MILK OF MAGNESIA An Efficient Antacid and Corrective. Useful in the Gastro-Intestinal Irritations of Infant, Child and Adult Life THE CHAS. H. PHILLIPS CHEMICAL CO., New York and London Original Communications. EXOPHTHALMIC GOITER; KIDNEY STONE; ESO- A Clinical Lecture Delivered at St. Thomas Hospital, BY WILLIAM D. HAGGARD, M.D., F.A.C.S., PROFESSOR OF SURGERY AND CLINICAL SURGERY, VANDERBILT UNIVERSITY, NASHVILLE, TENN. EXOPHTHALMIC GOITER. Gentlemen:-While the first operative case, one of exophthalmic goiter, is being prepared, I will show you the results in two other cases of the same type. Case I. This patient, Mrs. S., who lives in Lawrenceburg, was operated on two weeks ago. She gave the following history. Her neck was noticed to be larger about four years ago. Her attention was called to it by a choking sensation while eating. The enlargement had gradually grown until it was four times as large as a normal gland. The right side was very much more prominent than the left, and has pained her considerably, it being of a dull character. She still had trouble in swallowing at times. For the last three or four years she has been very nervous. Any noise startles her. She suffered with a shortness of breath and had a great deal of headache, for which she wore glasses without any benefit. There have been a number of periodical fainting spells, attended with unconsciousness which confined. her to bed for two or three days. She was at all times aware of her heart beating very rapidly and very forcibly. There has been a loss of twenty-five pounds during the last three years. The goiter pressing on her throat seemed to give her a dry cough. Her blood pressure was 165. Glasses did not relieve her headaches. "Please look up." The lower lids lag. This shows Von Graefe's eye sign. "Please look down at the floor." The upper lids lag and expose the sclera, Kocher's sign. Her tachycardia was not very severe, only 110. I regarded it as a favorable case. She was subjected to a right thyroidectomy, one-half of the gland being removed. The scar is the low transverse collar incision. She has had no post-operative trouble whatsoever and sat up on the fourth day. Her pulse has receded to practically normal and there had been no pain at all. I really think it is a very satisfactory case considering that she has had four years of trouble. She is going home today and I asked her to let you see the result of the operation and she gladly assented. Case II. Mrs. B., 26 years of age, resides in Atlanta. She had a severe type of exophthalmic goiter. In January, 1914, the patient noticed her heart beating very fast on the slightest exertion. She became very nervous and easily excited and has been progressively losing strength. Tachycardia has been her chief symptom. The least noise would excite her; whereas, formerly, she was very selfcontained. She had been very weak with marked trembling. The pulse has gone to 180. She stayed in bed fourteen weeks. Under this treatment she improved very much. In addition to extreme nervousness, tachycardia and great weakness, she had some trouble with her head and eyes, but she reads very well without glasses and the eyes are much better now. She has lost fifteen pounds, but has never had any nausea, vomiting, or diarrhoea. The enlargement of her thyroid was very appreciable. When the gland was removed it was found to be much larger than normal and was meaty, no visible colloid at all. One of her sisters had goiter when she was fourteen years old, the goiter of adolescence, and it disappeared. This patient was operated on a week ago yesterday. I believe she has had less trouble than most of the cases, having no pain and no difficulty in swallowing. She has been under the care of Dr. Richard Dake since July, with complete rest and other symptomatic treatment, and has improved so satisfactorily as to have been in excellent condition for the radical operation. She now has a pulse of 84, which would be practically normal for her. When she goes home she must lead the simple life until she gets entirely and completely well. Case III. Mr. R., aged 38. Six months ago noticed very loud beating of heart and became very nervous, which has gradually continued and become more marked. He noticed a considerable enlargement of his neck in December. It has been growing rapidly since. Synchronous with the rapid heart and great nervousness he noticed that his hands were so shaky that he could not hold them still. This continued and his tremor is marked. There is considerable shortness of breath aggravated by exercise. He has lost very little weight. Since October his eyes have troubled him to such an extent that his vision has been blurred and he had glasses fitted, but without much benefit. He is hot at all times, never puts on a coat, keeps his shirt open at the neck and can bear no cover at night. His spells of weakness are periodical and at times extreme. There is a peculiar feeling in the pit of the stomach that makes him Case III. Exophthalmic Goitre. (Photo taken Jan. 26.) weak and faint. There are frequent attacks of headache, which are very severe, and his loss of strength has incapacitated him for work. The most striking symptom is his extreme nervousness and excitability. He is at times flighty, so much so that one who did not know his condition would think he was losing his mind. Seven years ago he had an acute pleurisy, with effusion, which turned out to be tubercular, and I did a thoracotomy and drained the chest for a number of weeks. He has made a satisfactory recovery from that and his lungs are in good condition. There is a little dullness where the pleura has occluded itself at the drainage opening and at the apex there are a few moist rales. I will attempt to do the shockless operation. He has not been told about it. He was given scopolamine, grs. 1-150 an hour and a half ago, and morphia with atropia 30 minutes ago. He is taking nitrous oxid and oxygen anæsthesia lightly. I will also employ novocain as a local anæsthetic and in that way carry out the annoci-association principle. His pulse is 130. The gland on the right is very much more prominent. The right gland, as you know, is larger normally than the left, and it is surgically easier to remove. I will remove the right or diseased half. We have about six times as much thyroid as we need, so if a patient is not cured by the removal of half of the gland, it is a simple matter to remove a little more. Usually one-half seems to be quite sufficient. In doing that I plan to divide the gland at the isthmus. I make the incision across the neck and through the platysma muscle. With traction on the upper flap it is comparatively simple to dissect it up sufficiently to give a wide exposure. Here you see the anterior jugular vein. It will be necessary to divide this. I now go down in the midline and between the two sternothyroid groups. The gland is now exposed and is covered by its false, fibrous or surgical capsule. It is going to be necessary to divide the sternohyoid and sternothyroid muscles between forceps, in order to make a trap door to give |