laceration, or breach of continuity, with the general peritoneal sac. The hernial sac was in relation anteriorly to the sternum and costal cartilages, posteriorly to the pericardium, and, on the left side, to the pleura.

The most careful examination of the body failed to discover any cicatrix of an old penetrating wound of the thorax or abdomen, or any evidence of the fracture of a rib.

Remarks.-Pathological writers have made a threefold division of diaphragmatic hernia, viz. :-(1) Those due to a traumatic lesion of the muscle; (2) those due to a congenital deficiency of the muscle; and (3) those occurring through some of the normal openings, or weak points of the muscle. It becomes a question here as to which of these classes we are to refer the present specimen to. That it does not belong to the first, or traumatic class, is, I think, proved by-firstly, the entire absence of any evidences of such an injury as would produce such a lesion ; and, secondly, by the conclusive evidence afforded by the existence of a well-marked peritoneal sac. Cruveilhier, long ago, laid down the pathological law that the absence of peritoneal sac forms the distinguishing mark of a traumatic diaphragmatic hernia, as contrasted with that not due to injury. Is the present case, then, a congenital defect, or a protrusion through some of the weak or open points in the diaphragm ? As against the first of these suppositions, I think it is difficult to conceive of a congenital defect of this very limited extent, and in this situation; and it should be borne in mind that very few cases, if any, of congenital diaphragmatic hernia have been recorded in which life was prolonged to anything like the age of the present subject-the victim of such a deformity usually, in fact, dying within a few hours or days after birth. But anatomists will remember that, exactly at the spot where the opening exists in this case, there is, normally, a deficiency of the muscular fibres of the diaphragm, leaving a small, inter-muscular, triangular space between those of its fibres attached to the ensiform cartilage and those attached to the seventh costal cartilage. This space is, consequently, weak, and weak exactly in the way most predisponent to the occurrence of a hernia.* I think there can be little doubt that this affords us the true interpretation of the lesion before us.

Other cases of the occurrence of a hernia, through some one or other of the normal openings in the diaphragm, have been recorded-for example, I may instance a case given by Mr. J. D. Hill, in which such a protrusion occurred through the oesophageal opening (Med. Times and Ga.,

a There exist the widest differences, in different subjects, in the extent and arrangement of the attachments of the diaphragm in this situation. In some these intermuscular triangles at each side of the middle line are of considerable size; in others they can be scarcely said to exist. Moreover, they are often unsymmetrical; and I have satisfied myself, from repeated observation, that, as a rule, that on the left side is generally the larger of the two.

1869, Vol. II., p. 670); but I have not been able to discover any previously recorded case in which the site of the hernia was the opening here referred to; and, in fact, the only writer I am acquainted with who makes any allusion to such a possibility is the late Professor Harrison.

A specialty of this particular variety of diaphragmatic hernia, it appears to me worthy to be kept in mind, is the fact that the protrusion here occurs into the mediastinum, and not, as in the more common forms, into the pleural cavity, as such a condition would, presumably, lead to a very special class of symptoms and physical signs during life; and this case shows it to be a condition compatible with very prolonged life and apparent good health.

In consideration of the peculiarities of this individual case, it might be a question whether the long-standing existence of extreme spinal curvature low down, and the consequently longitudinal shortening of the abdomen, may not have predisposed to the occurrence of the hernia. It is conceivable that such a condition may have produced an exaggerated degree of upward pressure of the abdominal contents.-Feb. 9, 1878.

