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pushing back the muscles at the posterior part. Over the inner Isurface of the cavity thus formed of the muscles and surroundingparts, there R as an effusion of soft lymph; one pint of fluid stillremained in the cyst. The lower end of the femur presented thefollowing appearance:-The inner condyle, with the lower partof the bone attached to it, was destroyed for three or four inchesup from the cartilage covering the inner condyle, the destructionpassing also slightly outside the median line, and anteriorly moreexternally, where it was partially destroyed from the cartilage ofthe outer condyle. It presented a complete excavation, no bonymatter being left. The inner cartilage was entire, although ithad lost the whole of its osseous attachment, being still connectedto the synovial membrane. The outer cartilage was also entire.The attachment of one crucial ligament was destroyed, a smallhealthy scale of bone being separated with it; the synovial mem-brane was perfectly healthy.

In the situation of the inner condyle, and attached to the pos-terior part of the inner cartilage and surrounding parts, but lyingloose for the most part, and unconnected, and passing over theanterior part of the femur, was a mass which would have aboutfilled a pint measure. Its structure was fibrinous, mixed withcoagula; the fibrinous part was moderately consistent, and of theusual buff colour; in the interior of the mass were some irregu-larly formed cells, or small cysts, containing fluid. The massappeared to have laid over, and in the hollow of the bone, buthad no attachment at all to it. In the hollow was a smallquantity of unattached flaky caseous matter, soft, and resemblingmedulla. The section of the mass presented no appearance ofmedullary deposit, nor of the usual septa, but that of a fibrinousmass of a cellular character, with a few irregular cysts andcoagula. The bone being sawn longitudinally, was found quitehealthy down to the very margin of the excavated portion, withmo appearance of medullary deposit. The periosteum had de-posited some osseous matter, apparently from the irritntion it had

Ibeen exposed to from the fluid passing over it. The glands inthe groin were not enlarged, and all the thoracic and abdominalorgans were sound, though ansemic in appearance.

- Remark.—When we look over the symptoms of this case, andthe post-mortem appearances, and compare them with the ordi-nary diseases of the joints or bones, we shall find that it does notcoincide with any of them, and, in our opinion, from a considera-tion of its character, it’was not a case of medullary disease, nor,indeed, of any of those forms of disease called malignant. Thepeculiar mass and secretion, the destruction of the bone withoutthe cartilage, and the absence of the secretion of pus, distinguishit from the ravages of mere inflammation, or the consequencesof tubercular deposit; and as to its diagnosis from medullarydisease, we may remark, 1st, the mass itself, as already stated,did not present any appearance of medullary disease. Theessential character of scirrhoma, or cephaloma, consists in apeculiar deposit; in scirrhus, contained between dense ligamentousbands, and in medullary disease, generally contained in mem-branous septa. In the case before us, nothing analogous to this ’,structure was found; it was evidently a mere fibrinous mass; ’’,the only appearance of soft matter were the soft caseous flakesin the hollow of the bone, not, however, regularly deposited, andquite unattached ; nor did the margin of the bone present anyindication of its having been destroyed from the breaking downof medullary deposit in its texture. 2ndly. Another strongfeature in malignant disease is its tendency to spread to all thestructures around; thus, if it arises near the breast, the glands,the muscles, the mamma itself, the surrounding cellular tissueand the skin, soon become involved, and more rapidly in themedullary form. This case presented no such tendency; therewas no aifection of the glands, the bone was eound, and the car-tilagg and synovial membrane which were in contact with it werequite healthy, as were also the muscles and skin, except in thefact of their being much distended. We do not put any stressupon the fact of cartilage not being destroyed, as it also resiststhe ravages of other disease, even malignant, much longer thanosseous and other structures. The point most important is, thatall the surrounding parts were sound in their texture. 3rdly.The large quantity and peculiar character of the fluid, whichpresented no appearance of the deposit, and consisted of fibrineand a small quantity of blood globules, differs from the pheno-mena of malignant disease. Lastly. Another strong proof ofits non-malignancy exists in the fact, that all the thoracic andabdominal organs were healthy. If we remember that the onlyform of malignant disease we can at all compare with this is themedullary, and that in this form it is doubtful whether the ex-ternal structures are ever affected without the internal beingpreviously diseased, it throws great doubt on any case not pre-senting in itself the clearest evidence of malignancy. In thiscase, where the mass did not present any appearance of deposit,

it, to our minds, fully proves its non-malignancy. Neither didthe patient’s countenance (though exceedingly ansemic) presentthe usual sallow, wan appearance so constant in these cases; and,let it be remembered, the disease had existed at least four months,and went to the extent of destroying the patient’s life.

