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Like Alonzo, in the Tempest, the enthusiast exclaims-" Methought the billows spoke, and told me of it;The winds did sing it to me, and the thunderPronounced its name."

Thus every phenomenon of unascertained origin, every newidea gained from conversation, lectures, books, every actualdiscovery, is held, by the partizans of different dogmas, asshadowing forth so many exemplifications or proofs of thecogency of their peculiar views, (as the vast amount of corre-spondence received in THE LANCET Office has given us nume-rous opportunities of remarking.) The unknown cause of

cholera, in particular, has formed a great battle-field for allkinds of rival hypotheses.We do not assert that these remarks are more especially

demanded, by the little work before us, than by many otherswhich pass through our hands, though some portions of itscontents have called them forth in this place. Though wecannot more fully agree with the views of the author thanheretofore, he is at least indebted to us for a longer notice thanthe one we had previously bestowed on his production.

New InventionsIN AID OF THE

PRACTICE OF MEDICINE AND SURGERY.

Markwick’s Patent Respirator.AN ingenious little device for protecting the chest from theinspiration of cold air, consisting chiefly of Markwick’s

epithem covered with silk. It is evident, however, that theoval form is not the best suited for fitting the mouth. If the

upper part, instead of being convex, ran on in a straight line,or were even slightly concave, it would be an advantage, espe-cially with those persons who have not baboonish upper lips.

A MirrorOF 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.

ST. BARTHOLOMEW’S HOSPITAL.

Medullary and Blood-Cyst Tumour round the Femur.(Under the care of Mr. LLOYD.)

ALTHOUGH morbid anatomy has taught us a great deal withrespect to the nature of the various kinds of tumours whichmay spring up in bone, (especially since chemical analysis andthe microscope have lent their powerful aid,) very embarrass-ing cases will still arise in practice, where the surgeon is

called upon to bring into action all the knowledge, experience,and acumen he may possess. It may well be said, that incases of osseous tumours diagnosis is everything; indeed, uponthe words, " malignant and benign," often hangs the fate of alimb, and hence the vast importance, both to the surgeon andpatient, of a correct diagnosis.A day will perhaps come when an exploring puncture will

at once disclose the exact nature of an abnormal growth; thematter lying in the groove of the needle giving, by the aid ofchemistry and the microscope, the ready solution of theproblem. But as matters stand at present, perplexity may beexperienced in determining the nature of a tumour, even whenremoved from the body; this difficulty being mainly owing, ifwe mistake not, to the partial changes which not unfrequentlyOccur in abnormal growths. Look at the case lately broughtbefore the Pathological Society by Mr. Prescott Hewett,(THE LANCET, Nov. 9, 1850, p. 536.) A tumour of the lower

end of the femur, which was supposed to be of a malignantnature, gradually diminishes under the influence of mercury.Various ailments attack the patient, of which he partially re-covers ; he lives for about one year afterwards, and then dieswith ascites. Both the periosteum and the medullarycavity over the site of the tumour were infiltrated with tziber-cular matte1’. Mr. Hewett considered this as rather a raredisease in bone, and very justly added, " that the history ofthis case afforded a very good illustration of the great diffi-culties connected with the diagnosis of tumours affecting theosseous system."The case of malignant tumour under the care of Mr.

Charles Guthrie, which we reported last week, (p. 603),offers a good illustration of the uncertainty sometimes exist-ing, as to the exact extent of the disease; and we havenow to bring before our readers another instance üf ence-phaloid tumour connected with the femur, which exemplifies,in a very instructive manner, what combination of charactersa malignant growth may present, and how difficult it is torecognise these characters before the tumour is removed.We are indebted to Mr. Fletcher for the following details:-

E.M., an agricultural labourer,aged 20,appearing in good healthwas admitted into Pitcairn’s ward, under the care of Mr. Lloyd,Nov. 15th, 1850. Upon examination, he was found to have alarge swelling at the lower part of his left thigh, which feltlike a firm mass round the lower end of the femur. It wasof roundish form, smooth on its surface, projecting somewhatall round the femur, but mostly on its outer aspect. It ex-tended as low as the condyles, and surrounded the inferiorthird of the shaft. The tumour felt in every part firm,.tense, slightly elastic and scarcely compressible, and the skinover the outer part was reddened, but not adherent. A fewenlarged veins appeared in the integuments over the swelling..The kneejoint was moveable and apparently healthy.The patient gave the following history of the swelling

About six months ago, he sprained his knee, and has hadpain in or about the part ever since, though only latelyobliged to leave off work. About one month after the sprain,he received a severe blow on the lower part of the thighfrom a cricket-ball, and again, about ten weeks before hisadmission, he a second time sprained the limb, immediatelyafter which the swelling commenced, and has gone on increas-ing up to the present time; (the last three weeks the growthhas been very active.) No disease has appeared elsewhere.The aspect and general characters of the swelling were likethose of a malignant tumour; but as it might have been achronic abscess, it was punctured with a lancet; twelve orfourteen ounces of venous blood quickly flowed, and when aprobe was introduced, it could be passed easily through somesoft, and easily broken substance, down to the bare and roughsurface of the femur. The - case having been seen by all thesurgeons, immediate amputation was decided upon, but thepatient hesitated and would delay till the next morning.On the third day after admission, the patient was brought

into the theatre, placed under the influence of chloroform,and Mr. Lloyd proceeded to remove the thigh at the junctionof the middle with the lower third. We noticed, that whenthe circular sweep through the skin and cellular tissue hadbeen made, Mr. Lloyd detached these structures from themuscles about three inches and a half upwards; a longitudinalincision, about three inches long, was then made ’on eitherside of the thigh, the anterior and posterior portions of theskin being then turned upwards with the greatest ease.

