1317HOSPITAL MEDICINE AND SURGERY.

haemorrhage ; and the subsequent time that it remained

high perhaps covered the period required for the disintegra-tion and removal of the final clot. The case was notablefor the great mobility of the vaso-motor system, the faceflushing and blanching on the least emotion. The blood-

supply of the body was not deficient, but the arteries weresmall and the tension low. suggesting that the ruptured vesselwas more probably a vein than an artery. The heart wasnormal. The sputa now contain a few tubercle bacilli. Onthe maternal side an uncle died of haemoptysis, and on thefather’s side there has been phthisis in the family.

’A closing word as to treatment. It is clear that, when these Ibranching clots exist, cough is far more likely to be set upthan in cases in which the clot is small and simple. Amore extensive bronchial surface is submitted to irritation.This carries with it a greater liability to the displacementof the stanching clot and the re-establishment of the bleeding.Rest of the parts is essential. Here, then, is surely an indica-tion for treatment of this-variety of hasmoptysis. Ergot,which was freely tried, failed ; no doubt because it did notfulfil this primary indication. With Dr. Ord’s concurrenceopium was given instead and as a sedative. Half-grain doseswere taken every four hours at first and afterwards at longerintervals as safety seemed assured. The bleeding neverreturned after the opium was begun. Saline aperients werecarefully given, and subsequently bromide of ammonium wasprescribed to allay nervous irritability, with digitalis torestore a better balance between the arterial and venoussystems. The patient is going on well.

Ventnor, Isle of Wight.

CARCINOMA OF BREAST : RECURRENCE IN THEOTHER BREAST THREE YEARS LATER.

BY W. S. CRAWFORD, B.A. CANTAB, F.R.C.S. EDIN.,ASSISTANT-SURGEON, LIVERPOOL CANCER AND SKIN HOSPITAL.

A SINGLE WOMAN came under my care in May, 1890,with a large tumour in the right breast ; it was adherentto the skin, the nipple was retracted, the axillary glandswere hard and enlarged, and there was well-marked scirrhusof the breast. This was removed and the axilla cleared ; thesections were found to be hard spheroidal-celled carcinoma.The wound rapidly healed, the patient went home in threeweeks, and remained apparently healthy until March, 1893,when she again presented herself, seemingly in perfecthealth, but complaining of a "lump " in her left breast, whichon examination appeared as a large swelling occupying thecentre of the breast with the nipple on the summit. There

was no retraction of skin ; the tumour involved the breasttissue, but was soft and doughy in consistence ; the axillaryglands to the feel were not enlarged, the appearances suggest-ing sarcoma rather than carcinoma ; the patient gave a historyof only a fortnight’s duration. The tumour was removedand the axilla opened in view of the possibility that it

might be a carcinoma, but no glands were found enlarged.The wound rapidly healed and at present (May 24th) thereappears no sign of recurrence. On section the tumour wassoft and creamy and turned out on examination to be anexceedingly soft, well-marked, spheroidal-celled carcinoma.This and the previous tumour were microscopically examinedby my friend Mr. Thelwall Thomas. There was no evidenceof the dissemination of the growth ; the lungs appeared, asfar as one could tell by external examination, perfectly free.She had no cough.This case is worthy of recording on account of the reappear-

ance of carcinoma of a very different nature in the otherbreast and probably not a secondary growth to the originaltumour. The patient very nearly completed the three years’immunity period commonly regarded as cure.Mount Pleas 3,nt, Liverpool.

LITERARY INTELLIGENCE.—Dr. Peter Ilinski, thefounder of the uss7ucyc -31-editsina, has retired from theeditorship of that paper. The journal will be carried on byDr. N. P. Ivanovski, Professor of Military Medicine in theSt. Petersburg Medico-Chirurgical Academy.-Dr. Dobrzickihas resigned the editorship of the Polish journal .1IIedycyna,and Dr. Ludwig Guranowski of Warsaw has accepted it.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et mor-borum et dissectionum historias, tum aliorum tum proprias collectashabere, et inter se comparare.—MORGAGNI De Sed. et Caus. Morb.,lib. iv. Proœmium.

MIDDLESEX HOSPITAL.A CASE OF ANGIOMA LIPOMATODES OF THE ARM.

