GRACE HOSPITAL.

Drs. W. E. Butler and T. H. Russell operated on three cases of exophthalmic goiter. A brief history of the first case is as follows:

Mrs. S. M., age 33 years. This person had a goiter at the age of 16 which disappeared. Her maternal aunt and two of her cousins also had goiters. The second goiter appeared about one and one-half years ago, after giving birth to a child. Symptoms of hyperthyroidism developed at this time, viz., mental excitation, loss of strength, tremor, nervous excitability, tachycardia, dyspnoea, palpitation, loss of weight, a sense of heat with a tendency to perspire freely, nausea and vomiting with diarrhoea, also exophthalmos, pulse ran from 110 to 120. The right lobe is larger than the left. There was a loss of 30 pounds in weight, most of which has been recovered, making her at this time a good operative risk.

Cases two and three were typical exophthalmic cases showing the usual classical symptoms. Pool's method of excision was followed in all three cases. After the operations were completed a number of postoperative cases were exhibited, demonstrating the value of the low collar incision and the good cosmetic results obtained.

Dr. E. H. Arnold showed the following cases:

A Case of Tubercular Spondylitis and a Case of Hip Joint Disease.

E. H. ARNOLD, M.D.

Case I.-Abraham S., age 14. Was first seen October 1, 1912. At that time he had been in a hospital for two months with pain in the back which had started three months previous.

Examination.-Examination revealed a distinct gibbus in the upper dorsal region and some rigidity of the spine.

Diagnosis.-The diagnosis of tubercular spondilitis was made. Treatment. The treatment advised was a corset and neck support on account of the height of the lesion. This being declined, bone graft was advised and done on October 23, 1912. The recovery was prompt and uninterrupted. The boy was normal in every way and was not seen again till April 1st of this year. At this time, he came complaining of the body leaning over badly to one side, of pain in the side and of the legs giving out, he stumbled frequently.

X-ray.-An X-ray, plate 1, revealed a distinct destruction of the fifth lumbar vertebra and involvement of the articular surfaces between fourth and fifth lumbar, lesions in the sacro lumbar joints, rarefication throughout the sacrum and involvement of the sacro iliac joints.

The case presents lateral and forward sliding off of the spine from the sacrum, pressure being caused thereby on the cauda equina. He has had more or less anaesthesia, this being no wise constant. He has had reflexes undisturbed, exaggerated, and diminished at different times, according to the amount of pressure present. He has had loss of muscular sense as evidenced by his stumbling and falling. He has had constipation and retention of gas, the latter to considerable extent which is also shown in the X-ray. At times passage of gas has been involuntary. He has had spasms of the muscles of the leg, especially on excitation of the sole of the foot. His symptoms have been ameliorated when he was placed in a plaster of Paris bed and kept there for about a month.

The present operation is being done to stabilize the fourth and fifth vertebrae onto the sacrum, to impart more vigorous bone growth to the sacrum. Whether later a transverse graft across from the sacrum to the ilia will be necessary remains to be seen.

This being the second attack of tuberculosis in the case, the prognosis for the success of the operation is not as good as the first nor is the chance for general recovery as good.

Operation.-A bone graft 4 inches long being removed from the shin bone of the right leg, the spinous processes of the third, fourth and fifth lumbar vertebrae and the first two spinous processes of the sacrum were split longitudinally, the graft inserted into the trough, muscle and fascia sewed over with kangaroo tendon, the skin closed with No. I catgut continuous suture.

Case II.-Elizabeth B., age 9. Was first seen December 4, 1915. She was brought to the Derby Hospital suffering with some pain and swelling in the right hip but mainly from uncontrollable bleeding from the nose, mouth and gums. A petechial rash appeared on the second or third day at which time I was called in consultation and made the diagnosis of purpura haemorrhagica, based upon the condition of the hip. The hip was not opened at that time for fear of getting uncontrollable bleeding on account of the hemorrhagic condition.

Treatment. She was treated by rest, nourishing food, calcium and phylacogen, under which treatment the hemorrhagic symptoms stopped. The hip swelling became enormous, was finally tapped and pus evacuated, after which the patient became much more comfortable and allowing of manipulation of the hip for diagnostic purposes which had been, heretofore, on account of great pain and the precarious condition, not possible.

Diagnosis.-The diagnosis of hip joint disease was made.

Treatment.-Extension was applied and later a brace. The patient has been doing well till about a month ago when she was brought on account of a sinus on the posterior aspect of the right ilium and considerable leaning over of the trunk.

X-ray.-An X-ray, plate 2, reveals the destruction with crushing in of the fifth lumbar vertebra and also the upper part of the sacrum.

Treatment. The operation is undertaken to fixate the lumbar spine on the sacrum. Whether transverse graft will be necessary later on, remains to be seen. The local prognosis is good, the general prognosis, of course, grave.

Operation.-A bone graft 31⁄2 inches long being removed from the shin bone of the right leg, the spinous processes of the third, fourth and fifth lumbar vertebrae and the first two spinous processes of the sacrum were split longitudinally, the graft inserted into the trough, muscle and fascia sewed over with kangaroo tendon, the skin closed with No. I catgut continuous suture.