374 C. P. HOWAED 



in part to^the practice of the two or three stage operation in the more 

 severe cases. 



The indications for operation in exophthalmic goiter should be clearly 

 understood by the internist and surgeon alike. Cases of so-called Base- 

 dowized goiter, in which there is a mechanical compression of the struma, 

 are clearly in need of surgery. Further, in the absence of any contra- 

 indication, a patient with the typical syndrome which has not yielded 

 to a few weeks of good medical treatment should be advised to submit 

 to an operation. It is much harder to decide as to whether or not surgery 

 is indicated in the so-called atypical cases and in those which have im- 

 proved under medical treatment without getting well. Surgery is, at 

 least for a time, contra-indicated in emaciated patients with extreme 

 exophthalmos or advanced myocardial degeneration and also when there 

 is reason to suppose there is developing an acute exacerbation of the symp- 

 toms. Mayo (a) does not operate if the pulse be above 130 per minute, or 

 irregular in force or rhythm or if there be anemia or edema present; for 

 such cases he recommends the use of belladonna internally and the rontgen 

 ray locally. Kocher (a) warns against surgery in patients with low blood 

 pressure or periodic attacks of delirium cordis. 



The operations most in use at the present day are partial resection of 

 the thyroid gland or ligation of one or more of the thyroid arteries. In 

 early or mild hyperthyroidism or very severe cases of exophthalmic goiter 

 with secondary symptoms, ligation is often a preliminary measure and 

 indeed may suffice. In a later paper Mayo (c) recommends a preliminary 

 ligation with thyroidectomy four months later when the heart is dilated 

 more than one inch in its percussion outline. In 225 cases so treated 

 by Mayo the mortality was only 2 per cent, while fifty-nine per cent 

 were reported very much improved several years later. Balfour, of the 

 Mayo Clinic, advises the removal of the entire right lobe, the isthmus 

 and part of the left lobe of the thyroid as the usual procedure: in other 

 words, four-fifths of the gland should be removed to give the best results. 

 This is not the place to give surgical technical details, which will be 

 found in all special treatises of regional surgery. 



There is some difference of opinion as to the choice of anesthesia. 

 Kocher and for a time Halsted preferred local anesthesia. Mayo rec- 

 ommends general anesthesia with ether on the open mask and so avoids 

 surgical shock : in his opinion the struma in Graves' disease is rarely 

 large enough to make general anesthesia a dangerous procedure. Crile 

 prefers nitrous oxid general anesthesia combined with novocain local an- 

 esthesia : he believes that nitrous oxid as compared with ether anesthesia 

 protects more against shock because of its interference with the use of 

 oxygen by the brain cells. Crile's "anoci-association method" is possi- 

 bly unnecessarily elaborate but has for its object the lessening of the 

 elements of fear and shock in the production of hypeTthyroidism. In 