It is far more easy to point out what this disease was not, thanto give any just idea as to its real nature; the subject, however,deserves a few words. It would appear that the morbidgrowth did not arise from the interior of the bone, and destroy it,from having been deposited in its place. If this had been thecase, there would, in all probability, have been osseous spiculeadiffused through the mass, the remains of the bone, fragmentswhich had been separated by the growth of the deposit. It ismore probable that the bone was absorbed in consequence of thegrowth springing up in its vicinity, and gradually pressing uponit, or rather, upon its nourishing vessels, and in this way leadingto the production of an excavation. In a case which occurredsome time since in the hospital, which in a great measure resembledthis, the growth had originated in the bone itself, its lower partbeing much expanded, and converted into cysts which werein a great measure osseous, and filled with fluid. The resem-blance in the case before us between the mass and the fluid intheir constituent parts is worthy of notice.A structure which possesses no very peculiar properties, but

arranged as a cyst, will secrete a great variety of matters, andincrease greatly in size. We may therefore justly believe,thata mass of fibrinous structure, having from some unknown causethe power of forming cysts communicated to it, or one cyst withthe power of developing others, will increase to a large size,secrete enormously, and cause great irritation. It is most pro-bable, from the attachment of the mass, that it originated fromthe cartilage, or in its vicinity. We cannot think that the jointsecreted a fluid so different from its usual products under-dis-eased action, neither did it present any alteration in its structureto substanti ate the idea, and th erefore conclude that the mass itself,and possibly the lining membrane of the large cavity, secretedthe fluid. The disease appears to have had a local origin, andif amputation had been permitted, would, in all probability, nothave been followed by its return.Victoria-place, Limehouse, Jan. 1845.

ON ANÆMIA, OCCASIONING DEATH.By JOHN T. PEARCE, Esq. Surgeon, St. Austell.

Case.-Anaemia; murmur with the first sound of the heart venous murmur;probable corabgulation of the blood in the sinuses of the brain, and depositofJibrine; carus; and death.

A. Hņņ, aged nineteen, of lymphatic temperament, and faircomplexion, servant of all work, an occupation she has followedfor several years, with occasional interruptions from illness. Shewas unmarried, of very quiet habits, and regular mode of lifeHer food and clothing were ample, and of good quality.Habitually she was rather cheerful, and had received no mentalshock previous to her present illness. She has generally lived insmall towns, occasionally in the country. Her last residence issituated low, but is not damp or confined. Her father and onebrother died of phthisis; her mother is still living and healthy.She has been for several years the subject of anaemia, for whichI have treated her successfully, on two or three different occasions,with the preparations of iron. About eighteen months since, shehad congestion of the liver. I could never detect any tubersculous disease of the lungs; there was no preternatural dulnesson percussion, or bronchial respiration, &c., over those parts inwhich we find them in the early stages of phthisis.

She had been complaining of a sinking weakness in herstomach, and intense coldness of the feet and legs, several daysprior to Tuesday, Feb. 4th, on which day she complained morethan usual of her stomach, but considered the cause might arisefrom the medicine she had taken on the previous evening; shedid her work as usual, and attended chapel. On Wednesdaymorning, she had pain in her head; this became better, and shecommenced her work, but she was obliged to return to bed,saying she felt sick, and thought she should be better if she couldthrow up. About mid-day she came down and took some teaand biscuit, after which she vomited twice. After this she re-tired again to bed, where she remained three hours. Aboutseven P.m. she again had tea and biscuit, and soon after becamesick; the vomiting continued at intervals until seven o’clock thefollowing morning. When seen by her mistress, about half-pastseven A.M., she was sitting up in bed, looking like a madperson," throwing about her hands and legs, and when spoken to,began to scream. The convulsive movements continued tillabout mid-day, when she became perfectly quiet and insensible.

