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over the tibia on the inner side, and at the lower part of its upper third. The knife I,was then carried over the fore part of theleg to the outer side, over the fibula, to apoint opposite the upper part of the firstincision. It was then passed behind bothbones, and the point brought out at theincision on the inner side, the flap beingformed from the muscles of the calf, thebones were then divided, only one vesselbeing secured.

Mr. LISTON remarked that the ad-vantages of operating high up as he haddone, consisted in the pressure of the limbbeing made on the knee, and the avoidanceof the inconvenience of a long stump,which generally got entangled in theclothes, and was otherwise annoying. Hehad in six cases removecl the head of thefibula, as recommended by several militarysurgeons, but he did not think the plan agood or a safe one. He had only found itnecessary to secure one vessel in the abovecase, from the circumstance of the incisiorbeing made above the division of the pop-liteal.

ST. BARTHOLOMEW’S HOSPITAL.

ACUTE RIIEUMATISM AND PERICARDITIS.

MARY ANNE HAWES, a robust, healthy,good-looking girl, was admitted intoMary’s Ward under the care of Dr. LA-THAM, on the 22nd of July, the above dis- Ieases being evidenced by her symptomson her admission. Countenance flushed;augmented heat of the surface ; copiouscutaneous exudation; tongue much furredand dry; pulse 80, indicating a want ofpower; bowels influenced by medicine;great thirst, anorexia, acute pain in theknees, ankles, and wrists, more especiallyin the left wrist, which has undergonegreat tumefaction. She remembers aboutfive years ago having a severe attack ofrheumatism, that confined her to ber bedfor a period of nine weeks. At that time she experienced great pain in the left side,but has since enjoyed very good health,until about three weeks ago, when havingimprudently exposed herself to the banefu1eti’eets of sitting on wet grass, she wasunable to walk on account of severe pain I,in the knees. Leeches were applied, butthe symptoms have continued unabated.Prescribed half a grain of opium and fivegrains of calomel.

3. Has experienced some advantagefrom the treatment. The stethoscope dis-covers the heart’s first sound to be at-tended with a little roughness. Applytwelve leeches to the heart, and administer

a. senna draught. Rested pretty well;;bowels evacuated three or four times dur-

ing the day.4. Passed a more comfortable night than

she has for some considerable time. Tongueless furred but still dry; pulse 80; onealvine dejection voided to-day; the painand swelling have subsided in the knees,but have affected the hip and shoulders ;and the wrists and the elbows are verypainful. The heart’s first sound to-day isdecidedly prolonged, and the ronghnessis augmented. Ordered two grains of calo-mel and a quarter of a grain of opiumevery six hours.

5. Pain greatly diminished; countenanceless anxious; pulse, heart, and the concur-rent symptoms, unaltered.

6. Rested more tranquilly last night than,usual, but still suffers considerable pain inthe wrists and elbows. Pulse 90; tongue; much furred; bowels regular; her heartpalpitated for a short time to day. Aus-cultation cannot detect any distinct un-. usual sound.

7. Considerable improvement is appa-rent to-day; pain mitigated; can exerciseher elbows a little; the alvine functionsare regularly performed ; pulse 90.

8. She enjoys almost a freedom frompain; tongue still dry, and somewhat less

furred; pulse soft, computing 76 ; Bowelsstill act with regularity; there is somethirst.

10. Her symptoms viewed en masse,evidence decided improvement, but shecomplains of very severe pain in the

region of the heart, and the ear ascertains ,.

the heart’s first sound to be yet prolonged,with still a suspicion of roughness. Leteight leeches be applied to the heart.

11. There is pain now in the region ofthe heart, the stethoscope still affords averv dubious result.

13. Rests pretty well ; some pain in theright wrist still exist; tongue slightlyfurred ; pulse soft; in number 76 ; bowelsregular ; no return of appetite. Omit thecalomel.

15. Still evidencing improvement ; aus-cultation the same as in last report.’ IS. Acknowledges herself to be betterin every respect. Tongue cleaner; pulse80; alvine excretions normal; perfectfreedom from pain. All suspicion of un-natural sound of the heart appears to bereceding.