These lateral incisions unite generally very quickly. Thearteries were tied, the stump dressed in the usual way, andthe patient removed.The tumour was immediately examined by Mr. Paget, and

it was found that the greater part of the disease, lying overthe outer half or more of the lower third of the femur, con-sisted of a large, nearly hemispherical sac, full of black, fluid,and softly clotted blood. On the corresponding part of theinner half of the femur, but over a much less extent, was amass of firm, white, medullary-looking matter, mixed withbone. The coverings of this were continuous with those ofthe outer saccular portion, and evidently parts of the samedisease. The walls of the sac, or cyst-like portion of thetumour, were composed of periosteum and bone. The peri-osteum of the cyst was soft, normally connected with themuscles and other parts over it,and continuous with the samemembrane of the rest of the shaft, and also with that of theepiphysis. In some parts, the cyst appeared sacculated andthinned. The bony part of the cyst was arranged in promi-nent ridges, from half an inch to three inches high, variouslybranched, and connected, so as to form a complete networkThe margins of the ridges were rough and irregular, and their

631

substance was very fragile and weak, so that the inner wall Iof the cyst was easily flexible in nearly every part. There eappeared to be but one cyst.The solid part of the discase had the appearance of a milk-

white, and almost brain-like medullary substance, blotchedwith blood, and containing portions of hard, minutely can-cellous bone, which were placed irregularly in nearly everypart of it, and were like the bone of an osteoid tumour. (Themedullary character of this part was proved with the micro-scope.) In the part of the femur which was enclosed withinthis disease, the greater portion of the cancellous tissue wassolid, very hard, heavy, and " ivory-like," and similar to thehardest form of osteoid substance. The change appeared tohave been produced by gradual consolidation of the cancelloustissue, for faint traces of the original cancelli could be dis-cerned in the osteoid parts. In those portions of the cancelloustissue which had not undergone this osteoid change, medullarysubstance, like that on the exterior of the shaft, only firmer,was interspersed in irregularly circumscribed masses, or

nodules, in which the medullary matter was mixed up withosteoid bony matter.The walls of the shaft, enclosed within the disease, pre-

sented, especially in the part corresponding with the cyst, aseparation or removal of theit outer laminae. On lookingdown upon the cut surface of the shaft, there could be traced,for an inch or two above the disease, the outer layers graduallyseparating; then the two or three outermost ceased abruptlyat the cyst, as if they had been carried off with its periostealinvestment; and the remainder, retaining their position, wererough, irregular, and as if broken and fused with the osteoiddisease of the cancellous tissue. The appearance was exactlyas if the medullary growth had been formed among the layersof the wall of the bone, separating and pushing out the outerlayers, and wasting or eroding the inner ones. On the innerwall of the shaft there was a similar, but much less complete,separation of the layers, and some wasting of them under themedullary growth, situated above. But here, in the sameplaces where their wasting was seen, there had sprung uplow, brittle, osteoid growths, which extended into the medul-lary matter, and were mingled with it. The knee-joint washealthy; the front of the tibia presented the blotched, pur-pureous appearance of the surface of its shaft, so often seen inconnexion with medullary disease of the lower end of thefemur. The anterior surface of the patella was also deeplyvascular, and a livid hue extended for nearly a line into itsSubstance.Mr. Paget, to whom we owe the above accurate description,

was kind enough to point out to us preparations, in the museumof St. Bartholomew’s Hospital, which present much analogywith the tumour of Mr. Lloyd’s patient. We find, for instance,No. 220 of the Pathological Series described as follows :-

" Portion of a femur, of which the lower extremity is ex-panded into a large cyst, which was filled with liquid ccnd z,coagulated blood, and a small quantity of brain-like medullary substance. The cyst is nearly globular; its walls are from a II,line to two lines in thickness, composed of thin plates of bone ’’,and fibrous membrane, smooth externally, and presenting, in-ternally, at some parts, a rough surface of bone, and at others,numerous prominent, decussating, fibrous bands and cords, likethe texture of the basis of a spleen, or of erectile tissue. Below,the cyst is bounded by the articular cartilages, of which the ’,texture is unaltered; above, by the shaft of the femur, whichterminates abruptly, just before it is expanded into a cyst.The shaft above the cyst presented numerous small spots ofeffused blood, like ecchymosis, beneath the periosteum."