She had been in the habit of taking pills, which she procured

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from a druggist, who stated their composition to be as follows:-Sulphate of iron aloes, and myrrh pill, extract of gentian, powderof aloes, and cinnamon ; divide into pills. She took three ofthese pills on Monday evening. Previous to my arrival, a littlebrandy and water was administered.

I arrived at the house on Thursday, about half past twelve P.M.,when I found her lying on her back, perfectly insensible; thesurface of the body was natural in temperature, but blanched ;the feet and legs were cold and oedematous. Habitually her in-tellect was good; she had a deathly expression of countenance;no delirium; temperature of the head natural; cheeks and lipsvery pale; pupils very much dilated, and insensible to light.There was no tenderness or deformity of the spine. The respi-ration was perfectly tranquil, twenty-two inspirations in a minute.She had had no cough or pain in the chest. Physical signs;-The sounds elicited, on percussion, were perfectly healthy, andno bronchial respiration or râles could be detected by the stetho-scope. Violent palpitations were always produced by much exer-tion, but she was never subject to syncope. The impulse of theheart was felt over a larger space than natural. The first soundof the heart was accompanied by the bruit de souffiet, which washeard most distinctly at the base of the heart, and could be tracedalong the course of the great vessels to the neck. Pulse 100,easily compressible. The carotids were beating violently; bruitde diable heard in the jugular veins.The mouth was firmly closed, but with some difficulty I opened

it with a spoon, and gave her some brandy and water, which sheswallowed. Tongue white and flabby; she had not complained ’iof thirst, or any burning in the mouth or throat; the vomiting ’,had ceased several hours. The abdomen was natural in size;she did not move when pressed over the different regions ; hadnot complained of tormina or diarrhoea; bowels confined.By percussion, the liver was found to extend from the fourth ribto the borders of the ribs- below, and a little beyond the ensiformcartilage. There appeared to be a large quantity of bile withthe vomited matter. I could obtain no urine, as it- passed in-voluntarily.She first began to menstruate at the age of sixteen. The

catamenia appeared at very irregular periods, was always pale,and small in quantity. She had not menstruated for two monthsprevious to her present illness. There was no areola of thebreasts.

Ordered:-Stimulants, consisting of ammonia, brandy, &c., tobe given frequently ; a turpentine enema to be administeredimmediately; six leeches to be applied behind the ears; andcataplasms to the feet.The leeches bled freely; no redness produced by the cata-

plasms. The enema produced no effect by seven P.M., I there-fore ordered it to be repeated; the second operated by ten P.M.No change occurred till twelve P.M., when a 11 gargouillement"came on in her throat, which continued until half-past four P.M.,Friday, 7th, when death put an end to her existence.Remarks.-My first impression, on seeing this patient, and

learning the above details, was, that she laboured under theeffects of a narcotic poison; but as I could obtain no collateralevidence from the friends to support my supposition, and know-ing, from the dilated pupil, that it could not be the one generallyresorted to--opium, I had to seek another cause for the symptoms,and to guide me in my treatment.

Let us, first, consider the disease under which the patient hadfor a long period laboured; and in doing this, we will subdivideit into the general symptoms and those derived from physicalexamination.

Secondly, Whether that disease was sufficient to produce thesymptoms, and cause death.During two years, at least, this patient presented a well-marked

case of anaemia ; the general languor of the body, and pallid sur-face. The visible portions of the mucous membranes, as on thelips, gums, &c., instead of presenting that florid red colour, as inhealth, were pinkish; the tongue was flabby, and indented withthe teeth; the coldness of the extremities, and deranged secre-tions, more particularly of the catamenia, which was always paleand scanty, at once evinced that state of the body where there isa scanty supply of blood and an impoverished state of that whichremained.The only abnormal sounds ever detected by physical examina-tion were, a murmur with the first sound of the heart, and avenous murmur in the neck. The cardiac murmur was heardMost distinctly at the base of the heart, and could be traced alongthe course of the great vessels of the neck, from which we shouldinfer that it was produced by the aortic valves, or some obstruc-tion at the mouth of the aorta; for the only other disease whichproduces a murmur synchronous with the first sound of the heartJL.&. of the left side, to which we confine our attention) is regur-

