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strychnine, three grains ; quinine, one grain; confection ofroses in sufficient quantity. She was quite well in a month.

In Jan. 1867, she applied again, with similar symptoms, andstated that at the close of last year she had spitting of blood.A physical examination of the chest revealed tubercle in itsearly stage of development, and I should therefore despair ofaffording any lasting benefit.

CASE 5. Severe gastrodynia, conaplicated with hepatic con-

gestion.-R. P--, aged fifty-three (July, 1863), married, agamekeeper, complained of great pain in the stomach, and in-ability to digest food. He was so worn and emaciated that Istrongly suspected malignant disease. Has been unable tofollow his employment for six months, anclno medicine hasdone him any good. The urine is acid, scanty, and high-coloured ; the tongue is thickly coated ; there is great flatu-lence, pyrosis, and cardiac uneasiness. He was ordered bismuthand magnesia, with dilute hydrocyanic acid, and chloric ether.

Aug. Ist.-There was no material improvement. Tendernessexisted ovr the region of the liver, and he had a very sallowaspect. In addition to the mixture, he was ordered one grainof blue pill, and four grains of the extract of taraxacum,every night for a week.6th.-He was much improved in every respect. The in-

fusion of colomba was added to the bismuth draught.10th.-Tbe tongue was clean, and the urine clear. There

was no pyrosis, and the pain had much abated. Ordered thebismuth to be omitted, and one teaspoonful of the followingmixture to be taken in a wineglassful of water three times aday :-Citrate of iron and strychnine, two drachms ; water,four ounces.

Sept. 5th.-He was quite well, and able to resume his work,having gained flesh and strength, and being entirely free frompain.In July, 1864, there was a return of the symptoms, which

gave way in a week to the mercurial and steel. There was inthis case some hepatic congestion, not very apparent on ex-amination, which accounted for the symptoms so speedily yield-ing when the blue pill was prescribed.The following case is another example of the advantage of

similar treatment :-

CASE 6. Severe gastrodynia ; hepatic congestion.-E. M-,aged twenty-eight (May, 1862), a clergyman, suffered severelyfor upwards of two years with similar symptoms to those ofCase No. 5, and all medicines failed to give him relief till hetook a little blue pill. He was exceedingly thin, and had noappetite, and a feeble pulse. I prescribed bismuth, magnesia,and colomba before lunch and before dinner, and the follow-ing pills twice a week at bedtime : - Mercury pill, twelvegrains ; extract of hyoscyamus, ten grains ; compound rhubarb i

pill, two scruples : divide into twelve pills, two to be taken I,for a dose. He was quite well in a month, but could nevertolerate any preparation of steel.About this time another clergyman consulted me with very

.severe gastrodynia, and after trying several remedies to nopurpose (including bismuth in a mixture), the following pillthree times a day completely cured him :-Subcarbonate ofbismuth, one drachm ; powdered rhubarb, one scruple; muriateof morphia, two grains; powdered capsicum, ten grains ; inthirty pills.t::, Notwithstanding the best-directed treatment, cases now andthen go unrelieved, and we are obliged to admit the inefficacyof medicine to deal with them. The following cases are ex-amples :-

CASE 7. Severe gastrodynia; no 9-elieffroni treatment.-H.W-, aged twenty-seven (April 22, 1864), a cook, fat andflabby ; had fever fourteen years ago, and lost "small bonesfrom the ear"; very deaf ever since. She has had gastrodyniafor the past ten years at intervals; had synovial inflammationof the right knee-joint a year and a half ago. The tongue islarge, pale, and fissured; the gums white, and teeth large andirregular. There is occasional headache on one side. Thebowels are regular; there is flatulence, unattended by pyrosis.The following are among the remedies unsuccessfully pre-scribed :—

Dec. 31st, 1863.-Subcarbonate of bismuth and carbonate ofmagnesia, of each two grains ; muriate of morphia, one

grain; to be made into twelve powders. To take one in a littlemilk, three times a day.

