368 HOSPITAL MEDICINE AND SURGERY.

when it was being separated from the front of the trachea ; adouble siik ligature was then passed through the anterior partof the lateral lobes and tied in each case above and below,a considerable portion being thus removed. The substance ofthe gland was’granular and easily broken down. The tracheahad been slightly compressed laterally by the growth; itsanterior surface was quite cleared by the operation. Adrainage-tube was placed along the wound, the edges ofwhich were brought together by means of silk sutures, thelong ligatures of thick silk which were attached to thethyroid being brought out at the lower angle. The woundwas dressed under the carbolic spray in the usual manner.For some hours &fter the operation the patient had a

headache, but otherwise felt quite well. The day after theoperation the wound was redressed ; six days later thesutures were removed, plaster being placed across the woundto keep the edges well apposed. Two days later chlorinatedsoda lotion was substituted for the antiseptic dressing andthe drainage-tube removed, and twelve days after the opera-tion the last ligatures came away. He got up on the six-teenth day, and twenty days after the operation the neckmeasured fourteen inches. When seen after he had left thehospital there had been further diminution in the size of theneck.On the evening of the day of operation the temperature

was 98’8°, rising next morning to 1032°, falling duringthe day to 99°, and rising later. to 101’8°. There was then agradual fall (excepting on the 6th, when it rose to 102 2°) to96’8° on the 9ch; from that date until the morning of the12th there was a gradual rise, reaching 103°, and fallingnext day to 96’4, after which it rose to normal, and con-tinued so.Remarks.-In the cases which have been operated on in

the median line by Mr. Sydney Jones, in some a well-markedisthmus, drawing tightly together the lateral lobes, has beenobserved ; in others the isthmus has not been so well marked.In all cases the object aimed at has been to form a deepsulcus in front of the trachea so as to make a wide separationbetween the lateral lobes, and to effect this wide separationwhen the isthmus has not been well marked, and when thelateral lobes have been approximated part of each laterallobe has been removed after transfixion with a double liga-ture. In all cases shrinking of the lateral lobes has occurred,in addition to the relief to the difficulty of breathing anddeglutition. Free drainage has been secured in the middleline by a drainage-tube in front of the trachea, and nosymptoms causing any anxiety have occurred.

LIVERPOOL NORTHERN HOSPITAL.ANEURYSM OF ARCH OF AORTA ; EMBOLISM OF ABDOMINAL

AORTA ; NECROPSY ; REMARKS.

(Under the care of Dr. DICKINSON.)FOR the following notes we are indebted to Mr. S. W.

Roughton, M.B.Lond., house physician :-A. H-, a sailor, aged twenty-eight, was admitted into

the hospital on March 29th of the present year. He statedthat for four weeks he had suffered from pains in his jointsand across the front of his chest. On examination, nophysical sign of disease was discovered. The urine wasnatural. He denied ever having had any venereal disease,and said that he had always been temperate. The pains inthe joints subsided in a few days, but the pain in the chestpersisted and became worse. On April 12th he first com-plained of slight cough, and on April 16th an area of dulnessover the upper part of the sternum, continuous with thecardiac dulness, was first noticed. Over this dull area theheart sounds were very loud, but no bruit was audible; theright radial pulse was also noticed to be a little smaller thanthe left. He was ordered ten grains of iodide of potassiumthree times a day. On April 30th, distinct pulsation couldbe felt over the upper part of the sternum and costal car-tilages on the right side. A bruit was also audible at theright second intercostal space and conducted into the sub-clavians. A sphygmographic tracing showed a curve withrather slow ascent and a well-marked round top ; this wasmore apparent in the tracing given by the right radial artery.On May 22nd the patient was put upon Tufnell’s treatment.At first he behaved very well, andatthe end of a weekthe bruitwas a little softer and the pain not so severe. The pulse,however, always remained rather rapid, varying from 90 to110 per minute. About June l7th the patient began to

complain that he could only lie upon his right side, for if heturned upon his back his breathing became much impeded,and he began to cough. By June 23rd he had become tiredof lying still, and insisted upon sitting up in bed. His facesoon became slightly blue and cedematous, and the veins ofthe neck were a little distended. All these symptomsgradually increased, the pain in the chest becoming so severethat he could not sleep without morphia.On July 9th he was feeling rather easier than usual, but at

noon he was suddenly seized with violent pain in the abdomen, °became greatly collapsed, and- bathed in a cold perspiration.He complained of numbness in his legs, and of inability tomove them. No pulsation could be felt in either femoralartery, and both legs were cold and liyid. At 6 o’clock thesame evening he spat up some blood and gradually sank,death occurring at 10.30 P.M.Necropsy.-lmmediately above the attachment of the

aortic valves the aorta was dilated, forming a large, irregular,but more or less spherical cavity, about the size of a fcotdhead. The aneurysm involved the whole of the circum.ference of the artery from its origin to the beginning of thedescending portion. Its walls were very thin, and verylittle laminated clot was found adherent to them ; but thecavity contained a large quantity of soft dark clot in placesindistinctly laminated. The remainder of the aorta wasfairly healthy, but was completely filled by a soft dark clotterminating at the bifurcation of the aorta. On cutting intothe clot, no portion of different consistence was found in itsinterior, the whole clot resembled very closely that found inthe aneurysm. Besides some haemorrhage into the substanceof the left lung, there was no other pathological change.Remarks.-The chief points of interest in this case are :-

