LINCOLN COUNTY HOSPITAL.

852 the embolism has proved fatal from syncope or from asphyxia; the symptoms here were more consistent with the latter view, and the extensive disease of the left lung made it probable that for some time it had been almost useless for respiratory purposes. As is well known, a portion of thrombus detached from a vein of the lower extremities is the commonest cause of pulmonary embolism. The conditions favouring the formation of such blood clotting were present in this patient, and the remains of a clot found in the right femoral vein. For the notes of the following case we are indebted to Mr. Moriarty O’Brien, late house physician :M. V- was admitted in July, 1887. She presented the usual appearance of a person suffering from phthisis in its early stages. The account she gave of her family history o was very indefinite-that is to say, it was impossible to fix an hereditary taint. She said she was born in London, but had lived on the Continent for the greater part of her life, travelling about, her husband (an Italian) being Her last abode was Paris, and it was thence she a valet. She had been in good health until came to the hospital. twelve months previously to her admission. Her illness began The doctor whom she saw with a slight cold, with cough, &c. in Paris told her that she was suffering from bronchitis. She did not, however, improve under treatment, but gradually got worse, and eventually was admitted into the English hospital in Paris. During her illness she had cough all the time-often very troublesome at night. She had gradually lost flesh, suffered from increasing breathlessness, She had always been able to take night sweats, &c. her food, and never had diarrhoea. Catamenia had been regular. On admission, she was tall, well formed, and stately in her carriage. Her voice seemed natural, but i there was occasional huskiness. Her complexion was dark, eyes black and brilliant, skin on exposed parts sallow and bronzed ; where covered by clothing, the skin was very fair, and when grasped had a peculiar limp and wet feel. The extremities of the fingers and toes were clubbed, and the lips had a bluish appearance. She became quickly breathless when moving about or exerting herself. Pulse was moderately full, soft, and rapid. On examination of the chest it was found well formed; there was, however, distinct flattening under the clavicles, especially on the left side. There was no expansive movement, the left side seemed almost fixed on causing the patient to inspire deeply ; this want of movement was also to be felt; and while the hands were on the chest an increased fremitus was found on the left side. Comparing the percussion notes, a decidedly duller sound was elicited over the left side, and a bruit de pot fele was heard in the second left interspace. On auscultating, cavernous breathing, with large bubbling râles and pectoriloquy were found over the left apex, with fine crepitations in other parts of this side; the right gave exaggerated breath sounds nearly all over. Nothing abnormal was noticed about the heart sounds. The temperature rose to 1024° in the evening. The urine had a specific gravity of 1010 ; there was no albumen. A simple acid mixture was prescribed ; the sweats were checked with zinc and belladonna pills, and the temperature reduced with antifebrin. Under the above treatment, with occasional mild counterirritation, the patient progressed satisfactorily until the seventh week. There were some slight variations in the weight, but a steady increase on the whole. During the seventh week of her stay there had been some soreness of the throat, with hoarseness and increase of the fever. The parts were seen to be congested. The use of an astringent gargle relieved this, and she recovered her previous good condition, for during the subsequent week-viz., the eighthshe gained two pounds and a half in weight. Early in the following week-the ninth-which was the last week of her stay, she complained of increased dyspnoea. This was aggravated at night. Under the influence of large warm poultices it abated somewhat. Nothing was found in the chest to account for the increased difficulty of breathing. On the following morning the dyspnoea was still marked, and she became suddenly very much worse. She was gasping for breath. No obstruction could be detected in the throat, and air seemed to enter freely. Stimulants were quickly administered, but without result. Within seven minutes from the time she was first seen she was dead. At the necropsy, made twenty-seven hours after death, on opening the chest the right lung was found non-adherent, and, except for a few tubercles at the apex, seemed free from disease; it was paler than usual. The left lung was

adherent all over ; it was detached with difficulty from the side. When examined it was found solid and full of tubercles in the lower lobe and simply a multilocular cavity to represent the upper, the tubes containing purulent fluid whereever they remained. The heart was soft and flabby, and, asusual, slightly covered with a soft fat. On opening it, clots were found in all the cavities ; the right side was full of a. dark clot, which extended to the bifurcation of the pulmonary artery and along the right branch of that vessel, completely blocking it. On breaking through this soft clot a long, branching, and firm worm-shaped clot was found passing along the pulmonary vessel. Remurks by Mr. O’BRIEN.—Here, then, was the cause of death. The plug existed in the only sound lung. Hence. when the vessel was completely blocked death was almost instantaneous. The occurrence of death from this cause in cases of phthisis is not common, though cases have beer, reported. In this case I believe the clot came from the veins in the right leg, as on opening up the inferior cava, some small firm masses were found, and these were alsc’ found in the femoral vein.

LINCOLN COUNTY HOSPITAL. CASE OF EPITHELIOMA OVER UMBILICAL

HERNIA ; REMOVAL ; RECOVERY ; REMARKS. (Under the care of Mr. CANT.)

MALIGNANT GROWTH of the umbilicus, or in its neighbourhood, is somewhat rare, but has been met with both as. a primary and secondary affection. When epithelioma. affects this part, it usually does so as a primary growth,

spreading backwards and rendering it necessary to open the peritoneal cavity in order to thoroughly removethe disease. Thus Despresl found it necessary to remove a part of the. peritoneum and subjacent omentum which was invaded in the case of a patient aged sixty-five. Kupper collected eight cases of malignant growth of the umbilicus, and

Wulckow3 and Nelaton4 have drawn attention to the occasional presence of a scirrhous growth secondary to malignant disease within the abdomen. Nelaton describes this form of growth as frequently resembling that of a collar-stud,

presenting expansions externally and on the peritoneal surface. In the following successful case it is probable that

the disease resulted in consequence of the irritation of thetruss. For the following account we are indebted to Mr.. W. H. B. Brook, house surgeon. H. B-, aged fifty-eight, a widow, was admitted on July 8th, 1889, with umbilical hernia of twenty years standing, for which she has always worn a truss. She has. never had any trouble with it until five months ago, when, it became ulcerated. On admission, the patient presented a large flaccid umbilical hernia 9 in. in diameter and pendulous, the tissues over it being extremely thin except where the ulceration was. A little to the right of its. centre was a foul cancerous ulcer, 5 in. x 4in., oval, with an unhealthy and nodular surface, with everted indurated edgef? and a hard base. No enlargement of the lumbar or inguinal glands could be detected. On July 17th the new growth was. completely removed by a circular incision, half an inch from its margin, through the whole thickness of the hernial sac,, commencing at its lower edge. In order to expose as little of the intestines as possible sutures of carbolised silk were put in as the incision was made. The omentum was firmly adherent to, and formed part of, the tumour. The adhesions. were ligatured with catgut and divided, a very considerableportion of omentum being removed. The wound, dressed with carbolic gauze under the spray, healed rapidly, leaving: only a lined scar, and there was not any material rise of temperature ; but the skin over the hernia sloughed a little’ at the side in consequence of the irritation of the gauze, though this soon healed when dressed with salicylic wool. The patient was discharged on Aug. 26th, there being noreturn of the growth. The above case seems interesting from the fact that solargea portion of the abdominal parietes and omentum be removed under antiseptic precautions with so little reaction, and also the importance of stitching up the wound in such cases, as the tumour is removed, so preventing theescape and exposure of the intestines. "’

could

2

1 Annals de la Soc. de Chir. Med. Record, 1876, vol. ii., p. 64. 4 Med. Times, 1861, vol. i., p 67.

3

Ibid.