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A Mirror OF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum, etdissectionum historias, tum aliorum proprias, collectas habere et inter secomparare.—MORGAGNI. De Sed. et Caus. Morb., lib. 14. Proœmium.

GUY’S HOSPITAL.Cases of Rheumatic Fever treated by Citric Acid.

(Under the care of Dr. OWEN REES).THE treatment of acute rheumatism by lemon-juice, as

introduced by Dr. Owen Rees, bids fair to take a firm footingamong practitioners, as the good effects of the remedy havenow been observed in a great number of instances. Wereported a few cases illustrating this peculiar treatment, (THELANCET, Nov. 16, 1850, p. 551,) whilst pursuing our plan ofputting upon record the various modes of treating acuterheumatism in the hospitals of London. In accordance withour scheme, we now beg to direct our readers’ attention to thetrials lately made by Dr. Owen Rees, respecting the action of z,citric acid in the same disease. When considering the bene- I,ficial results of lemon-juice, the question naturally sprung up, ’,whether the principal agent was the citrate of potash, or the ’,acid of that salt ? 1 Dr. Rees has now instituted a series ofexperiments to elucidate this question, and we beg to adduce I

a few cases which form part of the group.

CASE 1. (Notes by Mr. CHARLES WniTE.)—John D-,aged twenty-three, was admitted into Naaman ward, Feb. 12,1851, under the care of Dr. Owen Rees. The patient is a pale, Isickly young man, with light hair and complexion; he is a Iwaiter at a tavern, has led a pretty regular life, and has, forthe most part, enjoyed good health, excepting an attack, similarto the present, which he suffered two years since. Threeweeks ago the patient caught cold, and a week afterwardspain begun in the ankles and feet; he was under treatmentfor a short time, but not becoming any better, he applied tothe hospital.When admitted, he was suffering severe pain in the knee,

which joint was swollen, but not red; the ankle was likewiseaffected. The skin is cool and moist, but profuse perspirationsets in occasionally. The pulse is 96, full, and compressible;the tongue slightly coated with white mucus; the appetitebad, and the thirst very intense; the bowels are inclined toconstipation; the urine is acid, reddish, twenty-six ounces arepassed in the twenty-four hours, and its specific gravity is1026. Dr. Rees ordered one scruple of citric acid, dissolvedin mint-water, to be taken three times a day.On the third day the urine was not so acid as on the second

day; thirty ounces were passed; specific gravity, 1026; pulsefuller, very compressible; the patient feels somewhat easier.Fourth day: Copious sediment in the urine; pulse 84. Fifthday: Urine quite clear; pulse 90. The patient is better, andcontinues to take the acid. Eighth day: Violent pain in theelbow; the other joints are easier. Eleventh day: Urinealkaline, with a coating of phosphates floating on the surface. IThe patient is more free from pain than he has been for sometime, and has now no distinct seat of pain; pulse 96. Thir-teenth day: Urine acid; the patient is not so well. He re-mained in about the same condition until the nineteenth day,when the urine became alkaline; there was still some pain inthe joints, but the general health was better. Twenty-fourthday: Much the same, with profuse perspiration. Up to thetwenty-eighth day the improvement was rapid; pain and feverhad disappeared, and were replaced by paleness and debility.’The patient now left off the acid, took compound steel mix-ture for a week, and was discharged well, thirty-eight daysafter admission.

The clinical clerk kept a daily and accurate account of thepeculiarities of the urine. From this table we find that thehighest amount of urine passed was fifty ounces in the twenty-our hours; with specific gravity, 1022, acid; this happened onthe ninth day, when the patient was in great pain. Thesmallest quantity was twenty-eight ounces, specific gravity,1030, neutral.

CASE 2. (Notes by Mr. HEDGER.)-Jane S——, agedeighteen years, a servant girl, was admitted into Mary ward,March 6, 1851. She is of dark complexion and dusky counte-nance, is constantly exposed to wet and cold, but has generallyenjoyed good health. About six months ago the patient expe-rienced a rheumatic attack, from which she soon recovered.Three days before admission, severe pain in the joints cameon, and when she entered the hospital the knees and ankleswere so involved that she could not move her legs; these arti-culations were slightly red, and exquisitely tender on pressure.The tongue is furred; the bowels confined; pulse 100, full andbounding; urine thirty ounces in the twenty-four hours,specific gravity, 1017; lungs and heart healthy.