gitant mitral, and when that exists alone, the murmur is heardmost distinct at the apex, and not in the carotids.Was this sound produced by disease of the aortic valves ; from

the thin state of the blood; or both conjointly? In a previousillness, the murmur entirely disappeared, when the fluids wererestored to their natural density by the administration of iron,&c. ; from this we should refer the production of the murmur tothe ansemic state of the blood; but if anaemia were the sole causeof it, this should be considered as an essential symptom of thatdisease ; whereas we find it varying much in well-marked cases,being inaudible in some, scarcely audible in others, whilst it isloud and harsh in others; consequently it must be dependent, inpart, on some narrowing or slight irregularity at the mouth of theaorta, which, when the blood is of due consistence and in suffi-cient quantity, is too slight to produce obstruction or sound, butwhen combined with an ansemic state of the blood, which is moreeasily thrown into vibrations, produces the murmur. The venousmurmur heard in the neck is also dependent on the same state ofthe blood, running with great rapidity in the partially-fllled ves-sels, being so easily thrown into sonorous vibrations.Was the disease above described sufficient to produce the

symptoms and death? I remember Dr. C. J. B. Williams(whose works have immortalized his name) impressing on theminds of his students, that in anaemia the excito-motorysystem might be excited in the midst of weakness and generaldepression, so as to affect the organic functions, and hencemay follow vomiting and other sympathetic irritations. In hiswork on the Principles of Medicine," he offers a beautifulexplanation for this derangement of the nervous system-viz.,the vessels of the body contract so as to adapt themselves tothe diminished quantity of blood sent into them, but those

supplying the nervous centres not being exposed to atmosphericpressure, and some of them being fixed in bony canals, cannotcontract to the same extent; hence they receive more than theirdue proportion of blood-congestion takes place, and if this beaccompanied by such feebleness of the heart’s action as to renderit inadequate to send on the accumulated blood, stagnation follows,and in extreme cases, produces permanent obstruction to thepassage of the blood through the vessels of the brain-hencearises coma. Dr. Williams has met with three cases where coma,dilated pupils, and most of the other symptoms detailed in thisease, were produced. In the post-mortem examination, he found,in the torcular herophili more especially, the coagulum blockingup the whole sinus, and exhibiting a separation of fibrine. Inthis case a coroner’s inquest was held, but I regret to state thatno post-mortem was ordered by the coroner, nor could be obtainedfrom the.friends. In taking the above view of the case, we mayconclude that the ansemia was the cause of the symptoms anddeath.

In this patient there was an absence of most of the causeswhich produce anaemia, such as loss of blood, profuse evacuations,scanty or poor food, impure air, organic disease, &c.; but infemales those causes are so frequently combined with scanty andpale secretion of the menses, that we naturally conclude that theyoperate as cause and effect; but as the secretions generally areimpaired in anaemia, we should anticipate that the uterine func-tions would also be deranged; in fact, we should expect thatNature, finding herself below par, would endeavour to maintainthe blood in as healthy a condition as possible, to support thosefunctions most essential to the existence of the individual, andwould therefore first curtail the secretion of the menstrual fluid,which probably serves merely for the perpetuation of thespecies.

Yet we must not infer that ansemia is the cause of amenorrhoea,for we often find that after a sudden cessation of the catemeniafrom cold, over exertion, or mental emotion, when it does notreturn, that the patient loses colour and becomes ansemic ; there-fore, instead of being the effect, it is sometimes the apparentcause of anaemia. But is it not most probable that they are boththe effects of one common cause-viz., the blood-making process?I believe it to be so; although whilst that process continues soobscure in its nature and seat, we must remain in doubt.