Nos. 32 , 83 of the above-named series offer, likewise,good examples of the same affection; and we would, in con-clusion, remark, that when a cyst, filled with fluid and clottedblood, is found to have sprung from a bone, the idea of the so-

I

called blood-tumour is immediately suggested. But it wouldappear that some caution is required in pronouncing as to theactual nature of such growths. Various surgeons present atMr. Lloyd’s operation were much inclined to regard the tumouraffecting the thigh just removed as a blood tumour; but, on closeexamination, both in the theatre and subsequently, the en-cephaloid nature of the growth was clearly made out. Thatthere may be such a blending of the two varieties of the dis-ease as to perplex the pathologist will be made evident by thefollowing case, related by Mr. Stanley, in his work on " Dis-eases of the Bones," p. 188:-"In an instance of sanguineoustumour, originating within the condyles of the femur, where Iamputated the thigh at its middle, it was considered probable,from the ecchymosed condition of the tibia and of the femurto its amputated extremity, that other bones had undergonea similar alteration; yet, in the sixth year after amputation, I

ascertained that the patient was in good health, and the re-maining portion of the thigh in a perfectly sound state. In.this instance, moreover, whilst the large cyst formed by theexpanded condyles of the femur was filled by fluid and ex-travasated blood, there were distinct portions of soft substanceattached to the inside of the cyst, so closely resembling brain-like matter as to suggest that the sanguineous tumour of bone.may be a variety, our the incipzient stage of encephaloid disease."We are glad to add that Mr. Lloyd’s patient has progressed

satisfactorily; and as cases of non-recurrence of the diseaseafter amputation are on record, we may hope that such afavourable circumstance will likewise take place in this in-stance. As for the little doubt which at first hung over thenature of the tumour, we would just quote the following linesfrom Mr. Stanley, p. 141:-" An arrangement of tumours ofbone cannot well be founded on their composition, two or moremorbid products being occasionally united in the same tumour.Another source of difficulty in classifying tumours of bone isthe changes to which they are liable."

ROYAL FREE HOSPITAL.

Sequelœ of Scarlatina connected with Anœmia.(Under the care of Mr. WEEDEN COOKE.)

IT is a fact worthy of remark, and one which must havefrequently occurred to the minds of practitioners who arecalled upon to prescribe for the young, that it is more often-the secondary ansemio effects of a primary disease which de-stroy the little patient, than the original fever or inflammationto which it has been subjected. The primary diseases, rubeola,scarlatina, pertussis, bronchitis, and pneumonia, destroy, un-doubtedly,alarge number of children, indeed a very much largerproportion than would perish were the purely medical aids ofour art assisted by those hygienic measures of cleanliness andpure air and light which are such necessary conditions for re-storing as well as preserving health. Should peace and pros-perity continue to afford our legislators time for the moraland physical improvements which characterize the age, wemay hope that these diseases of childhood, which have for solong been considered necessary occurrences, will be, if notconquered altogether, at least rendered so harmless,that deathfrom them shall be the exception, rather than, as now, almostthe rule.Medical men are doing their part in this social amelioration,

and already do we begin to see, in the registrars’ reports, theresults of increased attention to the diseases of infancy. It is,perhaps, almost too early to claim the great decrease in deathsunder fifteen years as a propter hoc, but at least it gives hopeand encouragement, and sweetens labour.We have travelled from the subject of our present report,

which is that of the sequelse, or secondary results of the exan-thems. Amongst Mr. Weeden Cooke’s little patients at theRoyal Free Hospital, it is extraordinary to witness theProtean forms of disease which result from, or are developedby, an attack of scarlatina or measles. Taking the head only,at least four or five different affections present themselves;porriginous eruptions on the scalp, attended by enlargementof the glandulse concatenat2e of the neck; purulent dischargesfrom the auditory passages, with or without partial deafness;corneitis, with, perhaps, ulceration, and muco-purulent dis-charge, of an offensive character, from the nares, arisingfrom ulceration of the Schneiderian membrane ; indolentulcers behind the ears, at the angles of the mouth, and alsenasi; ulceration of the vulva, (THE LANCET, Nov. 23, 1850,p.578;) and cerebral irritation. Other parts of the framesuffer from the exhausting effects of the primary disease; butinteresting and important as it is, thus to class togetherdifferent forms of disease owing their development to onecause, our space warns us to confine ourselves at present tothe illustration of one or two of these affections of the head.James B-, aged two years and a half, came under the

care of Mr. Cooke on the 27th of August. He was strongand well until four months previously, when he had scarletfever, since which he has been weakly, thin, and pale. Twomonths ago the mother noticed that he became deaf, acquireda vacant look, and put his hand to the left side of his head,although he did not complain of pain. A day or two elapsed,and then a discharge proceeded from the left ear, which hascontinued ever since. He is now very anaemic in his appear-ance, and the deafness and discharge from the ear remain.Ordered a nourishing diet, with meat once a day, and milktwice. The shower-bath every morning, cold, if he can bearit; if not, slightly heated. Six grains of the sesquioxide of

iron, in treacle, three times a Jay; and an injection for the