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fluctuation was perceptible. The pain was aggravated at night,so as to prevent sleep.

Feb. 7th.-The patient was rendered insensible by chloro-form, and the actual cautery was applied over the spot abovementioned.9th.-Complains of pain of a shooting character, particularly

severe at night, for which Dover’s powder was prescribed.The patient continues to have a tolerable appetite.

21st.-Suppuration was established, and the pain was some-what abated; but the patient still winced when slight pressurewas made at the outer side of the patella.The pain progressively became more and more distressing,

harassing him by night and by day, and in consequence hisgeneral health was giving way, when removal of the limb wasproposed, to which he assented. On the 19th of March Mr.Ure performed amputation through the lower third of the

thigh, by circular incision, the patient being under the influ-encb of chloroform. Two vessels were secured by ligature ;but little blood was lost. The section of the bone was morevascular than natural. The patient on being placed in bed wasin a very low state, and was therefore ordered half an ounce ofbrandy every hour.On making a section of the knee joint, the extremity of the

femur was found enlarged, and the seat of cancerous degene-ration, with the formation of cysts. There was a deep excavation just above the condyles, where the osseous tissue had beenremoved by absorption. The line of union of the former frac-ture was distinctly visible. The cartilage investing the arti-cular surfaces of the femur, patella, and tibia was eroded atdifferent points.March 20th.-The patient passed a good night; the pulse

tranquil, tongue natural. Allowed wine and brandy at suit-able intervals.

21st.--Complains of nausea; stump looks well. To takefour minims of prussic acid in an ounce of distilled water everyfour hours.22nd.-General amendment; has partaken with relish of

some broth for dinner. To have four ounces of port wine sndtwo ounces of brandy daily.

24th.-Patient doing well; slight discharge from the middleof the wound.

April 7th.-Has been convalescent for several days; woundall but united, presenting a well formed stump.

14th.-Dressed in his ordinary clothes, and sitting in an easychair by the fire-side; stump thoroughly healed; health good.

Mr. Ure saw the patient some six weeks afterwards, enjoy.ing good health, and getting about with a well-cushioneostump, on an artificial hmb.The chief feature in this case is the rapid recovery of a

patient of threescore years and ten from a serious operatioInecessitated by a most serious disease.

ST. GEORGE’S HOSPITAL.

NÆVUS OF THE SCROTUM, EXTENDING TO THE URETHRA.

(Under the care of Mr. JOHNSON.)THE extreme rarity of nævus in the scrotum is such that it

is not even mentioned by surgical writers ; and on referring tcMr. Curling’s valuable work on Diseases of the Testis and its

Coverings, this affection is also unnoticed.A well marked instance, in a boy eleven years of age, was re

cently admitted under Mr. Johnson, having been sent up fromthe country by Dr. Goodchild, of Ealing. He was examiued byRlr. Johnson three or four years ago, and the disease had remained stationary the greater part of that time. Latterly.however, it had increased in size, and had somewhat extendecover the right side of the scrotum. There had been haema.turia, from extension, as it was believed, of the naevus tc

the urethra. On micturition or on the slightest exertion, mudblood was lost; several hard masses were felt, as if the bloorhad coagulated. Under the use of ice, and by maintaining thehorizontal position, these masses became smaller ; but on allowing the boy to get up, they returned. When first seen someyears ago, the scrotum was not discoloured. Now it was, anfbehind the nævus a great hard mass could be felt independeutlJof the testicle.On the 12th June, the nsevus was ligatured in five differen-

places, by passing a thick thread beneath it, and tying the tw(ends outside the skin. The little fellow is going on wellbut the time since the operation is too short to say what thresult will be. We place the case on record, however, as on’of considerable interest and rarity.

WESTMINSTER HOSPITAL.

PEDUNCULATED BODY WITHIN THE BURSA SITUATEDOVER THE LEFT PATELLA; SUCCESSFUL

EXTRACTION.

(Under the care of Mr. CHRISTOPHER HEATH.)

IT is acknowledged that sometimes loose bodies in joints.primarily originate from some part of the synovial capsule, andbecome pedunculated. Their detachment is a subsequent pro-cess. The same occurrence happens in the interior of a bursa,although, perhaps, less commonly observed. An unmistakableinstance recently occurred in the rVestminster Hospital, in a.

male patient, who felt a loose body over the left patella. Itwas very small, shifted about, and caused a little uneasiness,especially if kneeling on the part. It could be felt very dis-tinctly, but not always readily. It was cut down upon (with-out administering chloroform) on the 10th inst., by Mr Heath,and discovered to be a little cartilaginous body of the size of asplit-pea, attached to the intra-bursal surface by a pedunclehalf an inch long. It was removed by dividing this, and thepatient has recovered without any resulting inconvenience.

