376 C. P. HOWARD 



the sympathetic ganglion for the relief of exophthalmic goiter : this method 

 was also practised by his pupils Abadie and Jonesco. Later Jaboulay 

 modified this procedure for the relief of the exophthalmos and by remov- 

 ing the superior or sometimes the middle ganglion procured slight ptosis 

 of the upper eyelids with a slight improvement in the unsightly exophthal- 

 mos. However, the procedure has been largely abandoned both as a 

 measure to treat the disease and to lessen the exophthalmos. 



Thymectomy with or without thyroidectomy was for a time resorted 

 to, but with such a high mortality that it was discarded. More recently 

 it has been quite enthusiastically recommended by Capelle and Bayer 

 from Garre's clinic in Bonn and with more caution by Halsted (c) of Bal- 

 timore. The rationale of the procedure has been discussed on page 351 

 et seq. Suffice it to say that the number of cases in which thymectomy 

 has benefited either with or without a coincident strumectomy, is as yet 

 too few to warrant any definite conclusions. 



One must also mention the local treatment of the tonsils, nose and 

 throat upon the assumption that in them may be lodged the primary 

 focus of infection. Thus Bergh believes that the infection spreads from 

 the nasopharynx along the lymphatics to the thyroid gland; he believes 

 that he has seen at least eleven cases of his own and refers to Sailing, 

 who found a similar focus of infection in thirteen patients in a series of 

 ninety-seven cases of exophthalmic goiter. Bergh collected forty-two ad- 

 ditional cases from the literature. He recommends massage of the nasal 

 mucosa, as well as the other necessary operative procedures, 



Resection of the colon was recommended by Arbuthnot Lane in both 

 exophthalmic and simple goiter on the grounds that there is an infection 

 of this organ which is the primary cause of the goiter. This theory of 

 the origin of goiter has been adopted by McCarrison (d] but has not been 

 generally accepted. McCarrison, however, recommends the administra- 

 tion of laxatives and the intestinal antiseptics and not surgery. 



Finally a word as to the end results of the surgical treatment of 

 Graves' disease. Mackenzie (c) writes that "my own experience of opera- 

 tion in exophthalmic goiter has on the whole been very unfavorable: in 

 St. Thomas Hospital of London there were three deaths in fifteen cases 

 of lii>ation of the poles and eight deaths in nineteen cases of thyroidec- 

 tomy: further, of the twenty-three patients who survived the operation 

 there was no change for better or worse in twelve cases." If such dis- 

 couraging results were universal surgery would rapidly fall into dis- 

 favor. However, Klose has collected the statistics of the surgical treat- 

 ment of ' exophthalmic goiter by various surgeons published between the 

 years 1896 and 1912: the percentage of cases of cure or at least marked 

 improvement ranged from fifty to ninety-eight. Mackenzie is more con- 

 vinced of the aeon racy of Halsted's figures, which admit of an approxi- 

 mate cure in sixty per cent of cases, in sixty to eighty per cent of which 