Ansemia has generally a favourable issue when the propertreatment is adopted, if it be not connected with, or dependent on,any organic disease; but in extreme cases it may prove fatal

suddenly, by any additional cause of exertion producing syncope ;by the affection of the head noticed in this case, or more slowly,by developing tubercles where there is a predisposition to theirformation.The treatment best adapted to restore the depraved system of

the blood is nutritious diet, pure air, and tonics. Of the latterclass, the preparations of iron are unquestionably the best, whenthey can be borne; but in some instances it is necessary to com-mence with some mild vegetable tonic, such as cascarilla, which

644I have often found very beneficial. In this case, however, wehad to apply means to relieve the immediate symptoms; and inconsultation with my brother, we determined on relieving thecongestion of the head by the application of leeches, whilst weendeavoured to stimulate the body by brandy, ammonia, &c.March 5th, 1845.

MALFORMATIONS OCCURRING IN A CHILD.

By F. ROBINSON, Esq. Newcastle-on Tyne.DANIEL C-, aged nine months, a stout, healthy-looking child,was admitted into the infirmary, under the care of Sir John Fife,with a short vascular tube projecting from the umbilicus, aboutthree-quarters of an inch in length, and the same in circumference.It is round, of an oblong shape and deep-red colour, and presentsa moist, shining appearance. It emerges from the lower half ofthe umbilicus, which presents the usual appearance, and the baseof the mass is much constricted, so as to give it somewhat theresemblance of a knuckle of intestine, where the strangulation hasbeen recent; on looking at it, however, more closely, it is seen todiffer from the latter, in presenting a granular appearance, and onbeing handled it feels flaccid. The tube is also slight, constrictedin the middle, and at the apex there is a small orifice, from which,on a probe being introduced, it passes in a direction, directlydownwards and forwards, towards the pubis; and from the limitedmotion that could be used with the probe laterally, the instru-ment seems to be contained in a prolongation of the tube.The latter is constantly covered on its whole surface with an

exudation of thin fluid, devoid of odour or colour, and a constantoozing of fluid of the same character proceeds from the orificeat the apex. The mass hangs pendulous towards the right sideof the abdomen, when the child is quiet, giving the tube ratherthe appearance of being slightly twisted; but when the child usesany exertion in which the abdominal wall is contracted, the massincreases slightly in size and becomes of a much darker hue, ren-dered very apparent each time that the child alternately con-tracts and relaxes the abdominal muscles in crying; and at suchperiod, instead of hanging pendulous, it projects straight out, in a idirection rather upwards. !The boy is stout, has been always healthy since its birth, has

never had any cough, diarrhoea, vomiting, or any affection likelyto cause relaxation of the abdominal muscles. He appears tosuffer no inconvenience from the tumour, and does not cry whenit is handled, but slight pressure at its base is sufficient to cause itto bleed round the apex, but not from the orifice itself. Nothingabnormal can be detected by examining the abdomen.The mother states, that the ligature which was placed round

the umbilical cord came off in nine days’ time, and that a smallround tumour, of the same appearance as at the present time,remained projecting from the abdomen, and evidently formingthe divided extremity of the cord itself. This tumour could bereadily reduced into the abdominal cavity by using slight pres-sure with the finger, but it soon became so constricted at thepoint of exit from the abdomen, as to render its reduction at firstdifficult, and afterwards wholly impracticable. No bleeding ordischarge ensued when the ligature dropped off, but about threedays after a small quantity of thin feeeal matter was dischargedfrom the orifice at the extremity of the tube, which was then firstnoticed. This continued, at first, every day, then every two orthree days, and finally ceased altogether at the end of three monthsfrom the birth of the child.The period when the faecal matter escaped was invariably the

same as when the child had an evacuation per anum. When thedischarge of fseces from the tube ceased, the exudation of thecolourless fluid from its surface and orifice commenced, and hascontinued ever since, becoming, however, rather less in quantitylatterly. The fluid never resembled urine either in colour orodour, and the child never had any symptoms of suppression ofurine, or any affection of the bladder. Ever since its existence,the tumour has shown a disposition to bleed when handledroughly, but not otherwise. It has gradually increased in size upto the present time. Bowels generally opened regularly, andmotions of natural appearance and consistence; has had variousemollient applications to the part, and has latterly been poulticingit, without, however, causing any diminution in size. !On the morning of the 25th, Sir John Fife determined to

remove the mass, and commenced the operation by passing aligature tightly round the base of the tumour, close to the abdo-men ; this immediately caused it to turn to a purple hue, and toexude blood at the apex. It was then excised close below theligature, and the latter not having exerted sufficient pressure, astrong jet of arterial blood proceeded from the inside of the ex.tremity of the divided tube. This was immediately suppressedby the application of a second ligature, after a very small quantity

