364 C. P. HOWABD 



organs. The immediate operative mortality at the Mayo Clinic is about 

 three per cent, while another two per cent die of degeneration incidental 

 to the disease or from some intercurrent disease made possible by the 

 lowered vitality resulting from the thyrotoxicosis. 



The actual mortality is variously given by different authorities : Thus 

 Buschan gives 11.6 per cent, Sattler 12.5 per cent, Mackenzie 24.5 per 

 cent, and Hale White 39 per cent. Osier points out that statistics are 

 misleading as only the severe cases come under hospital treatment. 

 Further, as Dock adds, the actual death rate is nearly impossible to de- 

 termine because first there is great variation in the severity of the symp- 

 toms, second a relatively large number of the severe cases is reported, 

 and lastly death is often due only indirectly to the disease itself and more 

 often to complications or accidentally associated diseases. However, we 

 believe that Mackenzie (c) is not far from the mark when he writes: "In 

 about 25 per cent of the cases death results from the disease; in about 

 50 per cent, more or less complete recovery will eventually take place. In 

 the remainder the disease continues in a chronic form during life." That 

 exophthalmic goiter plays a considerable economic role is shown by the 

 fact that during the four years 1911-1914 in England and Wales 1558 

 women and 155 men died of exophthalmic goiter ; the maximum age period 

 at the time of death was between the thirty-fifth and fortieth year. 



Among the causes of death cardiac insufficiency is the most frequent; 

 then comes exhaustion from vomiting, diarrhea., fever and other toxic 

 phenomena. About half the fatal cases succumb to some intercurrent 

 disease; pneumonia, bronchitis and pulmonary tuberculosis are frequent 

 terminal infections. The end may be sudden and due to syncope even 

 when the patient is getting on well. 



Treatment of Exophthalmic Goiter 



The number of modes of treatment of exophthalmic goiter is 

 legion. This, of course, is a certain indication that no one form of 

 treatment as yet devised is causal or specific. Even the various surgical 

 procedures must be regarded as symptomatic though we are not yet pre- 

 pared to accept the ultra-conservative view of Bram (a,) (&), who states 

 that "the large majority of cases are curable by non-surgical procedures," 

 and again that "the disease is one strictly outside the domain of surgery 

 unless dangerous pressure symptoms or malignant changes set in." 



We will, for purposes of convenience, consider treatment under I Gen- 

 eral measures, including (1) rest, (2) fresh air, (3) hydrotherapy and 

 electricity, (4) dietetic, (5) medicinal, (6) organotherapy, (7) serum 

 therapy, and II Local measures, including (1) cold applications, (2) 

 X-ray and radium, (3) injections in the gland, (4) the surgical procedures 



