CLINICAL SYNDROMES 373 



tial thyroidectomy to relieve dyspnea in a case of exophthalmic goiter. In 

 1880 Tillaux, according to Benard, performed a successful thyroidectomy 

 for Graves' disease. Rehn (a) in 1884 contributed a paper which is usually 

 considered the earliest one in this special field. The pioneers in this 

 field of surgery, Theodore Kocher, J. L. Reverdin, Halsted, C. H. Mayo 

 and Crile, have published such statistics that we are forced to admit that 

 surgery is at least of symptomatic benefit. The physician has for years 

 been rather skeptical about the value of surgery in Graves' disease, while 

 ready to admit that if there be hyperfunction of the thyroid, a removal 

 of the hyperplastic tissue or at least reducing it in amount would cure 

 the disease; however, internists have pointed out that one cannot remove 

 the entire thyroid gland, and that one cannot know when a part is re- 

 moved whether the remaining portion is not relatively more dangerous; 

 lastly they recall how hypertrophied tissue may keep on growing or even 

 grow more rapidly if partially removed. Bram (a) in a recent paper gives 

 the various objections of the extreme conservative against thyroidectomy 

 and any of the later modifications of the surgical treatment of Graves' 

 disease. While not prepared to accept this ultra-medical point of view, 

 we believe it is a paper that should be read by internist and surgeon 

 alike. The immediate effect of the operation is invariably an exacerba- 

 tion in the symptoms of hyperthyroidism, which sometimes proves so 

 severe as to result in death in a few hours after operation. However, 

 after the first few days, there is commonly marked improvement in the 

 entire syndrome, usually first seen in the tachycardia and other cardiac 

 symptoms and shortly in the tremor and other nervous symptoms. Even 

 the exophthalmos is said sometimes to disappear, though we personally 

 have never seen this event. 



The part of the gland that has been left behind does not always 

 hypertrophy ; indeed, Kocher, Reverdin and Mayo state that it more often 

 contracts. Nevertheless, in a considerable proportion of cases hypertrophy 

 does occur with a return of the symptoms, necessitating a second or 

 even a third operation. Postoperative recovery does not always occur; 

 the earlier statistics showed a death rate of over 12 per cent in all types 

 of cases and as high as 22 per cent in the more severe cases. Death due 

 to operative procedure depends upon the condition of the patient, but 

 still more upon the skill and experience of the surgeon. In Rehn's (b) 

 series of 177 cases collected from the literature in 1901 the operative mor- 

 tality was 13.6 per cent. In marked contrast are the statistics of Kocher 

 (d), who in his first 176 cases had a mortality of only 4.5 per cent; Crile 

 reports a series of 206 consecutive thyroidectomies and 87 ligations without 

 a goiter death, the one death in his series being due to a double pneumonia. 

 C. H. Mayo (h) has performed 278 consecutive operations in exoph- 

 thalmic goiter without a death. These figures are due in part to the 

 remarkable progressive improvement in the technic of the surgical art, and 



