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wife stated that the vomiting continued until his death, andthat the left arm became quite cold.

Autopsy, thirty-four hours after death.-On removing thesternum, an abscess, the size of a hen’s egg, was opened,which had for its anterior wall the conjoint cartilages ofthe seventh, eighth, and ninth ribs of the left side. TheBoor of the was formed by the upper surface of theleft lobe of tli(3 liver; while the diaphragm, covered by thepericardium, fraied the upper wall. The pericardium wasgreatly distended with fluid, measuring 6 in. in length and4 in. in its greatest breadth. On opening the pericardium,it was found to be full of a thin, opaque, milky fluid;the whole internal surface, together with that coveringthe heart, was incrusted with a layer of flocculent, re-cently deposited fibrin. At the posterior part of the peri-cardium, which rested on the diaphragm, there was a smallaperture, which communicated with the abscess cavity,through which pus had escaped into the pericardium. The

pus in the abscess was thick and creamy. There was verylittle fluid in the pleura. The left lung was slightly ad-herent. The lungs were healthy, except being congestedat their bases; they were more or less crepitant through-out. The endocardium and valves of the heart were healthy.The liver was healthy, except immediately beneath the ab-scess, where there was a firm cheesy mass, the size of a pea,triangular in shape, with its base towards the surface; thiswas situated in the substance of the liver. The omentumformed a band, which extended from the left side across theabdomen, and descended through the right abdominal ringinto the scrotum, where it was adherent to the cicatrix ofthe old wound. There was no peritonitis, but the band ofomentum was matted together, so that it could not bespread out at its lower part.Newchurch, near Manchester.

A MirrorOFHOSPITAL PRACTICE,

BRITISH AND FOREIGN.

GUY’S HOSPITAL.DILATATION OF THE STOMACH; KUSSMAUL’S TREATMENT;

DEATH ; CLINICAL REMARKS.

(Under the care of Dr. WILKS.)

Nulla autem est a1 ia pro certo noscendi via, nisi quamplurimas et morborumet dissectionum historias, tum aliorum, tum proprias collectas habere, etinter se comparare.—MoMatfl De Sed. et Cau8. Morb., lib. iv. Ptocemium.

IN speaking of the subjoined case, Dr. Wilks remarkedthat the subject of dilatation of the stomach has been undetdiscussion by clinical observers and pathologists for sometime, but opinions are still divided as to the existence of a

primary disease which can legitimately receive this name.The evidence in favour of such a condition has received fresh

support from the mode of treatment suggested and success-fully carried out by Kussmaul. He has said that in casesof scirrhous pylorus, owing to the retention of food in thestomach, the organ becomes immensely distended, and, byits weight a.nd dragging, aggravates all the symptoms whichwere in the first place due to the stenosis alone; in fact,this distension in itself, however brought about, would benecessarily accompanied by all the symptoms which areusually attributable to pyloric disease. Thus, in cases

where, during life, the symptoms of almost perfect obstruc-tion have existed, the pylorus has been found still to admitthe passage of the finger through it. If, therefore, thisdistension could be overcome, the patient’s suffering wouldbe much relieved, and in case of primary dilatation a perfectcure be effected. Kussmaul and some authors believe thatthis dilatation may, in fact, be the only disease, resultingfrom ulceration at the pylorus which has been cured, ormay arise altogether from a chronic catarrh or dyspepsiaparalysing the organ for a time and thus leading to thisresult. Whether primary or secondary, the dilatation becomesa very important element in the case, and it can be overcomeby adopting Kussmaul’s plan of washing out the stomach.

By so doing a quantity of fermenting food is got rid of, themucous membrane is cleansed, and the stomach will imme-diately contract. By daily adopting this method the organis never allowed to become again in like manner distended,and a slow return to its natural size occurs. In two orthree cases of scirrhous pylorus treated in this manner inGuy’s Hospital, the relief afforded to the patient was verygreat; and in the case below mentioned, where the causeof obstruction was a curable ulcer, some chance of a perfectrecovery seemed reasonable. Under these circumstances,an accurate diagnosis is not necessary before the adoptionof the treatment ; for if a pyloric tumour be found it maybe used with advantage, and if no disease can be felt a stillfurther success may be anticipated. The condition requiringit is generally well made out by an examination of the ab-domen. The swelling is full and soft; and after exposureto the cold and manipulation the stomach is found to swellup and contract under the hand. It may sometimes be

grasped like a hard india-rubber ball, and if struck orshaken loud splashings are produced. The outline is oftenquite visible, there being a depression of the abdomen atthe epigastrium, and then below this lies the protuberantstomach, its lesser curvature above and the greater curva-ture well defined below, reaching sometimes to the pelvis.The following notes were taken by Mr. Wingate K.