Medical Societies.ROYAL MEDICAL & CHIRURGICAL SOCIETY.

TUESDAY, JUNE 10TH.DR. BABINGTON, PRESIDENT, IN THE CHAIR.

ON THE TREATMENT OF ACUTE RHEUMATISM, CONSIDERED WITHREGARD TO THE LIABILITY TO AFFECTIONS OF THE HEARTUNDER DIFFERENT REMEDIES.

BY W. H. DICKINSON, M.D. CANTAB.,ASSISTANT-PHYSICIAN AT THE HOSPITAL FOR SICK CHILDREN, CURATOR OF

THE PATHOLOGICAL MUSEUM OF ST. GEORGE’S HOSPITAL.

THis paper was based upon a tabular condensation of thecases of acute rheumatism which were admitted into St.George’s Hospital during the five years ending on Dee. 31st,1861, and in whom the heart was, on admission, unaffected bythe disease. The method of treatment adopted in any par-ticular case depended very much upon the chance of the patientcoming under one physician rather than another ; and a compari-son of the results would, to a certain extent, be a guide to thevalue of the means used. The cases, therefore, were classifiedaccording to the treatment made use of. As the main objectof the investigation was to ascertain the effect of remedies inpreventing cardiac mischief, the arrangement was not alteredby measures adopted in consequence of its occurrence. Thetables were fourteen in number. The first gave the results of8 cases in which venesection was early resorted to, other medi-ciues being at the same time used. In 3 of the cases endocarditisor pericarditis was clearly recognised. In 1 there was incom.

plete evidence of cardiac derangement. The heart, therefore,was absolutely uninjured in only half the number. The pa-tients remained in the hospital for an average period of forty-one days. Bouiltaud, who is the great advocate of bleeding inthis disorder, and trusted to it almost exclusively, expresses hisopinion that such complications are the rule, and not the excep-tion. The second table gives the result of 6 cases treated solelywith repeated doses of cilotiiel and opium. In two subsequentclasses were seen the effects of the same medicines aided bysaline draughts, with and without nitre. The progress of thedisease under each plan appeared to be much the same. Thetotal of 24 cases presented 6 of inflammation of the heart or itsmembranes, of which 2 proved speedily fatal. The averagenumber of days in hospital under mercurial treatment wasthirty seven.The action of some reputed specific remedies was then con-

sidered. With regard to opium, reference was made to sometables published by Dr. Stbson in the Association MedicalJournal, 21 cases are here recorded, in which, when the treat-ment was commenced, the sounds of the heut were natural.Upium was given in frequent doses, sometimes as much as agrain an hour, besides other remedies supposed to have aneffect in rheumatism. No less than 14 of these cases, or exactlytwo-thirds, manifested while under treatment symptoms ofvalvular or ppricardial inflammation.The cases, 7 in number, treated with nitre alone, gave only

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1 of cardiac complication. The average duration of the treat- drachms of the two latter salts together are taken in thement was reduced to twenty seven days. Further evidence in twenty-four hours. Half a drachm ot the acetate, with afavour of nitre was deduced by comparing the result of cases drachm or a drachm and a half of the bicarbonate, and tentreated with saline remedies alone, and those which had salines grains of nitre, would answer the purpose.with nitre in addition. A table contributed by Dr. Basham to A brief review of the history of the alkaline treatment ofthe " Transactions" of the Society was quoted. Of G7 cases of rheumatism concluded the paper.acute rheumatism treated with large doses of nitre, the heart Dr. GOODFELLOW had long been in the habit of employingbeing in each case unaffected at the commencement of the plan, the nitrate of potash in cases of rheumatism, in doses of ten6 only had symptoms of infla,mrnatinn of that organ, grains to two scruples every four hours. This mode of treat-In considering the treatment of silitie remedies, the use of ment had no m:vteritl influence orr the duration of the disease,

the term was limited in an arbitrary manner. It was assumed but prevented cardiac complications. In one case out of sixtythat the salts which potass and soda form with the vegetable only was the heart affected. He combined, however, with theacids undergo such changes in the system as to become equiva- nitrate the bicarbonate of potash. He always took the precau-lent, or nearly so, to the sarne quantity of alkali in combination tion in these cases of covering the chest with cotton wuol. Hewith carbonic acid. Whether a certain quantity of potass is had found this mode of proceeding most effectual in preventinggiven as citrate, ta.rtra.te, acetate, or carbonate, the effect upon cardiac disease. He had tried other remedies, however, inthe urine and upon the system generally was held to be much combination with the nitrate of potash, such as Dover’s powderthe same. The arrangement was made accordingly. Those and the acetic extract of colchioum. Opiates at uijht with thepatients treated with an aggregate of such salts not reaching colhicum seemed to cut short the duration of the disease, andthree drachms a day were considered as under s dine treatment; prevent heart affection. Under this treatment also relapsesthose taking as much as three but less than four drachms, as were rare.

