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