Dr. Rees ordered a mercurial purgative powder, and onescruple of citric acid, dissolved in mint-water, every fourthhour. On the third day, the pulse had fallen to 90, and wasnot so full; urine thirty ounces, specific gravity 1018, veryacid. On the fourth day the pain was much abated in thewrists and ankles; these joints can be slightly moved; bowelsnot open. The purgative powder to be repeated, and the citricacid continued. Fifth day, urine thirty ounces, very clear; thepain has quite left the wrists and ankles, but the right kneehas become very painful and slightly swollen. Urine thirtyounces, specific gravity 1017, acid, very clear.Up to the twelfth day she progressed very favourably, and

continued the citric acid, the uriue varying in specific gravityfrom 1016 to 1022. She now expressed herself as quite well,though feeling rather weak, and the pain and swelling of thejoints had quite subsided; the bowels were regular, the tongueclean, and the pulse 86. The patient took the compound steelmixture for a week, and left the hospital, quite well, eighteendays after admission.

CASE 3. (Notes by Mr. HEDOER.)—Matilda. R-, agedthirty-eight, admitted Feb. 14, 1851, under the care of Dr.Owen Rees; pale and ansemic; married, without ever havinghad children. First attack of rheumatism two years ago. Oneweek before admission the patient got wet through, and twodays afterwards she experienced pain in the loins; the kneeswere then attacked, and on getting worse she was admittedinto the hospital. When examined, she was unable to turn inbed; the arms and elbows were red, swollen, and very painfulon the least pressure. The knees were not quite so sensible,but became very bad at night. Lungs and heart healthy, butthe respiration is somewhat hurried; the eyes are dull; thetongue thickly coated with a white fur; the bowels confined;the thirst great, and there is much drowsiness; pulse 86, small,and very compressible; urine normal, acid; about thirty ouncesare passed in the twenty-four hours, specific gravity 1020.

Dr. Rees ordered a mercurial purgative powder, and onescruple of citric acid, in mint-water, three times a day. Onthe third day, the arms and wrists were much less painful, butthe knees worse. Urine, twenty-eight ounces; specific gravity1021; acid. The patient now took the citric acid every sixthhour. On the seventh day, the bowels were freely moved bya mercurial purgative; the improvement became marked;urine, twenty-eight ounces; specific gravity 1018; acid. Onthe ninth day, the patient expressed herself as a great dealbetter; the joints were much.. less painful; the swelling andredness had subsided; the pulse was 72; the tongue clear; thebowels open; and the skin moist and supple. The citric acidwas cont,inued; and on the sixteenth day, the patient walkedabout the wards, though very weak. Urine, thirty ounces;specific gravity 1020; acid. The citric acid was now discon-tinued, steel-mixture substituted for about ten days, and thepatient was discharged, quite well, twenty-eight days afteradmission.

CASE 4. (Notes by Mr. Coucn.)—Joseph H-, aged forty,a baker by trade, was admitted, Feb. 12, 1851, into Lazarusward, under the care of Dr. Owen Rees. The patient has oflate been very temperate in his habits, and experienced, twoyears since, a severe attack of rheumatism, though the diseaseis unknown in his family. From this he speedily recovered,and five weeks since, all the symptoms of acute rheumatismrecurred after getting wet, and remaining all day in the bake-house in damp clothes. The right knee is the most affectedjoint; the elbows and ankles in a less degree; tongue furred;appetite bad; pulse 92, soft; bowels confined; urine moderatein quantity, with a dark, muddy-looking sediment, which isdissolved by heat; nitric acid dissolves it likewise, producingeffervescence; acid reaction, and ammoniacal odour aftertwenty-four hours; specific gravity 1015.