under partial alkaline treatment; those taking from half an Dr. FULLER had long employed alkalies in cases of rheuma-ounce to an ounce and a half, as under full alkaline treatment, tism. Under this treatment he had never found the heart be-

Sixty-two cases appear to have been subjected to saline treat- come affected, except in two or three instances, where infltm-ment, alone or with other remedies. These afforded a proportion mation had setup within twenty-four honrs after the comrnenee-of heart affection of 1 in 3 6. The conclusion was that salines in ment of the treatment. He was in the habit of employingsuch quantities had but little influence upon the course of the large doses of the alkalies with a view of producing an alkalinedisorder; when used in conjunction with more potent remedies, condition of the urine. When this was effected, he thoughtthe result always corresponded with the observed effect of the that it was unnecessary to test the condition of the heart, as headditional medicines when used independentlv. considered the patient safe from such complications. The dura-With the increased doses, which the author distinguished as tion of the disease under this treatment he thought was de-

partial alkaline treatment, no diminution of the heart symptoms cidedly lessened. It was not necessary that the a1 kali should bewas observed, although the disorder terminated in rather a potash, for the carbonate of soda had the same effect. His ex-shorter time. perience, however, of the carbonate of ammonia was that it wasThe full alkaline treatment was exemplified by two tables, not productive of such decided results.

It consisted in the administration of the salts which potass and Dr. GULL remarked that alkalies had been extensively em-soda form with carbonic and the vegetable acids, in quantities ployed in Guy’s Hospital in cases of rheuma. ism. Dr. Goldingvarying from half an ounce to an ounce and a half daily. Half Bird was the first to recommend this plan of treatment. Thea drachm of the acetate, with twice as much of the bicarbonate, practice, however, in his (Dr. Gull’s) hands had proved a de-of pota,ss, dissolveri in the haustus ammonias acetatis of the hos- cided failure. He had never thought that there was any proofpital pharmacopoeia, furnished an ordinary form of prescription. that there was an acid state of the blood or urine in these cases.This was given every four or six hours, and sometimes made to The prspiration was not always acid in the worst forms of theeffervesce by the addition of a little citric acid. Salts of soda complaint. In some cases the patients’ sweat ha, j assumedwere sometimes resorted to. The total of 4S patients thus three distinct forms-alkaline, neutral, and acid. He could,treated passed through the dangers of the disease, with only a therefore, see no expectation of relieving the patient by adopt-single instance of any cardiac affection. In the exceptional ing a merely chemical plan of treatment. Colchicum, Dover’scase the murmur came on within twenty-four hours of the com- powder, hot baths, nitrate of potash, opium, and other re-mencement of the treatment, and did not prove permanent. medies he had tried without satisfactory results. His expe-The average number of days in hospital, when this treatment rience led turn, therefore, to treat the disease empirically.was applied simply, was 25, the smallest of all ; when other After all, he thought it should be regarded mainly as all affec-medicines, as colchicum, were used in addition, five days were tion of the nervous system. He had been most successful byadded to the average period. Dr. Gtrrod’s published cases, in keeping the patient perfectly quiet, confining ’him to his bed,which bicarbonate of potass was used alone, were quoted as preventing the influence of all disturbing causes, and support-rather less successful than those at St. George’s, in which ing him on the simplest diet. He had found rheumatism thusneutral salts were given in addition. 24 of Dr. Garrod’s cases treated usually do well. Under it the heart was kept from dis-afforded 3 of inflammation of the heart or its membranes. It turbauce, and cotiseqiieiitly from anything like infi,1mmatorywas concluded that the carbonates of po ass and soda. and disease. This treatment, with the addition of a httle extractthose of their other salts which in the body are capable of being of taraxacum and peppermint water, administered as a placebo,converted into the carbonates, exert an especial curative power had been most effectual in his hands. Out of sixty-four casesin rhenlJ1a.tic fever, and, if given in time, will completely pro’ which he hao thus treated, there was scarcely a case in whichtect the heart from the dangers by which it is surrounded. the heart had been affected. The author of the paper had ad-