Occlusion of the Superior Vena Cava.-DR. BENNETT read the following communication from DR. WILLIAMS of Liverpool :

"Maria Davies, aged twenty-seven, married, childless, came under observation at the Chest Hospital, in 1875, as an out-patient, under the care of Dr. Sainuels, and continued attending at intervals till her death. She complained of great difficulty of breathing, especially on exertion, and stated that this symptom, with swelling of face and chest, came on after an attack of rheumatic fever eight years before. She had also great giddiness, and, when stooping, would frequently fall down in what was supposed to be a fit. In appearance she was stout and florid, rather dusky looking; breathing slow and laboured, with laryngeal stridor; the least exertion increased the dyspnoea; lips bluish; pulse 30, sometimes only 25, never over 38. On examining the surface of the chest, remarkably enlarged and tortuous vessels at once attracted attention, the cutaneous veins being as large as the index finger. It was now noticed that the swelling was confined to the face and thorax, while both arms were free from swelling, also that the veins were somewhat larger on the right than on the left side. The only abnormal sign detected by the stethoscope was a loud basic systolic bruit, heard most distinctly a little to the right of the sternum on a level with the fourth intercostal space. There was no dysphagia. On the 1st October, while removing her furniture, she stooped, had a fit, and died in a few minutes. Post mortem, made eighteen hours after death.-Rigor mortis well marked, face, eyelids, ears, &c., all blackish-blue. Considerable bleeding occurred when the skin was cut, and a large quantity of blood continued to flow during the autopsy. Encircling the vessels, at apex of thorax,

was a mass of indurated areolar tissue, and some enlarged glands, but no tumour, aneurismal or otherwise; through this indurated tissue the superior vena cava felt like a firm cord, and with the finger could be traced to the innominate veins, which also felt indurated. Lungs healthy, but old pleuritic adhesions on the right side. Liver much enlarged. On removing the heart the superior cava and innominate veins were found to be completely obliterated, having contracted into strong impervious cords, the cut ends showing a smooth surface, without trace of an opening. The mitral and tricuspid valves were healthy, but the auricular septum was, to a great extent, ossified, and feeling quite hard when tapped. This has, to a great extent, disappeared since the preparation has been in spirit. Right auricle rather thickened; no vestige of an opening into it from vena cava superior could be found, the internal aspect of that portion of the auricle presenting a smooth polished surface. Permission could not be obtained to examine any

other organs."

This woman, Dr. Bennett said, was seen by several medical men, and the nearest approach that any of them could make to an accurate diagnosis was that she suffered from partial obstruction of the superior vena cava. The heart now exhibited was in spirit for some time, and is in consequence discoloured and deformed from the way in which it lay; otherwise it is a fair specimen of a heart for an individual of the age recorded-twenty-seven. There is no apparent hypertrophy or atrophy, or any material deviation from the normal structure. In the right auricle what should be the entrance to the vena cava is occluded, the openings of the inferior vena cava and coronary vein being normal; where the superior opening should be there is a depression, but nothing more. On the endocardium two or three stripes of lymph and false membrane are to be seen, adherent on the surface, showing that the opening was in all probability occluded by inflammatory action. On the outer side of the vena cava, and as far as the bifurcation of the innominate veins, a mass of indurated tissue includes the cord-like remains of the cava, as the author states. In the other chambers of the heart there is nothing remarkable. The left auricle is quite normal. In the septum is a considerable quantity of calcareous matter, which rings when struck. It is not easily seen, but can readily be felt, and the sound is very distinct. It is clear from the condition of the parts that an attack of inflammation, starting probably, as described, in the mass of areolar tissue round the glands, at the top of the mediastinum, occluded the veins, and, at the same time, involved the tissue of the heart about the auricular septum. The only other point is, that the extreme slowness of the pulse suggested to me that, as the author had not made an examination of the tissues of the heart, I should make a microscopic examination of the tissues. I accordingly examined a piece from the carnes columnæ, and I do not

think I ever saw healthier fibre. There was no trace of fatty degeneration, nor any change, as far as the microscope could show, which could explain the slowness of the cardiac action. I was also struck with the fact, on examining the case, that the site of the inflammatory action which dated eight years before the woman's death, when she was somewhere about nineteen or twenty years of age, and the whole of the inflammatory induration, was situated round the nerve centre at the base of the heart and the pneumogastric nerves. Those nerves have not been preserved, but there is enough to show that the cardiac plexuses would have been considerably involved in the matter. Whether these may afford any explanation of the slow pulse or not I cannot say.

