is tinged with blood. Dysphagia is
rarely a prominent symptom. The lymph glands become enlarged after the
tumour bursts through the capsule; and metastases to the lungs and
bones, particularly the skull, sternum, and mandible, are common. When
the goitre extends behind the sternum--the _malignant form of
retro-sternal goitre_--the pressure symptoms are due to the
encroachment upon the limited accommodation of the upper opening of
the thorax; the trachea especially suffers, and the pressure on the
veins causes distension of the anterior and external jugulars and
their tributaries. The patient is unable to lie down; there are
violent paroxysms of coughing, and an abundant frothy expectoration.
Death may take place suddenly from asphyxia, from heart failure, or
from displacement of a thrombus from one of the veins in the neck.

_Treatment._--It is only in the earliest stages that a malignant
goitre can be successfully removed. In the later stages complete
extirpation is not to be attempted, as it usually involves the removal
of a portion of the trachea or oesophagus, and the operation is
attended with grave risk to life.

Operative interference is often called for, however, for the relief of
respiratory embarrassment. _Tracheotomy_ may prove a difficult and
dangerous procedure, owing to the trachea being buried under the
goitre and displaced or narrowed by it, so that it is not easy to
reach it or to introduce an efficient tube beyond the point of
obstruction. A more certain method consists in exposing the goitre by
an incision as for thyreoidectomy, rapidly removing sufficient of the
growth to expose the trachea and admit of a tube being introduced. If
there is a retro-sternal prolongation compressing the trachea within
the thorax, a long flexible tube may have to be passed beyond the site
of the compression before the dyspnoea is relieved. The benefit is
immediate and decided; the accumulated secretion is coughed up, and
after a few deep breaths the patient is able to lie down, and usually
falls asleep. The stridor disappears. Unfortunately the relief is
only temporary, and the patient soon succumbs to a broncho-pneumonia,
or to secondary haemorrhage from the trachea.

#Toxic Goitre#--#Exophthalmic Goitre#--#Graves'# or #Basedow's
Disease#.--These terms are applied to a variety of goitre
in which the symptoms due to absorption of thyreoid
secretion--_thyreotoxicosis_--predominate. The name "exophthalmic
goitre" is mi