(Under the care of Mr. HULKE.)EXCLUDING from consideration multiple lipomas widely

scattered in the form of small knots through large areasof the subcutaneous fatty tissue, since these often containso large a quantity of connective fibrous substance that

they might without inaccuracy be called °’ fibro-lipomas";disregarding also the affection named "lipoma nasi,"which, as it consists essentially of an overgrowth of the

tegumental sebaceous glands, has not any affinity with truelipomas -new growths composed dominantly or wholly offatty tissue differing little or not at all from the normal

fatty tissue of the body-it is a matter of common ex-

perience that these last evince little tendency to undergopathological changes ; they are little liable to inflamma-

tion, and when attacked by it the seat of the processis commonly limited to their capsule, causing adhesionsbetween this and the contiguous parts, particularly to theintegument, when such lipomas occur in situations where

they are subject to pressure by parts of the patient’sdress. Hardening processes, such as calcification andossification, are nearly restricted to the interlobar connec-tive dissepiments. Similarly, in connexion with angiomas,if we except those commonly called "port-wine stains,"which have a stronger claim to be regarded as ectases,and if we take the bright, deep red, slightly raised tegu-mental form so frequently seen in infants as a common type,these, consisting almost entirely of vascular tissues with aminimum admixture of connective substances, appear littleliable to spontaneous pathological change, unless simpleatrophy be recognised as such. But angiomas into the com-position of which venous tissues largely enter, such as mayoften be noticed in those somewhat more deeply situatedthan are the strictly tegumental nsevi, have not a similarimmunity, for these angiomas appear very liable to processeswhich entail thrombosis and the usual sequels-the formationof solid fibrous knots and of phlebolites &c. This is wellillustrated in instances of angiomas more deeply placed thanthose just mentioned-viz., those which lie beneath the deepfascia between and beneath muscles. Such are often highlyvenous, and they are particularly liable to the morbid changesto which reference has just been made. The museum of theMiddlesex Hospital contains an example of the extreme formof this variety of angioma. It was removed after death frombeneath the trapezius and sterno-cleido-mastoid muscles.The preparation shows a bunch of venous blood spaces, someone centimetre and even more in cross section, which com-municated by short wide channels with the internal jugularvein. The late Sir W. Fergusson, in whose private practicethe case occurred, had regarded the tumour as inoperable.The patient, an infant a few months old, died of another dis-order. Of not very infrequent occurrence are tumours inwhich fatty and vascular tissues are mingled-in certain in-stances one, in other instances the other tissue, commonlythe venous, preponderating in amount. These are often deeplyseated, and they are frequently the seat of those morbid pro-cesses first mentioned in connexion with venous angiomata.This instance is a fair example of the composite form. The

diagnosis was based on the lobular figure, the ftuxionaryswelling, and on the hard knots scattered through the softmass.

An anaemic brunette, aged twenty-two years, a kitchen-maid, was admitted into the Bird Ward on May 25th, 1892,with a swelling in her right forearm which she said swelled sooften and became so painful, particularly after work, thatit quite prevented her from continuing her employment. Theswelling occupied the ulnar side of the flexor aspect of the

1318 HOSPITAL MEDICINE AND SURGERY.

forearm from the distance of one finger’s breadth below theinternal humeral condyle to within four finger-breadths ofthe bend of the wrist. The skin was freely movable overit, but the swelling itself appeared to be intimately con-nected with the deeper strictures. It became slightly moreprominent when the flexors contracted ; it was firmer whenthe hand was pronated and softer in supination. Its con-sistence suggested that the swelling was a soft solid, in thegeneral mass of which were embedded small, hard, bead-likeknots. Peripherally an unevenness of margin was noticed,suggestive of lobulation. At the date of the patient’s recep-tion into the hospital-after a few days’ rest-the swelling wasneither painful nor tender. She had first noticed the swelling,she said, eleven years before, and its growth had been veryslow. The diagnosis formed from these data was a deep lipoma,probably naevoid, and since its presence seriously interferedwith her earning her living its removal was advised and thiswas done on June lst. The dissection was rendered trouble-some by the free venous hasmorrhage, requiring many liga-tures for its arrest. The mass was under the deep fascia andpartly between the deep and superficial layer of muscles ; itwas also in part incorporated with the fleshy part of the flexorcarpi ulnaris. It was found to be composed of fatty tissue,with a larger admixture of nasvoid tissue in which the venouselement predominated. Some of the venous channels wereplugged with clot exhibiting every stage of transformation,from that of recent formation, scarcely changed, to that ofold date in the form of hard fibrous knots and of vein-stones.Immediate union was obtained throughout nearly the wholeextent of the large, irregular wound, and this was completelyhealed on June 13th, when the patient left the hospital.

ROYAL VICTORIA HOSPITAL, NETLEY.A CASE OF SCIRRHOUS CANCER OF THE CHEST.

