determined to make scarifications on the inside of the thigh, from which an abundance of serum issued. By this remedy and proper regimen, together with fomentations, &c. the malady seemed to yield, and in six weeks the limb was reduced to its normal dimensions. She was discharged apparently cured. But in the course of the next year, the patient returned, with the limb still more swelled than before; and now the swelling had attacked both the lower extremities. The least movement excited insupportable sufferings-the tumefaction was at its utmost degree-and the swelling pitted on pressure of the finger. The health of the patient was greatly deranged-digestion difficult-stomach unable to bear, without pain, the lightest nourishment-bowels constipated-breathing short, difficult, and laborious-sanguification imperfect, and face of a blueish tint, as in hydrothorax-pulse small, quick, and irregular-urine obliged to be drawn off daily. At this time, there was felt in the hypogastric region, a hard globular mass, which was supposed to be a scirrhous ovary, or enlarged

uterus.

The disease made rapid progress-emaciation advanced-eschars formed on the back, and the patient died.

Dissection. There was no disease in the chest. The abdominal viscera presented nothing extraordinary. On the front of the lumbar vertebræ was a large tumour of a fatty lardaceous nature, in the midst of which was found the ascending cava, greatly enlarged, its diameter being more than two inches and a half. On prosecuting the dissection, the primitive iliae and hypogastric veins, their principal divisions, the cava ascendens, as far as the diaphragm, were found extremely dilated, and filled with a dense, whitish, fibrinous-looking substance, in the centre of which there was a small canal, one line in diameter, through which the venous blood returned from the lower parts of the body. The parietes of these vessels were somewhat thicker than natural, and they were surrounded by degenerated cellular substance. The aorta was not affected. The lower extremities were infiltrated, and their veins much dilated.-Journal Gen. de Med. January, 1827. Here is another case of phlegmasia dolens !—another proof that the cause of the disease is inflammation and obstruction of the pelvic or iliac veins ! It is only necessary to clearly and fairly state these cases, to convince every observant and experienced practitioner that they are not the disease known by the term (however improper) phlegmasia dolens.

But the discussion of the new doctrine is very advantageous, and all these cases are interesting specimens of pathology, which are highly deserving of record.

Were we pressed for our own opinion as to the nature of phlegmasia dolens, we would say that it approaches nearer to what is termed diffuse cellular inflammation than to any other malady with which we are acquainted —but that it is not identical with that. In the diffuse cellular inflammation there is a "boggy" feel, to use the expression of Dr. Duncan and others; while in phlegmasia dolens, it is a tense elastic feel. This last disease, too, is not near so dangerous as the former. It is, therefore, a peculiar, or specific malady, sui generis, the proximate cause of which is not yet ascertained. But, from all that we have yet seen or heard, we are satisfied that this proximate cause is not PHLEBITIS.

16. HERNIA OF THE STOMACH THROUGH THE DIAPHRAGM.

At a late meeting of the Westminster Medical Society, a remarkable case of wound of the diaphragm was detailed by Mr. Hunt. The particulars are as follow:-The patient was stabbed in the left side with a knife, and for a month afterwards his life was in jeopardy. He then recovered from the effects of the wound, but from this time began to suffer from dyspepsia. When Mr. Hunt first saw the patient, nearly 16 months after the injury, he had cough, but unaccompanied by pain, or inability to expand the chest, attended by a peculiar kind of vomiting, apparently more dependent on the action of the stomach itself, than on that of the abdominal muscles and diaphragm. There was no febrile action, the pulse being below 70. Twelve ounces of blood were taken from the arm. Next day, the symptoms being much exasperated, a larger quantity of blood was abstracted, and with relief to the patient. To check the slow inflammation which appeared to be going on in the stomach, blisters, &c. were applied to the epigastrium. For eight days the case seemed doing well, but at that time a low remittent fever was set up, which, however, at the end of a week or so, had nearly subsided under proper treatment. In the course of a day or two he became anxious, and was attacked with retching and vomiting of matters resembling coffee-grounds. From this period no food could be retained upon the stomach, nor could any passage be procured through the bowels, and on the 5th day he died exhausted. Dissection. On raising the sternum, a large mass was seen, which at first was thought to be an enlarged heart and pericardium, but which turned out to be the stomach greatly distended, and situated entirely in the left cavity of the thorax. On exposing the cavity of the abdomen, there was found a large opening in the diaphragm to the left, and rather below that for the passage of the oesophagus; it had a smooth and rounded margin, and through it the stomach and part of the duodenum had passed into the chest. It was with great difficulty, owing to the distension of the viscus with fluid, that it could be drawn back through this opening into the abdomen. The lung was apparently uninjured, and the intestinal canal sound, but near the pylorus there were marks of chronic inflammation, with ulceration of the mucous membrane.

Remarks. This is certainly a curious case. The manner in which the stomach got into the thorax, seems, in spite of a good deal of hot discussion which took place on it, simple enough. The knife pierced the diaphragm most probably in expiration. Through this wound a portion of the stomach was forced, partly, no doubt, by the suction power of the chest, as Dr. Barry well observed, but principally by the pressure of the abdominal muscles, and descent of the diaphragm itself. The opening continued to enlarge, and more of the stomach protruded through it, giving rise to irritation, and chronic inflammation of its coats, as shewn by the dyspepsia and vomiting. At last the whole of the organ, dragging with it part of the duodenum, became located in the thorax, and it was at this time, in all probability, that the violent retching and vomiting occurred, and that the passage of food through the alimentary canal ceased. The preparation is sent to the museum of the College of Physicians.

