CHRONIC GOITRE. — In goitrous re gions it is a matter of common observa tion that the localized or generalized en largement of the gland may, during a course of years, attain a very large size without causing its owner anything more than the discomfort attached to its weight and its position. If the gland undergoes a general slow hypertrophy, the firm growth of the whole, by form ing, as it were, a well-built arch sur rounding the trachea, may lead to sin gularly little disturbance, and, where there is disturbance, it is more often due, not to growth inward, but to the pressure brought to bear upon the enlarged gland by the muscles' passing over its surface.
On the other hand, a relatively-small enlargement of the gland may, by press ure, bring about a very considerable dis turbance; much depends upon the exact position of the growth.
[Thus, only recently, at an autopsy upon the body of a woman who had for some years past suffered from occasional paroxysms supposed to be asthmatic, and who died almost suddenly from ex treme dyspnma, I found that all the trouble was due to a localized enlarge ment of the isthmus of the gland, an en largement which from the general stout ness of the woman had not been recog nized during life. Dr. Anderson, of Toronto, recently exhibited, at a meet ing of the Ontario Medical Association, a very similar case. J. GEORGE ADAMI.] As might be expected from its posi tion, it is in connection with the trachea that most often the first symptoms arise, pressure upon this leading to some em barrassment in respiration. The par oxysms of dyspncea, which not infre quently occur, are ascribed to the catar rhal condition of the mucosa secondary to the pressure; but in some cases it would seem to me that the paroxysms are directly due to the pressure and con nected with sudden enlargement of the organ, either through hypermmia or, again, through hmorrhage into the organ.
Case of wandering thyroid. It arose from the right lobe, lay behind the ster num, and caused paralysis of the right vocal cord by pressure on the right re current laryngeal nerve. The tumor
could be brought above the sternum by coughing. Reuter (Deutsche med. \Voch., July 23, '91).
A person who has goitre, but who has not suffered from dyspncea at all or who has only suffered moderately, may have a sudden attack which may be fatal. A very few cases have been caused by limorrhage into the goitre; but this condition is excessively rare. The theory of Rose is that the pressure of the en larged thyroid makes the tracheal rings non-resistant, so that the trachea is apt to be bent and its lumen become ob structed. He thinks that in these cases of sudden dyspncea the trachea becomes kinked from relaxation of the muscles, which maintain the head in such a posi tion as to keep the tube open, and that this is probably brought about either during sleep or ancesthesia. These cases do not occur always during sleep or amesthesia. Very urgent dyspncea is rarely brought on by the relaxation of the muscles during sleep, for if the posi tion of the neck were the cause of the dyspncea alternation of the position should relieve it, yet this is not the case. Charles A. Morton (Bristol Med.-Chir. Jou•., Sept., '96).
Where there is gradual compression upon the trachea, it is in general lateral, and it may be so extreme that the side walls are pressed together and a trian gular or even flat-sided tube be produced.
The alteration in the voice not infre quently met with in the goitrous is to be ascribed in different cases to two different causes: (1) to actual pressure upon the cricoid and thyroid cartilages, causing impediment in their proper action; and (2) to compression of the recurrent laryn geal nerves. There may also be press ure upon the phrenic and sympathetic nerves.
By the very size of the organ obstruc tion may be brought about in the veins of the neck and upper half of the chest, leading to chronic congestion of the upper portion of the body, so that the skin assumes a dusky appearance. It has been noted by several authorities that in general the jugular veins are dragged in ward, while the carotids are dislocated outward.