J(,hnston.The patient, a dock labourer, aged sixty-three, was

admitted Feb. lltb, 1874. He had always enjoyed goodhealth up to the middle of November last, when he beganto lose flesh rapidly, and often to bring up his food a fewhours after meals. For some months previously, however,he had occasionally suffered pain at the epigastrium afterfood. About Christmas the abdomen became swollen, thepain near the umbilicus more severe, and the vomitingincreased, although as a rule the patient did not vomit morethan once during the twenty-four hours, and that generallyabout half an hour after getting into bed at night. Heused to bring up 11 half a pailful of brownish-looking fluid,with some frothy-looking material floating on the surface."Considerable relief was always afforded by vomiting. Hehad been in the habit of taking two pints of beer a day,but rarely drank spirits.On admission he was pale and emaciated, and had an

anxious expression; the skin was hot and dry; nails curved;conjunctivee jaundiced; tongue pale and flabby; teethground down; appetite good; but nearly every day thepatient brought up a large quantity of dark-brown fluidmixed with a frothy material. The fluid teemed with

vibriones, but no sareinae were detected.On examination a large swelling, occupying the whole of

the front of the abdomen, was detected when the patientlay on his back. The swelling was tympanitic, except in theright hypochondriac and iliac regions, but when he turnedon to his left side these parts also became tympanitic. The

lesser curvature of the stomach extended from the junctionof the ninth and tenth rib-cartilages on the left side acrossthe abdomen to the right lumbar region, about an inch anda half above the umbilicus. There was no palpable thicken-ing of the pylorus. On exposure and on manipulation thestomach could be felt to contract. The lungs and heartwere healthy; urine normal.

Feb. 13th.-Stomach to be washed out daily; contents ofstomach were removed by stomach-pump-two pints twoounces of a clear, watery fluid, with a thick brown sediment.No sarcinae to be detected; patient expressed great reliefafterwards.14th.-Feels much better; stomach not so much distended;

has not been sick again. Ordered brandy-and-egg mixture,one pint of beef-tea, one pint of milk, and eight ounces ofbread.17th.-Stomach washed out; feels much easier; has not

been sick again; sleeps well; abdomen not so tense norresonant.

19th.-Complains of pain at umbilicus; is troubled withflatus rising into his mouth.25th.-Is not so well; was sick yesterday after his dinner;

stomach emptied daily; bifurcation of aorta distinctly felt;vertebrae more prominent on left side.27th.-Was sick again yesterday, brought up two pints;

bowels not open; tongue furred. Ordered half a grain ofextract of nux vomica and one grain of extract of aloes threetimes a day.

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The stomach was washed out daily, and the patientimproved for several days; but on May 8th the house-physician was called at 7.30 A.M., and found the patient in-sensible, and suffering from twitching of the muscles of thearms, hands, and lower jaw ; at 11 A.M. he was sensible, andsaid he felt well, but at 3 P.M. he again became insensible,in which state he continued till his death at 8 r.ni.

Post-mortem examination.-B rain healthy, with the excep-tion of slight changes in the middle cerebral arteries.Lungs emphysematous. Larynx, heart, and peritoneumhealthy. (Esophagus not dilated, but the epithelium wasdigested up to the larynx. The stomach was much dilated,and filled the greater part of the abdominal cavity. Theomentum was matted at the greater curvature, which layjust above the pubee. The lesser curvature was considerablypulled down, so as to leave a space between it and theanterior margin of the liver, in which the jejunum bulgedforward, covered only by a thin layer of gastro-hepaticomentum. A small hard nodule, of whitish colour, wasvisible at the pylorus, and other nodules were felt at theupper part of head of the pancreas, which was situated justabove the jtjunum. The pylorus did not appear to havebeen dragged upon to any extent. The whole of the anteriorpart of the left hypochondriac region was occupied by thestomach. The spleen was pushed up high in this region.On lifting the stomach forwards, the intestines were seen tobe behind it all closely contracted. The colon was aboutthe size of the thumb, and lay in the meso-colon behindthe stomach. A pint and a half of slate-coloured fluid wallwithdrawn from the cavity of the stomach, and aboutanother pint remained behind. On opening the viscus, thecoats did not appear to have suffered any alteration; themuscular coat was of fair thickness, though, taking intoaccount the size of the organ, it was perhaps rather hyper-trophied. At the pyloric end there was an excavated ulcer,about two-thirds of an inch in diameter, with thick, hardedges; it was not unlike an old chronic ulcer which hadhealed, rather than the excavation of a cancerous mass.The deeper part of this, which extended round the anteriorwall of the pyloric cavity, and a little along the lessercurvature, was composed of a firm, whitish growth, whichshowed well-formed epithelial cells of a scaly type. The

pylorus would only just admit the tip of the little finger.Some tissue about the head of the pancreas was also

changed into a whitish growth, and two small hard whiteglands existed near with similar disease. Spleen small,firm, and pushed upwards. Kidneys weighed eight ounces;capsule adherent, surface granular, and cortex wasted.