(Communicated from the Medical Division.)PRIMARY tumours of the mediastina are not very rare,

but it is unusual to meet with scirrhus at the early age ofthis patient. The disease ran a somewhat prolonged courseand throughout one of the usual indications of intra-thoracicgrowth was absent-that of enlargement of the veins of thechest-wall or neck from pressure on the main trunks withinthe chest. The symptoms in the early stages being as usualvery vague, the patient presented little to indicate the characterof the disease from which he was suffering until the glandularenlargement (which is well shown in the engraving at a latestage) appeared. The character of the fluid removed byaspiration from the pleura does not appear to have differed inappearance from that usually met with in pleuritic effusions.The patient was twenty-one years of age, having served four

years, nearly three of which were spent at Mediterraneanstations. The family history was unimportant. His formertrade was that of a fla-spinner ; his habits were intemperate.In June, 1890, he contracted syphilis, for which disease he wasthree times admitted into hospital between June and Decemberof that year. On Feb. 24th, 1892, he went to hospitalsuffering from bronchial catarrh ; he remained eleven daysunder treatment. In March of the same year he was againadmitted, after having to fall out on parade in consequenceof a stabbing pain in the left side accompanied by shortnessof breath. A collection of fluid was discovered in the left

pleura on admission. He was treated with tonics. Aspirationwas performed seven times between the date of his admissionand the month of June, clear fluid being removed on eachoccasion. On July 2nd, 1892, he embarked for Englandand on the llth of that month -the day of his arrivalat Woolwich-he was admitted into hospital for pleurisy ;he remained under treatment 101 days. During thistime he was twice aspirated, fluid similar to that withdrawnat Malta being removed from the left side of the chest; hewas placed on cod-liver oil, but as it caused vomiting it wasdiscontinued after a three weeks’ trial. He was admitted tothe Royal Victoria Hospital, Netley, on Oct. 19th, 1892. The

patient stated that he had suffered from slight pain of astabbing character in the lower part of the chest on the rightside in March, 1892 ; he had had very little pain in the leftside of the chest during his illnesses ; he had suffered muchfrom shortness of breath. He said his chest was bulged inMarch, 1892, about which time he noticed that the glands inthe left axilla were becoming enlarged. After the aspirationsperformed at Woolwich it was found that the left chest did

not return to its normal dimensions, but remained consider-ably bulged. Whilst in hospital at Woolwich the glands in-the right axilla and along the posterior margin of the sterno-mastoid muscle became enlarged ; when he left the WoolwichHospital the glands were about the size of broad beans. The

only other symptoms noted at that time were pallor and aslight but continuous elevation of temperature.On Dec. 13th the following was the condition : His body

appeared well nourished, contrasting with the rather emaciatedcondition of his limbs ; his colour was described as earthyyellow, the skin being dark round the eyes. The chest wall was,cedematous. It was noted that his face became flushed duringsleep and that his favourite position was to lie on his left side,.slightly propped up. He was permitted to sit up every after-noon for about three hours ; when up he seemed weak andmoved about with difficulty. His temperature had, since hisadmission, varied between 98° and 102°, more often betweennormal and 100 5°, with an evening rise and morning fall. Onlooking at the chest an enormous bulging was seen on theleft side, especially over the upper ribs, the left nipple beingprominent. The intercostal spaces were bulged, but did notgive the impression that the tissues were pressed forward byfluid. The superficial veins were prominent on the right side.As regards the respiratory system, the right side of the-chest from the spine to the mid-sternal line measured

eighteen inches and a half at the level of the nipple, anctthe left side of the chest at the same elevation measured

nineteen inches and a half. On respiration there was verylittle movement on the left side of the chest. The front.of the left chest was absolutely dull to percussion and re-sistant. The dulness extended from one inch to the innerside of the right nipple line to the mid-axillary line onthe left side. On the right side of the chest the dulness didnot extend above the level of the nipple, but on the leftthe whole front from the apex downwards was dull and re-sistant. The breath sounds were absent over the area ofdulness and the heart sounds were so muffled as to be almost,inaudible, but they appeared normal. In the left pleural sac asmall amount of fluid was diagnosed, indicated by relativedulness and deficiency of breath sounds and vibration. Inthe other parts of the chest the lung sounds appeared normalsave for a few rhonchi. The respirations were 28 a minute.The glands in the right axilla were enormously enlarged,forming a mass about the size of a clenched fist ; continuous.with the mass was a chain of enlarged glands, each aboutthe size of a hazel-nut, along the posterior margin of thesterno-mastoid muscle. In the left axilla the glands were alsoenlarged, but not to the same extent as on the right side.

, The gland above the elbow-joint on each side was like-, wise slightly enlarged. No enlargement of glands was noted. on the left side of the neck or in the groin. The glands wereL not adherent to the skin. The digestive system was normal.L The liver and spleen were apparently normal. The pulse wass soft, thready and easily compressible. The red blood cor-l puscles were normal ; leucocytes more than doubled, number-