Jan. 12th.-Great relief followed, tillMarch 22nd, when the pain returned as violently as ever. A

liniment was rubbed over the epigastrium night and morning,and a pill of steel, quinine, and rhubarb taken three times aday.

April 7th.-Pain is not mitigated. The oxide of silver,with rhubarb, and very small doses of morphia and capsicum,were prescribed.10th.-No relief whatever. Ordered the purified black

oxide of manganese, in doses of ten grains, three times a day,and counter-irritation over the epigastrium.22nd.-The pain subsided for four days, and then returned

as acutely as before. The citrate of iron and strychnine was nowgiven, and this afforded relief for a week. I did not see heragain till

July 13th, when the pain was again most severe. She wasadmitted into the Cambridge Hospital, and came out muchrelieved. Some time after, I heard that her suffering was sogreat that she had to give up her situation as a servant.On referring to my note-book I find that a nobleman con-

sulted me, for atonic neuralgia of the stomach, on the 29th ofApril, 1861. He was sallow, and had a worn and exsanguineaspect. The suffering had been of ten years’ duration, comingon invariably at night, and depriving him of rest and sleep.He would get up and walk for hours in his room. He hadalways been most temperate in his habits, and never smoked.Two of his family died of malignant disease of the stomach.The tongue was tolerably clean, the bowels regular, and theurine clear. There was no vomiting, no flatulence, no head-ache, only the severe, gnawing, incessant pain. His diet con-sisted of cocoa, milk, and arrowroot. He described himself asa complete "vegetarian," and said travelling from place toplace did him more good than all the physic he had ever taken.He had consulted the most eminent men in London and Paris,without deriving the least benefit; on the contrary, medicinesincreased his sufferings by acting as strong irritants. Ionce prescribed for him, and added greatly to his misery; andthis had been the case with others who had been consulted. Amonth ago (June, 1867), he told me that he now ate pastry,and almost any kind of diet, and never felt the slightest painwhatever. His general health and strength had vastlyimproved.

Manchester-square, W., Aug. 1867.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

ROYAL FREE HOSPITAL.ENCEPHALOID CANCER OF UTERUS AND RIGHT OVARY;LATENCY OF SYMPTOMS; SPONTANEOUS PERFORATION,WITH HÆMORRHAGE INTO PERITONEAL CAVITY;DEATH.

(Under the care of Dr. RICKARDS.)

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborumet dissectionum historias, tum aliorum, tum proprias collectas habere, et interse comparare.-MORGAGNI De Sed. et Caus. jtfof&., Ub. iv. Procemium.

THERE are some interesting features in the following case,for the excellent notes of which we are indebted to Dr. A.

Lloyd Owen, house-surgeon. Points worthy of remarkare :-

1. The localisation of advanced medullary cancer of bodyand fundus of the womb, neither os nor vagina, nor any pelvicstructures being involved.

2. The latency of the symptoms : the apparently rapidgrowth of tumour only recognised by patient three weeks beforetreatment ; pain only complained of during last two months oflife ; absence of serous or sanguineous discharge till withintwenty-four hours of death.

3. The mode of death : by rupture of fungoid mass intocavity of peritoneum ; whereas progressive cachexia andancemia, resulting from continued suffering and exhaustivedischarges, more frequently, though more slowly, bring aboutthe fatal issue.A solid nodulated mass, occupying the greater part of lower

half of abdomen, not necessarily connected with the womb asfar as careful repeated vaginal examinations revealed, wasthought to have been possibly cancer of omentum, until the

804

characteristic uterine discharge cleared up the diagnosis. Thepassage of a uterine sound might perhaps have afforded someassistance in revealing the state of the interior of the womb,in ascertaining its diminished mobility, and in bringing awaydebris ; but its passage into such a mass of disease mighthave hastened if not caused the fatal perforation, which naturesoon employed to rid the woman of further suffering.Mary H-, aged fifty-four, a charwoman, was admitted