DR. LITTLE.-A remarkable point in the case is the extremely small size of both auricles, and the evidences of intense inflammation existing at the base of the heart.

DR. HARVEY asked are the pulmonary veins all right?

DR. BENNETT.-They are. I should have mentioned that the vena azygos must have been occluded, although it is not mentioned in the communication.

DR. HARVEY said the slowness of the pulse is the most interesting point in the whole case. I am very doubtful as to whether it can be accounted for by any nervous lesion. If it be supposed that there was a nervous lesion affecting the ganglia at the base of the heart, the results would have been much more serious than followed in this case. If it were a lesion of any branch of the pneumogastric nerve it would have the effect of accelerating the heart, or it could only act by slowing the heart as an irritant. I can hardly imagine an irritant arising from such a source and so continuously acting. It may be accounted for better by a lessening of the endocardial pressure on the auricular walls from the slow return of the blood.-February 9, 1878.

Fracture of the Shaft of the Femur, with Inversion of the Lower Fragments.-DR. BENNETT said: The specimen now submitted is one which I obtained some time ago, fortunately with the history of the case during life. Perhaps few museums contain specimens of a femur more deformed by fracture than this is. Again, it presents the remarkable peculiarity of complete osseous ankylosis of the knee, both as respects the tibia and the patella, while the fibula is not ankylosed. The characters of the ankylosis are those resulting from disease and not from injury. The tibia is sub-luxated backwards, and has rotated, perhaps, a fifth of its circumference outwards, while the patella is ankylosed to the outer condyle. In the shaft of the femur two fractures have occurred, and are united with these very remarkable features. Both fractures are characterised by the exceptional features of inversion of the lower fragments. If I place the head of the femur in normal relation to the pelvis the

F

central fragment is seen to be inverted, while again the lower fragment is inverted upon the central-so that if the head of the bone be in a normal direction, the leg bent at an angle on the thigh would be placed at right angles to the mesial plane of the body. The history of the case shows how cautious one should be in expressing an opinion as to the history of an accident deduced from a mere examination of post mortem specimens. Almost every one that has seen this up to the present has been inclined to say that the bone presents evidences that the fracture never could have been treated by any respectable surgeon; and again, most men who have examined the specimen have been apt to attribute the destructive disease of the knee-joint to the injury which fractured the bone. The patient was an old man, who was admitted to the hospital with malignant disease of the abdomen and stomach, which was proceeding very rapidly to a fatal issue. I took the opportunity on seeing his crippled limb to investigate his history very carefully with reference to it. In early life, when he was about sixteen or seventeen years of age, he suffered from destructive disease of the knee-joint. He was not very definite as to the cause, but he gave the ordinary history of destructive disease of the knee-joint, which laid him up for many years. When he began to go abont, he was strongly addicted to drink; and on two occasions-one of them not very remote from the time of his death, when he was somewhere near seventy years of age-he got falls while drunk, by which, among other injuries, the fractures were produced. On both of those occasions it was the stiff ankylosed knee that determined the nature of the fracture. He was on one occasion treated by a surgeon of some eminence in his own house, and on another by a surgeon of one of the leading hospitals; so that this extreme deformity occurred while the case was under recognised efficient treatment. But anyone who has treated a fracture of the femur, happening under the condition of an ankylosed knee, will not wonder at the extreme deformity. I have treated two of them, and both were nearly as crooked as this. In addition to the case being a curiosity as exhibiting remarkable inversions in the two fractures, it shows how guarded our inferences should be as to the antecedents of such a deformity. One of the fractures occurred about fifteen or twenty years ago, and the other seven or eight years ago. I should have mentioned that the bone is remarkably heavy and strong, and free from any sign of malignant disease. From an old man of that age it is a remarkably heavy dense femur, and not in the least greasy.-February 16, 1878.

Carcinoma of Liver.—DR. J. W. MOORE said: This specimen of carcinoma of the liver was removed from the body of a woman whose age was stated to be forty, but who was apparently older, and who died at the Meath Hospital yesterday morning. There are some very interesting