Dr. Rees ordered the same treatment for this patient as forthose mentioned above, On the fifth day, the bowels had been

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freely opened by mercurial purgative powders; the knee wasnot so painful, hot, or tumid, but there was tenderness overthe patella, where a little circumscribed effusion is felt; pulse78, compressible; urine, four pints and a half; specific gravity ’,,1011; alkaline. The patient had, between the sixth and the ’,twentieth day, alternations of pain and ease in the joints; ’,metastasis took place several times, and the affection provedof a very erratic kind. The bowels required now and thenbrisk purgatives, the patient slept badly, and perspiration wasrather profuse. He continued to take the citric acid like theother patients; the urine varied in quantity from three and ahalf pints to four and a half, and the specific gravity from1013 to 1010. The report was, on the twenty-eighth day, thatthe pain had again returned, with the troublesome itching ofwhich he has so often complained. The disease has nowbecome chronic.

Dr. Owen Rees observed, among the various remarks whichhe made to the pupils, that the urine had been observedattentively as to the quantity in the twenty-four hours, andalso as to its specific gravity, his view being to ascertainwhether or not the solid matters excreted by the urine in-creased in quantity as the patient improved. He (Dr. Rees)thought that the above cases showed that this was by no meansthe rule. The convalescence of these patients was more tardythan it had been with the subjects treated by the lemon.juice,instead of citric acid; and Dr. Rees thought that this circum-stance may have depended either on the greater efficacy of theformer remedy, or upon the peculiar state of weather which wehave experienced this spring, and which has been very un-favourable to those recovering from severe disease,-he beingmore inclined to adopt this latter view. He (Dr. Rees) wassatisfied, from the observations he had now made, that bothlemon-juice and citric acid are remedies for rheumatism, whenproperly exhibited, and that this method of cure possessesgreat advantages over that by antimony, colchicum, andcalomel, in all cases free from complication. The restrictionsas to complications are exactly the same for citric acid as forlemon-juice. -

ST. GEORGE’S HOSPITAL.

Encephaloid disease of the Femur; Amputation; Recovery.(Under the care of Mr. HENRY CHARLES JOHNSON.)

W]HICH is the final cause of malignant transformation inthe structures of the human frame? How does it come to passthat changes of a destructive and contaminating nature takeplace in a limited portion of the body, while healthy nutritionis carried on in other parts? Why does encephaloid disease,a morbid alteration so widely distinct from any of the events ofordinary inflammation, attack the young in preference to theold How can we explain that bone is so frequently the seat ofthis terrible affection? These questions naturally suggestthemselves to the surgeon when pacing the wards of ourhospitals, where he so frequently meets with instances of4Dsteo-cephaloma; and he is the more anxious to find ananswer to them, as such knowledge would lead to the prac-tical application of prophylactic measures. Much obscurity,however, still reigns as to the points just named, and a wideand useful field is, in this respect, opened to perseveringinquirers.

Until the veil is partly withdrawn, the attention of thesurgeon may, however, be very advantageously occupied byrendering the diagnosis between malignant and non-malignantgrowths more and more accurate. It is satisfactory to notehow much has been done in this respect by Cruveilhier,Carswell, Dupuytren, and the modern school of microscopists;(see a case of Malignant Disease of the Wrist Joint, operatedupon at the London Hospital, in THE LANCET, March 29,1851,p. 354;) and how near to certainty we may arrive by thecareful watching of the symptoms. By the study of the latter,pretty correct distinctions may now be made betweenexostosis, enchondroma, osteo-cystoma, (as an example of thisaffection, see Mr. Fergusson’s case in THE LANCET May, 17,1851, p. 545,) osteo-sarcoma and osteo-cephaloma, but amongthese affections, the differential diagnosis most frequentlyrequired is, between osteo-sarcoma and osteo-cephaloma, thedistinction being of the most vital importance to the patient.And here we would refer the reader to a list of ten dis-

tinctive characters given by Professor Miller in his PrinciplesOf Surgery (second edition, p. 484,) between the two last-named diseases, a list not less practically useful than credi-table to its author. It is a pity, seeing how clear and easy ofcomprehension are the Greek appellations used for theseaffections, that the French surgeons should use the word