Nov. 7th, 1867, suffering from abdominal tumour. She was awidow; has had twelve children ; parturitions protracted, butnatural ; no catamenia for twelve years; occasionally slightlencorrhcea. For the last six weeks she has suffered pain inthe lower part of abdomen, and occasionally an uncomfortablefeeling of distension, but the latter would subside after freemovement of the bowels, which are sometimes unopened for afortnight. No leucorrhcea of late, and no other kind of dis-charge at any time. Only three weeks ago noticed a tumourin the belly.Symptoms on admis8ion.-Rising out of the pelvis, extending

upwards to the umbilicus, and laterally to the flanks, is seenand felt a solid tumour. It pushes the abdominal wall forwardin front and to the right, where it dips down into the rightiliac fossa ; less prominent and perceptible on the left side.Irregular, hard, and solid in the main, it nevertheless gives hereand there a doughy, quasi-fluctuating sensation to the fingers,as if containing loculi with fluid. The tumour is not sufficientlylarge to cause tension of the abdominal walls, which are flaccidand non-adherent to the subjacent mass. Skin of belly muddy-yellow, wrinkled and scaly. No ascites. Vaginal examinationreveals nothing abnormal. The region around the os is soft andsmooth ; its lips are patent and slightly puckered, as is usualin the multiparous womb; but there is no infiltration, indura-tion, excoriation, or erosion, and the vagina is similarly intact.On withdrawing the finger it is perfectly free from discharge,even at the tip, which has been inserted between the lips of theos. Manipulation of the tumour and vaginal examination in-crease the pain in the abdomen, which is also exaggerated atnight. No cancerous cachexia evident ; skin of face of abrownish hue, and wrinkled. Emaciation not more than wouldresult from insufficient food and exposure to privations. Urinepassed freely; no albumen.Nov. 19th.-Has been given a nourishing diet, with wine;

occasional aperients to relieve constipation, and opiates to sub-due abdominal pain, which has been so severe as to preventsleep ; in fact, pain and an obstinate state of the bowels wereher only symptoms until yesterday afternoon, when suddenlyshe was seized with excruciating agony in the abdomen, and aprofuse discharge of sanious fluid and medullary debri.s issuedfrom the vagina. Symptoms of collapse, as in perforativeperitonitis, ensued, and opiates with stimulants failed to avertdeath, which occurred in the course of twenty-four hours.Autopsy, twenty hours after death.-Body somewhat ill-

nourished ; scarcely any fat. Lungs healthy, with the excep-tion of slight emphysema. Heart flabby; atheromatous streaksin aorta. Liver, stomach, spleen, pancreas, and kidneyshealthy. On laying open abdomen, haemorrhage was noticed onsurface of intestines ; omentum adherent to an irregular nodu-lated tumour, the size of an adult head, to the right side of whichis inseparably united another mass as big as a cocoa-nut. Thetwo, though so blended together, are at once recognised as theuterus and right ovary, both of them enormously enlarged,and transformed into medullary cancer. On attempting tobreak through the omental adhesions, a quantity of dark gru-mous blood issues from a slit on anterior surface of tumour,which slit, seen on first opening the cavity of abdomen, andbefore touching the parts, as a distinct rupture, has now be-come larger on attempting to clear the way, and bring theobjects into view. Surface of tumour soft and pulpy ; patchesof opaque yellow colour are visible through a vascular peri-toneal covering. After excising the womb, ovaries, and

genital organs en masse, an incision was made in the middle lineof uterus from fundus to os. The whole of its interior consistsof medullary cancer, rapidly disintegrating; in the centre soft,yellow, and scmi-diffluent ; but approaching the circumferenceit is somewhat firmer, and haem:ttuid fungi and clots are hereand there working their way towards peritoneal lining, onehaving reached the surface and perforated the serous mem-brane, and two or three are now threatening. In portions oftumour, vessels, stratiform and arborescent, on a pinkishground, are noticed. ]Uterine cavity obliterated. Medullaryinfiltration has involved the whole of cervix, down to internalsurface of os ; but anterior and posterior lips of os, as well asvagina, are perfectly free from ulceration or other abnormal con-dition. Right ovary on section presents precisely the same cha-

racters as uterus: the original structures gone, and only the ex-ternal coverings distinguishable in either case. Left ovary of

proper size, and healthy. Rectum and bladder uninvolved.Some sanious fluid and yellow débris in pelvic cavity. Nosecondary deposits anywhere. Lumbar glands unaffected.Under the microscope were seen the characteristic encepha-

loid cells in abundance.