The above are the remarks of our correspondent; but we have some doubt as to the supposed wound of the diaphragm in this case. It is not impossible that there might have been a congenital opening in the dia

phragm, although the hernia might not have occurred till after the accident above detailed. The fallacy of the "post hoc, ergo propter hoc," proposition is well known. The Editor of this Journal examined the infant of a medical gentleman (Dr. Golding), in which there was a large congenital opening in the diaphragm, through which the stomach accidentally passed, and caused the death of the child. Another instance, still more remarkable, has lately been communicated by M. Sigaud to the Royal Society of Medicine of Marseilles, of which we shall here state the particulars.

A young man, 21 years of age, died suddenly, after a fit of indigestion, and the body was examined for the purpose of ascertaining the cause of this sudden and mysterious death. The dissection was performed by M. Sigaud, in the presence of Messrs. Giaud and Magail, when the following notes were recorded. In the left side of the diaphragm there existed a circular aperture, with rounded edges, and at least three inches in diameter, through which aperture a large mass of intestines had penetrated into the left cavity of the thorax, and had there become strangulated, causing the death of the patient. The preparation is preserved in the museum of the Society.—See Archives Generales. Janvier 1827, p. 130.

Now, had this young man received a penetrating wound in the direction of the diaphragm previously to this sudden death, it might, and probably would, have been said, that the aperture was thus produced, and that death had taken place in consequence of the opening left in the muscular partition between the two cavities.

16. REMITTENT BRONCHO-ENCEPHALITIS.

Under this head M. Broussais has related a curious case in his Journal (Annales de la Med. Physiolog.) for October last. The patient, a young man, was attacked with symptoms indicative of inflammatory action in the bronchial membrane, and also in the brain, with violent exacerbations, during which the cough was incessant, and the cephalalgia greatly aggravated by the successions of the cough. After three bleedings from the arm, and several applications of leeches to the temples and neck, the disease took on a decidedly periodical character, and then the sulphate of quinine was administered, with an allowance of light nourishment, especially as no symp toms of gastric irritation were present. The appetite was good, and the tongue clean. The medicine but slightly mitigated the paroxysms of coughing, and presently the skin became permanently hot and dry, the bowels irritable, and the embarrassment of the chest increased, the expectoration being viscid, and brought up with difficulty. The sulphate of quinine was discontinued, and leeches were applied to the lower part of the trachea. The strict antiphlogistic regimen was again adopted. This plan was crowned with success. "What," says M. Broussais, "would have been the result, if we had persevered with the febrifuge, because the disease assumed a periodical character? The patient having lost much blood, the inflammation might not, perhaps, have assumed an acute character, but certainly a chronic gastro-enteritis would have been established, and possibly the bronchial inflammation would have been converted into suppurative pneumonia."

EXTRA-LIMITES.

PRIZE HOSPITAL REPORT,
No. I.

MR. THOS. H. SMITH, PUPIL,

ST. THOMAS'S HOSPITAL, BOROUGH.

TWO CASES OF

I.

TREATED BY F. TYRRELL, ESQ. AT ST.
THOMAS'S HOSPITAL.

fore, Mr. T. could now have not the slightINJURY OF THE SPINE, est hesitation as to the plan to be adopted; he having determined, although his former case terminated unsuccessfully, to repeat the operation of removing the arch of the vertebra, which pressed the medulla spinalis, whenever a case favourable for it should present itself; and such the case under consideration appeared to be. Mr. T. therefore, now sent for his able colleague, Mr. Green, in order to have the advantage of his countenance and advice. The pulse was 70 and full-he had had no sleep-complained of much pain in his back, but none elsewhere-feet warm-bowels not yet open.

1. Case of Fracture of the Spine, with displacement; with the Operation, &c. JEREMIAH MAHONY,

Æt. 26 Yrs. Treated by Mr. TYRRELL. 1827,

Isaac's Ward,
St. Thomas's
Hospital.

February 5th. J. M. was brought to the hospital, about 2 o'clock, P. M. on 5th Feb. with the account, that an immense piece of timber (said to weigh near 2 tons) had fallen on his back.

There was paralysis of the lower extremities, with tension, and considerable effusion in the region of the loins; there was also loss of sensation from the tuberosities of the ischia, and, on more minute examination, by Mr. Tyrrell, it appeared evident that there was displacement of the (?) last dorsal or first lumbar vertebra, He was a strong and well made man, and evidently of a good constitution. His pulse was 70 and strong-his feet were at first cold, but soon became warmer. Mr. T. ordered his dresser, Mr. Whitworth, to apply leeches-fomentation, and afterwards spirit-wash during the night, so as to relieve the tension and effusion as much as possible. The catheter was introduced, he having, of course, lost all power of voiding his urine. February 6th. From the perseverance of the attendants in the plan ordered last evening, the effusion was considerably lessened, and the depression of the spinous processes could now be much more distinctly felt; thereVOL. VI. No. 12.

Operation, by Mr. Tyrrell.

The patient being placed in as favourable a position as possible, with his chest somewhat raised, so as to have the light full on the back, an incision was made over the spinous processes, to the extent of five or six inches, the depressed vertebra being in the centre of the incision. The muscles were then dissected off between the spinous and transverse process of the vertebra above, and the one below, as well as from that which was displaced, so as to expose completely the arches. It was found very useful in this, as in Mr. T.'s former operation, to have two bent pieces of steel, with which the assistants could very satisfactorily keep apart the divided muscles, and bring every stage of the operation within the view of the operator. Having thus exposed the arches of the vertebræ, it was then found that the inferior articular processes of the 12th dorsal were thrown for2 R

2