44 osteosarc6me," for malignant disease of bone; much confusionresults from this. The same may be said of the meaning offungus hsomatodes on both sides of the Channel.When the diagnosis is satisfactorily established, comes the

question of operating or non-interference. We conclude, onthis head, from the practice of the London hospitals, thatsurgeons are in general willing to operate, provided the diseasebe not too far advanced, the chances against the return being,of course, greater, the less time the patient has suffered fromthe disease. We must say that examples of the recurrenceof malignant disease, either in the neighbouring absorbentglands or other parts of the body, not unfrequently meet theeye in our metropolitan institutions. Still some escape foryears, or are entirely freed; and even with those who are againvisited, is it not of some importance to procure for themmonths and years of comparative comfort? (See, for viewsdiffering from these, Mr. Holt’s cases at the WestminsterHospital, THE LANCET, March 1, 1851, p. 237.)We mentioned a short time ago (THE LANCET, March 15,

1851, p. 293) an instance of recurrence of encephaloid diseaseof the femur at St. George’s Hospital, under the care of Mr.Hewett; we have now to report a case of an analogous naturelately operated upon by Mr. H. C. Johnson at the samehospital. The patient is about twenty-four years of age, un-married, of a nervous temperament, and was employed as shop-man at a tobacconist’s. No disease of a malignant characterhas existed in his family, and he has himself been sufferingonly for the last eighteen weeks. When admitted, Jan. 25,1851, under the care of Mr. H. C. Johnson, the patient lookedill and cachectic, with a pulse of 104, though up to the timewhen his knee became the seat of pain, he had enjoyed verygood health. He presents on the left thigh a tumour occupyingthe whole distance between the knee and lesser trochanterposteriorly, giving the limb the appearance of about twice thesize of its fellow. The skin is tense, but not inflamed; thetumour tough, though somewhat yielding to pressure; it isrounded in form, and occasions a great deal of pain. Thepatient gives the following history :-

; About eighteen weeks before admission, he felt some painin his left knee, though not aware of having struck or injuredthe joint in any way. This continued for about a fortnight,when he awoke one morning with a more severe pain in theaffected knee, and found the part swollen to nearly the sizeit now presents. The patient contrived, in spite of hissufferings, to attend to his occupations for five or six weeksafter this, but the pain soon obliged him to keep his bed.During the whole of this period, no regular advice wasobtained, but he was treated by his friends, who applied agreat number of poultices, both of herbs and bread.

Getting, however, no better, he came to London for advice.The surgeon under whose care he placed himself used leeches sblisters, poultices, &c., and punctured the tumour twice witha grooved needle, and once with a lancet, when about anounce of blood exuded.When admitted into the hospital the malignant nature of

the disease was ascertained, and as the affection was not oflong standing, Mr. Johnson resolved to amputate the thigh.The only question was, whether the operation should be per.formed at the hip-joint, or close to the lesser trochanter. Itwas thought advisable, on consultation, to amputate in thecontinuity of the bone. (See Mr. Hewett’s case, THE LANCET,Dec. 8,1849, p. 615; Mr. Hawkins’s, THE LANCET, August 10,1850, p. 184; and Mr. Charles Guthrie’s, THE LANCET, Nov. 30,1850, p. 603.)The patient was brought into the theatre a week after ad.

mission, and having been narcotized by chloroform, Mr. John-son amputated the thigh, just below the lesser trochanter,with as much rapiditv as was consistent with safety, in orderto avoid the loss of blood, since the haemostatic means werenaturally limited to compressing the femoral artery with thefinger in the groin. The flap operation was preferred to thecircular method for the same reason, and the patient lost com-paratively little blood.A longitudinal section of the thigh-bone and tumour was

made immediately after the operation, and the pupils wereshown at once the structure of the growth. It was now seen

that the latter was principally connected with the femur, theknee-joint being quite unaffected; the tumour was about thesize of the head of a child five years old, enveloped in adense capsule, studded here and there with sanguineousnodules; the medulla seemed sound, with the exceptionof a few dark spots about two inches above the knee, andMr. Johnson mentioned, in the remarks he made, that thebone appeared sufficiently sound to allow of the hope that