UNIVERSITY COLLEGE HOSPITAL.

A NOTE ON CHRONIC URTICARIA.

CHRONIC URTICARIA is often a very troublesome affection,and a few hints regarding it, based on hospital experience,will be doubtless acceptable to our readers. Dr. Hillier, phy-sician to the Skin Infirmary of this hospital, considers the dis-ease to be one requiring the utmost discrimination for its treat-ment. Occasionally a case will be found to depend on onearticle of diet, which it requires careful inquiries and observa-tion to ascertain. One case was found to be caused by cheese,another by coffee, another by tea. In such cases the meredisuse of the offending article will sometimes cure the disease.When the patient is of a rheumatic tendency, alkaline medi-cines are of use. In very many cases colchicum is of greatservice; some of these are probably gouty in their nature. In

many of them, however, it is not possible to find any indica-tions of a gouty constitution. Dr. Hillier has seen great benefitfrom the use of quinine, especially when the attacks occur withmarked periodicity. When there is no gastro-intestinal irrita-tion, arsenic has been sometimes found useful. Unfortunatelyit is not always easy to decide what remedy shall first be tried.One case coming under Dr. Hillier’s care from time to time isalways cured by a few doses of cod-liver oil. Dilute nitric acidhas occasionally been found serviceable.Of 28 cases of which Dr. Hillier has notes, 9 were either

cured or received much benefit from the use of colchicum andalkalies. In 4, quinine was given, of which 3 were cured, andof 1 the result was not known. In 2 cases nitric acid relievedthe patient. Of 3 cases under alkaline treatment alone, 2were cured, and in 1 the result was unknown. Arsenic cured1 very obstinate case, and aggravated another case.In all cases of chronic urticaria it is important to inquire as

to the possible existence of bugs, fleas, pediculi corporis, orof the acarus scabiei. It is not uncommon for patients tosuffer a long time from urticaria caused by one of these para-sites, whilst other signs of their irritation are almost absent.In these cases ointment containing stavesacre or sulphur, withattention to cleanliness of bed- and body-linen, will cure thedisease. Local applications in other cases appear of little per-manent use ; lotions or ointments containing chloroform, ornitric or acetic acid lotions, give momentary relief.

Pruriginous strophulus, a disease of infants, closely alliedto urticaria, is usually relieved by the syrup of the iodide ofiron.

Provincial Hospital Reports.HUDDERSFIELD INFIRMARY.

A CASE OF ANEURISM OF THE FEMORAL ARTERY;LIGATURE OF THE EXTERNAL ILIAC.

(Under the care of Mr. RHODES.)WE are indebted to Mr. Thomas Brown, house-surgeon, for

notes of the following case :—

George B-, eleven years of age, was admitted into theinfirmary on January 29th, 1865. On examination a pulsatingtumour was found situated at the lower border of Poupart’s

ligament, on the left side, about the size of a walnut. Theboy stated that he had not much pain except when the tumourwas pressed upon, or the leg moved. A very slight differencewas found to exist in the size of the legs. Both motion andsensation were considerably impaired, and two sloughs, eachabout the size of a florin, occupied the dorsum of the left foot.The swelling was first noticed about three months ago, andimmediately after recovery from an attack of acute rheumatism,for which the ordinary alkaline treatment had been adopted.Distal compression was tried for some time with no good effect,for the tumour enlarged rapidly, and became very painful.The external iliac artery was tied on February 21st by Mr.