(a) The absence of any discoverable cause, and the age ofthe patient-viz., twenty-eight years; (b) the gradual apepearance of the symptoms made the case very interesting towatch clinically ; (c) the failure of the method of treatmentemployed was no doubt mainly due to the aneurysm in.volving the whole circumference of the aorta, and thus beingvery badly suited to the deposition of laminated fibrin;(d) the immediate cause of death was, no doubt, the detach-ment of a portion of the soft clot contained in the aneurysmand its impaction in the bifurcation of the aorta, followed bysecondary thrombosis filling nearly the whole vessel. ’

CUMBERLAND INFIRMARY, CARLISLE.LARGE IRREDUCIBLE UMBILICAL EPIPLOCELE ; REMOVAL

OF OMENTUM, SAC, AND REDUNDANT SKIN; WOOD-WOOL DRESSING ; RECOVERY ; REMARKS,

(Under the care of Dr. LEDIARD.)THE patient, a married woman, first applied at the out-

patient room with an umbilical hernia of large size, contain-ing omentum and bowel, the latter only being reducible.The tumour had gradually increased in size since the date oforigin-viz., six years previously. As the patient wasseven months pregnant she was advised to return after herconfinement, which she did upon July 9th, 1884. The pyri-form tumour was central and about the size of a fist.On July 14th an incision was made over the hernia, the

sac opened, and the few adhesions which united the omentumto it were broken down. The omentum was then ligaturedand cut away and the pedicle secured by catgut stitches tothe margins of the ring; the sac was next separated from thecellular tissue and cut away, and the skin was also freely cutaway so that a few stitches brought the edges together neatlyover. A drainage-tube and some wood-wool was the onlydressing used. The wound healed in two weeks.Remarks by Dr. LEDIARD.-This is the fourth case of

hernia treated in nearly the same manner. Two cases weresmall femoral ruptures, the sacs of which contained irre.ducible bits of omentum, and upon which the pressure of atruss was unbearable. The other case was an inguinalhernia the size of a duck’s egg, containing adherent omen-tum. In each instance the sac was cut away, ligatured, andstitched to the margins of the ring. In all good recoverieswere made, and the dressings were strictly antiseptic. It isespecially desirable to obtain a radical cure in umbilicalhernise, on account of the increasing disability they seem _

to cause, and not disability only, for sooner or later theygenerally become a positive source of danger. The patientwhose case I have given was but twenty-nine years of age,and future pregnancies may imperil the lasting success ofthe treatment. When the history of the rise and progress

369REVIEWS AND NOTICES OF BOOKS.

of Listerism comes to be written one, by no means the leastimportant, of the gains to be recorded will be the dating ofthe performance of operations which were formerly con-sidered either impracticable or dangerous, and amongstthese I venture to place hernim of all kinds, for in thefuture we shall hear more of the knife and the needle thanthe truss in the treatment of this class of ailments.

Reviews and Notices of Books.Compendium der Pathologisch Anatomischen Diagnostik.

Von Dr. JOHANNES ORTH. Dritte Auflage. (A Com-pend of Diagnosis in Pathological Anatomy. By Dr.JOHANNES ORTH. Third Edition.) Berlin : A. Hirsch-wald. 1884.

THE first edition of this useful work is known to Englishreaders in the translation (New York : Hurd and Houghton)of Drs. Shattuck and Sabine; but so numerous have beenthe additions and so careful the revision that this thirdedition is practically a new work. Dr. Orth, who is Piro.fessor of Pathology at Gottingen, has made many contribu-tions to the subject, and is at present engaged upon a hand-book which promises to take a prominent place in theliterature of this subject. The plan of the present work isthat of a guide to the post-mortem room. It opens with

general directions for the performance of post-mortem exami-nations and microscopical investigation, and then deals inturn with the external appearances of the body, cutaneousand subcutaneous lesions, before treating of the internal

