other words, 

 seventy per cent feel well enough to attend to the ordinary business affairs 

 of life and even forget that they have been sick. 



Twenty per cent of these so-called "cured" cases still show slight 

 widening of the palpebral fissure, which, while not realized by the patient, 

 is noticeable to the trained physician. Further, in Mayo's experience 

 sixteen per cent are noticeably improved but are not quite well in that they 

 have some symptoms that remind them of the necessity of being careful. 

 Another four or five per cent have the progress of the disease checked 

 but too late to overcome the permanent degeneration of the essential 