GREAT NORTHERN HOSPITAL.EXCISION OF KNEE-JOINT, FOLLOWED BY AMPUTATION;

RECOVERY.

(Under the care of Mr. GAY.)

FOR the notes of the following case we are indebted toMr. Young, the house-surgeon.Henry K-, aged twenty-three, was admitted March

2nd, 1874, for disease of the knee-joint of about two years’duration. He was in the army when the disease began,and was sent to the military hospital, whence he was dis-charged after two months’ treatment as unfit for furtherservice. He then went into a metropolitan hospital, wherehe remained seven weeks, and subsequently into a parochialinfirmary. The disease during this time made rapid pro-gress, and, on admission into the Great Northern Hospital,appeared to admit of no remedy but excision or amputation,of which the former was preferred.The patient was much emaciated and hectic; his tempera-

ture high, pulse quick. The knee-joint was much swollen,the skin over it smooth and glistening, and the seat ofintense pain, aggravated at night, and exquisitely sensitiveto touch. He suffered from painful twitchings of the wholelimb at times, especially at night and during sleep, so thatit was difficult, by any narcotics, to procure him any pro-longed or useful rest. The knee was flexed at an acuteangle on the thigh.

Mr. Gay excised the joint on the 4th. The bones werebrought into exact apposition without any strain on the ham-string tendons. The operation was followed by entire ex-

emption from all pain, and with promise of immediate unionand rapid recovery. Six days afterwards, however, thespasmodic twitchinga of the limb returned, but with muchgreater severity than before the operation, and became soincessant, distressing, and uncontrollable, notwithstandingremedies of all kinds which were given and applied tacounteract them, that Mr. Gay, with the concurrence of hiacolleagues, Mr. William Adams and Mr. Carr-Jackson, de-termined on amputation, which was done on the 5th ofApril. During these twitchings the muscles of the thighand hamstring tendons were called into action, at times mor&violent than at others. At one time it was thought thatthey were due to inflammation of the theca of the peronealnerve, for there was tenderness along its course, and leecheaand blisters were applied, but without effect. At another,.matter was suspected deep in the popliteal space, and anexploratory puncture was made, but in vain. All kinds ofnarcotics were employed, but without any positive results.It was not deemed necessary to divide the hamstring orAchilles tendons, since there was no traction on them ex-cepting during the spasms, and then it was general, whilstthe rapid failure of health did not justify further delay.The amputation was followed by immediate and complete

relief, and the patient made a rapid recovery. In a fort-night the flaps had completely united, with the exceptionof one small sinus, and by the 20th of May he left thehospital for the convalescent home.The disease was the old "white swelling"—Brodie’8’

pulpy degeneration of the synovial membrane, with re-

moval of cartilage at the articular edge of the bone-histo-logically well described by Barwell. The thickening wasenormous, and involved other tissues around the synovialmembrane, even muscular tissue; so that the whole of the-morbid material was not removed, although the amputationwas carried higher up than would otherwise have beennecessary. This did not, however, in any way interferewith the healing process.The pulse and temperature, during the course of the case,

after the excision, were as follows :-May 4th : Pulse from116-120; temperature 99½°—100°. 6th: Pulse from 112-120 ; temperature 102½°. Then both began to fall until the15th (the day of the amputation), when the pulse was 96and temperature 98°. After the operation both rose gradu-ally, and culminated on the 21st, the pulse being on thatday from 112-136, and the temperature 103’. Rapid sub-sidence followed until the 26tb, when the pulse dropped t112, and the temperature to 99°.

It was decidedly a strumous case, but without the usualhistory.The case, Mr. Gay remarked, was one of considerable

interest-indeed, as far as his knowledge and experiencewent, unique. The bones, after resection, were in closeapposition, but the union was only effected by a kind ofgelatinous material without trace of osseous deposit. Thecause of the spasms could not be discovered; all the nervesseemed healthy, and there was no apparent impaction ofsoft parts between the bones. There was a small quantityof healthy pus behind the bones, at the site of their junc-tion, but the surfaces of the bones themselves were freefrom diseased action.

THE HOSPITAL FOR WOMEN, SOHO SQUARE.CASES OF OVARIOTOMY.

THE following is a continuation, from p. 727, of the series.of cases of ovariotomy performed at the above hospitalduring the past year.CASE 7. Multilocular ovarian disease; operation ; recovery.-

Maria W-, aged forty-five, single, servant, was admittedunder the care of Mr. Scott on the 12th of May. The cata-menia had always been regular, though scanty and painful.The patient stated that she had noticed the abdomen some-what full for the last eighteen months, but for the lastseven months only had she observed a distinct swelling inthe lower abdomen, which had gradually increased to itspresent size.On admission, the abdomen was found distended, and

occupied by a soft, distinctly fluctuating tumour, reachingup to the ensiform cartilage. The girth at the umbilicallevel was 37 in. There was dulness on percussion overthe whole tumour, and resonance in both flanks. For