29. Since the last report she has beenwalking about, and complains of an impe-diment to her breathing; pain in the re-gion of the heart and some palpitation;auscultation announces some degree ofroughness at the base of the heart.August 5. She left the hospital (pro

tempore) the day before yesterday, and

751

evinces to-day some pain in the left side.On examining the chest a bruit de souflletis observed.August 14. She has attained her pre-

vious healthy appearance, and purposes to,day to take a farewell of her Bartholomewfriends, to revisit the place of her nativityin the vicinity of Dover.

DIAPHRAGMATIC HERNIA.

Mr. LAWRENCE, during some clinicalobservations, directed the attention of thepupils who were present to a case not lesssingular as he said in its history than itproved rare in occurrence; it was that ofdiaphragmatic hernia, or where a portionof the contents of the abdomen, such asthe intestines or omentum, was protrudedthrough the diaphragm into the cavity ofthe chest. These were circumstancesunder which a just diagnosis was verydifficult to be formed, from the impossi-bility of getting at the immediate seat ofthe disease; for although the concomitantsymptoms of strangulation obtained, stillthere was wanting that proof so confirma-tory of the existence of hernia, the ex-ternal protrusion or swelling, cognizablealike by the taxis and the sight. Thehistory of the case above alluded to wasas follows, furnished by Dr. Norris, for-

merly a pupil of this hospital. The patient,a strong healthy man, after exerting him-self to an unusual extent in walking adistance of twelve or thirteen miles, wasattacked with sickness, retching, and pain,referable to the left side, under the carti-lages of the ribs ; his pulse was frequentand hard, and there were general symp-toms of fever, accompanied by difficulty ofbreathing. On examination Dr. Norrisdiscovered that there existed little or norespiratory murmur on the left side of thethorax, and that the pulsation of theheart was not audible in its normal situ-ation, but was heard to beat on the rightside ofthe chest. Notwithstanding severalremedies which were employed, all theunfavourable symptoms became aggra-vated ; tension of the belly, increased pain,a higher state of fever, and great restless-ness, were but the precursors of the moreformidable signs of approaching dissoln-tion. Hiccough, cold sweats, and spasmodicrigors, in a few days ended the tragedy.At the examination after death the follow-ing appearances prevailed ; on openingthe abdominal cavitv no omentum what-ever could be discovered, and the intes-tines were distended with flatus and pre-sented various stages of inflammation ; onendeavouring to trace the course of the

colon, its descending portion was foundwanting; a small hole, however, was seenpenetrating the substance of the dia-

phragm at its posterior part near its

spinous origin, through which the intes-tines might be traced. On removing thesternum the extraordinary contents of theleft pleural cavity became discernible, con-sisting of a large portion of intestines, thewhole of the omentum, a great portion ofthe spleen, and the entire pancreas,-socompletely occupying the left side of thechest, that the lung was compressed to thesize of a man’s fist, and the heart and me-diastinum were pushed towards the rightside, as frequently obtains in empyemaoccupying one cavity of the pleura, where,in the same manner, by pressure, thelung becomes consolidated by the oblite-ration of its air-cells, or, in other lan-guage, is carnified, and the heart is like-wise displaced. This hernia did not ap-pear to be an actual rupture through thesubstance of the muscular septum, occa-sioned by any sudden and violent com-pression of the abdominal viscera, becausethe protruding parts were not envelopedin a sac. They had not carried throughthe opening an investment of peritoneum,and the edges of the wound through whichthey had egressed were quite smooth andround, apparently formed by a continua-tion or junction of the two serous mem-branes which composed its upper and un-der surfaces. This circumstance Mr. LAW-RENCE observed would lead one to con-clude that the communication betweenthe two cavities was of congenital forma-tion, though he should imagine that thedisplacement of the abdominal viscera hadexisted but recently, in consequence ofthe violent exertion the poor fellow hadmade during his unusually protractedwalk. Mr. L. again alluded to the diffi-culty of diagnosis in this case, though,he remarked, the fixed pain of the side,the change of situation of the heart, andthe arrested respiration in the left side,might perhaps have led to a conjecture ofthe nature of the disease. A preparation,showing the parts as removed by Dr.NoRRis, was then exhibited, and sentround for the inspection of the students.

ANATOMY AT THE DUBLIN COLLEGE.

To the Editor of THE LANCET.

THE late season being the last I coulddevote to the study of anatomy, it was myobject to get as much information on thesubject as possible, and with this view Isought about to ascertain where I couldget the greatest assistance, as I was some-what backward in practical anatomy. Iwas at once captivated by the parade of noless than five names in the advertisementsfrom the school of the Dublin College of