organs, The description of these latter is taken systematicallywith reference to the cavities of the body, the spinal canal andthe cranium, the thoracic and abdominal cavities; and lastlythe extremity is considered. Directions are given for theexamination of all these parts before the detailed systematicdescription of the morbid anatomy of the various organs isentered upon. As an example of the method pursued may becited the chapters dealing with the lungs. The lesions of thepulmonary pleura are first described, and the externalcharacters of the lung as regards size, form, colour, and con-sistence. The method of incising the lung and the general’characters of the exposed surfaces follow, with directions formicroscopical examination of the fresh organ. Theauthorthendescribes in turn the diseased conditions, commencing withdisorders of circulation—hypersemia, hsemorrhage, infarc-tion-distinguishing with Rindfleisch between the "simple"infarction from rupture of vessels, and the " embolic," whichleads to mention of metastatic suppuration and fat embo-lism. Pulmonary oedema closes this section. The varieties ofpneumonia are fully described-fibrinous, catarrhal, suppurating, and caseous. As to caseous pneumonia, he dis-

tinguishes three main forms-caseous bronchitis or bron-chiolitis, pneumonia proper, and caseous peribronchitis ;holding apparently to the view that tubercle is a secondaryevent in these conditions. Under the head of "productive" "inflammation is described cirrhosis of the lung in its variousdegrees. Specific inflammations follow, the chief beingtuberculosis, which is described in the disseminated form,in the acute partially disseminated, and in the infiltratingor pneumonic form. He explains that the distinction ofthese varieties is arbitrary, and employed only for the sakeof facilitating description, for he admits that they are oneand all the result of the same virus, the " bacillus Kochii";and he shows that all depends upon the sense in which theterm "tubercle" is applied. Tumours of the lung, atrophicand degenerative changes (including emphysema), are nextdealt with, which enables him to dwell at greater lengthupon the distinctive lesions of phthisis. The chapter closeswith abnormalities in the amount of air (atelectasis) in thelung, foreign bodies (pneumono-koniosis) and parasites. Acomparison with the former edition shows here, as in other

chapters, how widely the author has departed from thearrangement there adopted, with the effect of rendering hisdescriptions more comprehensive and exact.

Post-Nasal Catarrh. By EDWARD WOAKES, M.D. Lond.London : H. K. Lewis, Gower-street. 1884.

THIS work is the first volume of the third edition ofDeafness, Giddiness, and Noises in the Head "; it treatsnot only of post-nasal catarrh, but also of the variousdiseases of the nose causing deafness. The author hastaken great pains throughout this volume to establish aphysiological theory, on the full understanding of which heattempts to explain all the phenomena met with in theregion to which he has devoted so much labour and atten-tion. Every theory or principle which may be held by anyphysician or surgeon is unquestionably open to attack,generally from more points than one. We do not care inthis place to enter into an elaborate discussion of the prosand cons of Dr. Woakes’ hypothesis, but we may state thathis principle of reflex nervous action in the sympatheticnervous system may fairly be accepted as a tenable position,which, if perhaps taken up somewhat too positively by itspromoter, will nevertheless stand many of the tests of ascientific examination. The brief chapter on chronic or post-nasal catarrh and its sequences is a graphic description ofthe symptoms from which the patient suffers, as anyone whohas the misfortune to know from personal experience willtestify. The section on the hygienic management of thecatarrhally predisposed is one with which we find ourselvesin almost complete accord. The author is in his element in

treating of the diagnosis of chronic catarrh by the aid of thevarious appliances and methods of examining the fauces,nose, and post-nasal space. Fig. 4 however, does not con-vey much information to our minds of the normal appear-ance of the fauces. The pathology and treatment of acutecatarrh are briefly but ably dealt with. The various formsof chronic pharyngitis are all considered, and taught as

modifications of one and the same process. The chiefvarieties discussed are the chronic hypertrophic catarrh ofthe naso-pharynx, follicular hypertrophic catarrh of the pha-rynx, or follicular pharyngitis, and chronic atrophic catarrhof the naso-pharynx, or pharyngitis sicca. Chapter IX.is concerned with simple hypertrophy of the pharyngealtonsil; and the opinion that "although it is possible toeffect some slight subsidence in the enlargement of thepha-ryngeal tonsil by the repeated application of such stypticsas nitrate of silver &c., this method of treatment gives onlya partial result, and requires a long period to accomplisheven this. Evulsion of the mass is the only measure inwhich confidence can be placed." Lymphoid papillomataof the naso-pharynx form the subject of a lengthy chapter,which deals with their etiology, pathology, and diagnosisin an able, and with their treatment in a practical, manner.Stenosis of the nasal fossae is considered as resulting from(1) diseases originating in connexion with the turbinatebones, and (2) diseases originating in connexion with thenasal septum. Considerable space is occupied with thepathology and treatment of the various affections blockingthe nasal passages. Taken in every way, this excellentmanual is well fitted as a guide to the student of the subjectof which it treats.

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OUR LIBRARY TABLE.

The Asclepiad. Vol. I., Nos. 2 and 3. London : Eadeand Caulfield.-This quarterly periodical is solely the pro.duction of Dr. B. W. Richardson, and evinces, it neednot be said, considerable labour as well as ability; wewonder what fractional part of the author’s labours thesevolumes alone represent. Dr. Richardson succeeds in

making the material at his command both instructive and