CLINICAL SYNDROMES 375 



his article in 1913, he writes: "The ideal plan of approach, at least in 

 my experience, is to assure the patient that hers is a cur able, malady, that 

 it can be treated in a hospital, and that non-operative measures will 

 first be tried; then if they prove inadequate a simple operation will be 

 done, that it will be best to leave the decision to the judgment of her 

 medical adviser, and that since even the discussion is both unpleasant 

 and injurious it would be best not to open this subject again. The patient 

 usually gladly consents to leaving the whole matter to the judgment of 

 the physician and the way is then opened for the most effective treatment 

 which in my judgment has ever been proposed namely, ligation or ex- 

 cision on the new principle of anoci-association. The patient has received 

 no psychic stimulation arising from the knowledge of the imminence of 

 the operation and none on being anesthetized and finally no afferent im- 

 pulse reaches the brain from the field of operation." 



In the postoperative period vomiting and secondary hemorrhage are 

 particularly to be feared. The latter is to be avoided by the most careful 

 ligation of all vessels and subsequent observation of the wound. The 

 postoperative hyperthyroidism, manifested by tachycardia, bounding 

 pulse, insomnia, vomiting and diarrhea, must be promptly met by the 

 hypodermic administration of epinephrin, atropin and morphin and by 

 absolute quiet and avoidance of visits from importuning friends. Post- 

 operative tetany was formerly not infrequent, owing to injury to the 

 parathyroid glands; the risk has been largely removed by the so-called 

 "intracapsular operation," which also lessens the likelihood of injury to 

 the recurrent laryngeal nerve. C. H. Mayo has noted only one case 

 of postoperative tetany in 3203 goiter operations, and in this patient some 

 of the diagnostic points of tetany were wanting. 



Postoperative treatment along general and hygienic lines should 

 be continued until the patient is restored to comparative health. Ochsner 

 gives his patients very specific directions, a practice which might be fol- 

 lowed by all surgeons to great advantage. As Crotti states, "When once 

 a patient has been operated on he becomes again a medical patient." He 

 should be asked to report for further examination upon the return of any 

 of the serious symptoms of the disease. 



Just a word about the other surgical procedures that have been ad- 

 vised from time to time in the treatment of exophthalmic goiter. 



The "exothyreopexy" of Poncet, as described by Jaboulay, consists of 

 the exposure and fixation of the enlarged thyroid gland in the wound 

 where it is left to shrink under an aseptic dressing. In the opinion of 

 the majority of surgeons it is as dangerous and less efficient than the 

 other surgical procedures. 



Sympathectomy or resection of the sympathetic ganglion has sometimes 

 given good results, but also many failures. Jaboulay in 1896, following 

 the suggestion of Trousseau, was the first to introduce an operation on 