Taking the proportion of heart affection under the alkaline duced forty eight cases in support of the treatment which hesystem, 1 in 48, and, with this as a standard, reviewing the had advocated ; but this was altogether too small a number onother plans of treatment, the result was striking. 113 cases which to found a theory. Rheumatism was so different atwhere other remedies were used gave 35 instances Gf cardiac ! various times, that it must alway s he studied in reference tomischief, or a proportion of 1 in 3’2. Nitre, next to the alka- what he might call its natural history. He doubted exceed-lies, was the most successful. The general symptoms were ingly whether the alkaline treatment could he regarded as

shortened under its use. and the frequency of cardiac inflam- specific against the occurrence of heart disease. Dr. Goodft-liow,mation was reduced to 1 in 10.Regarding the Ouher remedies who so strongly advocated the employment of the nitrate ofwhich have been credited with the cure of acute rheumatism, potash, seemed glad afterwards to add something else to hisit simply became a question which were useless and which in- remedy. If the alkaline treatment was so successful, why didjurious. Mercury allowed a proportion of cardiac inflammation he do so ?of 1 case in 4. saline treatment gave a worse result. With Dr. STEWART agreed in the main with the observations madebleeding, one-half of the cases became thus complicated. Under by Dr. Gull. He had found tlut the perspiration in cases ofopium the mischievous influence of the disorder attained its rheumatism was not always acid. On the contrary, he hadmaximum. Two-thirds of the cases so treated had the symp- found it in some instances intensely alkaline. Tlie disease musttoms of endocarditis or pericarditis. With the exceptions be treated on common principles. Under simple remedies,stated, it was maintained that the more active the remedies, with a due regard to the cunclitious of the patient, the greatestthe more untoward, generally speaking, is the progress of the succ ss would be attained.disease. It was shown that the use of colchicum retarded the Dr. O’CONNOR differed from Dr. Gull in regard to his do-recovery of the patient. nothing treatment. On the whole he thought the general treat-The practical deduction was, that acute rheumatism is best ment by alkalies noticed in Dr. Dickinson’s paper the best; but

treated by giving at short intervals a, solution of nitrate, ace- he cousidereei that the bicarbonate of po ash shotrld be combinedtate, and bicarbonate of potass in such doses that ten or twelve with the nitrate of potash or the acetate of ammonia so that

690

they might act upon the skin ; the object of treatment being,in fact, to eliminate from the system a morbid matter. llheu-matism was a disease which must be treated according to thesymptoms presented to us, and the condition of the patient.In exceptional cases moderate bleeding might be advaii-

tageously employed. In other instances, the administration ofopium and calomel might he indicated. In fifty cases which hehad treated at the Hoy"l Free Hospital, only two women had

been the subjects of cardiac inflammation, and one of those hadcardiac affection on admission. All the patients recovered.

Dr. DICKINSON, in reply, stated that the doses of alkalineremedies administered in the cases which he had brought for-ward were much larger than those which had been resorted toin Guy’s Hospital. To be effective the remedy must be carriedout with energy and perseverance, and it was only in suchcases that the treatment which he had advocated could be fairlytested.

Dr. GULL, in reply to Dr. O’Connor, remarked that so farfrom his treatment of rheumatism being liable to the charge of

. a do-nothing system. it was, on the contrary, a most carefuland active mode of treatment. The patient must be watchedand subjected to the most stringent rules which the medicalattendant could adopt. So far from doing nothing in such- cases, he did everything that the nature of the case under his

treatment required. By regarding rheumatism as a diseaseessentially differing under different circumstances, the prac-titioner who took into consideration the state of the patient

’ and the indica.tious presented to him, would, in his opinion, be’ more successful than the man who adopted a theory as appli-cable to all cases, and carried it out. t.

Dr. BABINGTON had been surmised that in the discussionwhich had taken place no allusion had been made to the in-fluence of lemon-juice in the treatment of rheumatism. No

remedy would appear to have been more effectual in controllingits duration, or preventing cardiac complications.

Reviews and Notices of Books.The Asclepiad. Vol. T.: Clinical Essa,ys. By BEKJAMIN W.

RICHARDSON, M. A., M.D., Senior Physician to the RoyalInfirmary for Diseases of the Chest. pp. 272. London:Churchill.

DR. RICHARDSON is well known as a most intelligent andindustrious observer, whose researches have borne the test ofexperience, and any fresh results of his labours are alwaysgladly welcomed by the profession. In the present instancehe has furnished us with a series of valuable practical essays,abounding ia facts of great clinical importance. The subjects

discussed in the seven essays of which the volume is composeda,re-Subclavian Murmur ; a Diseased Condition of the Nails ;Reduplication of the Second Sound of the Heart; Contributionstowards a more perfect clinical history of Scarlet Fever ; Pulsa-tile Puhnoiuo Crepication; Uræmic Coma; and Cardiac Apnoea.We may honestly say that all will be read with profit, but our- Space will only allow us to draw attention to some of thesalient points in a few.The sixth essay, on Uræmic Coma, is the longest in the

book, and probably the most important. After giving hisobserved facts and their analysis, the absolute and differentialdiagnosis, the etiology, pathology, and complications, togetherwith the cause of death, the author dwells on the relations ofuraemia to forensic medicine. There can be no doubt whateverthat the symptoms of urcemia, will often simulate those of poi-soning by many different substances, and the necessity of thecareful interpretation of the former is therefore of the utmostimportance in a medico-legal point of view. Uræmic coma andconvulsion are closely allied with the coma and convulsion in-cident to poisoning by belladonna ; the distinctions which

apply to the diagnosis between these two forms of disease areclearly pointed out on page 155. Uraemic poisoning may alsobe confounded with the effects produced by fatal doses of opium,’and indeed of all those poisons which induce narcotism in addi-tion to irritation of the alimentary mucous surface.

" As the tests for these poisons, moreover, are doubtful, the

difficulty of distinguishing between their action and the actionof urea would be, or at all events might be, alarmingly great.The nearest approach to accuracy in any such doubtful in-stance’s will be obtained by a careful comparison between thesymptoms and pathology actually presented, and the symptomsand pathology of acute ursemia in its simplest and most abso-lute type."

Another poison, now getting into common use for suicide, isthe cyanide of potassium. Death is generally rapid ; but occa-sionally cases occur in which, the dose of the cyanide takenbeing small, a slowly developed class of symptoms are set up,which, in many respects, are similar to the symptoms of uraemia.Dr. Richardson next indicates another class of cases, in which,during the existence of a uræmic condition, actively presentingitself or remaining latent, agents are given as medicines whichhasten the effects of the natural disease, and induce, by thisindirect means, a fatal result.With regard to treatment, the author recommends a free

abstraction of blood as the best remedy ; for, as he says, thereis a soluble poison in the blood, and in venesection we securethe readiest means by which to remove the noxious agent. Italso relieves visceral congestion, especially of the kidneys. At

pages 143, 147, and 217 some good examples of the success ofthis practice are given. The arguments used in favour ofbloodletting are, we think, sound. If our forefathers erred in

bleeding so frequently, we fall into as serious an error in almostwholly discarding it.The essay on Cardiac Apncea is one of practical value, and

deserves to be read and re read. 1,17’ho has not met with suchcases ? It consists in a form of breathlessness often terminatingin death, which is due to the fact that, in the cases in which itis presented, the pulmonic current of blood is being withdrawnfrom the air. In this apncea, the entrance of air into the lungsmay be entirely unobstructed; for it is, as its name implies,an apnœa commencing exclusively in the circulation and at theheart. The symptoms of this form of breathlessness have beennoticed at different times by various titles, such as " anginapectoris," "cardiac asthma," "spasmodic respiration," and"syncopal asphyxia;" but these terms, Dr. Richardson re-

marks, have only served to connect the symptoms with someparticular form of disease, and were introduced without anyspecific attempt to define the exact cause of the symptoms suigeneris. He further states that cardiac apnæa has often beenconfounded with syncope, and the prominent features of eachare contrasted. Apncea, according to its cause, is divided into"laryngeal," when arising from obstruction in the larynx;"bronchial," if it is in the bronchial tubes ; if in the structureof the lung, "pneumonic;" and if from arrest of blood to thelungs, "cardiac." "For be it observed that the apncea fromarrest of blood on the right side of the heart has for its essentialcharacter a disturbance between the normal relations of airand blood. The blood inspires and expires: and the productionof apnœa is as perfect and as obvious in effect when the bloodis cut off from the air as when the air is cut off fiom theblood. "

A series of cases of cardiac apncea are detailed which fullyillustrate the author’s views ; these are followed by a descrip-tion of the differential and the absolute diagnosis, the latter ofwhich is thus stated : " It is an apnoea with open air passages;not panting breathlessness, but suppressed breathing. The

struggle for breath is due to spasmodic contraction of themuscles of respiration, and consequently is marked by no rapideffort of those muscles to overcome a difficulty in the respiratorytract." Besides the above, there is a darting pain through thechest-cramp. The other parts of the muscular system, if in-volved, are cramped, not convulsed. The mind is usually un-affected. During the paroxysm there is either irregular orprolonged absence of the pulse. In all cases of death the finalact is one of persistent muscular contraction, the heart firstfailing; the muscles of the chest become fixed from tonic spasm,the voluntary muscles follow next, and the whole body may at