of blood had escaped. A piece of wet lint, compress, and band-age, were then applied, and the child sent to bed. It did notappear to be at all affected by the operation.On examining the tumour after its removal, it was found to be

a tube capable of containing a quill in its cavity, and formed of astrong fibrous coat internally, lined by a thin membrane, andcovered over by skin externally, a good deal of loose cellulartissue separating the two tissues. The fihres were all arrangedlongitudinally, with the exception of a few scattered ones- thatpassed transversely across. Numerous small vessels were observed,running up to the apex of the tube, among the cellular tissue. Afew minutes’ maceration in tepid water rendered it quite colour-less.The mother took the child away after the operation, but re-

turned in five days’ time with it, when it was found that the partwas almost well. The ligature had dropped off, and the portionof tube behind it had retracted to a level with the umbilicus, andhad quite cicatrized, except a very minute space. The child wasin good health, and had been so since the operation.Much difference of opinion existed regarding the nature of the

malformation. It would seem to be a portion of the umbilicalcord, which, instead of withering and dropping off, becameorganized, but whether it communicated with any of the viscera,or terminated in a cul de sac, of course could not be determinedsatisfactorily.

Setting aside the latter hypothesis, the principal doubt existingwas, whether the tube communicated with the intestine, formed aportion of it, or was continued down in the cavity of the abdo-men to the bladder, forming an abnormal connexion with thelatter, and possibly communicating with the intestinal canal, atthe time of birth, and for a period after. The latter appearedthe more probable of the two hypotheses, as, first, its directionwas in favour of that opinion; secondly, as the bladder of achild in the healthy state is known never to contain a large quan-tity of urine at a time, that viscus being instinctively emptied ofits contents when but a small quantity is contained in it; thisfact, together with the opposition afforded by gravity, wouldaccount for little or no urine being discharged by the tube, and ifany, it would probably be evacuated when the child was in thehorizontal posture, and perhaps asleep, and therefore it wouldbe liable to escape the notice of the mother, especially as suchapplications as ointments or poultices were pretty constantly ap.plied. Lastly, the exudation of fluid, which kept the part con-stantly moistened, might be accounted for by effusion of serum ofthe blood arising from the obstruction to the circulation in theextremity of the tube, which manifestly existed.With regard to the supposition of the tube forming a portion

of and terminating in the intestine, this, though at first consider-ation the most probable, is yet unlikely, from the straight direc-tion of the tube ; while the composition of its coats seem atleast to prove that it did not form any part of the intestinalcanal. Certainly, the force of gravity and the consistence offseces might hinder the escape of any, but purgation, when used,had no effect in causing this. -

Perhaps the most probable theory is, that the tube may be acontinuation of the hypogastric artery, terminating in a cul desac, and differing from the general rule in course or origin, orboth. In support of this opinion the history seems to prove-ifwhat the mother says can be relied on-that the tube was evi-dently a portion of the umbilical cord, and if so, the former ismost likely the remains of the artery only, partially obliterated;and instead of dropping off, continuing organized, and coveredwith a prolongation of skin, from the margins of the umbilicustThe little disturbance of the general health, and the perfect per-formance of the functions of the digestive and urinary apparatusseem to be also in favour of the latter opinion, as well as the rapidcure effected by the operation.March2nd, !8i5.

CASE OF ACUTE LARYNGITIS.By WALTER CHAPMAN, Esq. Surgeon, Norwood, Middlesex.

TRACHEOTOMY.-RECOVERY.

ON Wednesday, the 19th of last February, at ten o’clock P.M., iwas summoned to attend Mrs. M-, residing in this neighbour-hood. My patient was thirty-one years of age, the mother of fivechildren, and was attended by me in her last confinement, aboutten months since. Mrs. M- was an extremely thin, spareperson, possessing but little physical power, and addicted (as Ihave been informed) to gin-drinking, which, however, she deniedShe has generally enjoyed good health, and was suckling herinfant when she became the subject of the present attack. Thefollowing is the substance of her own account of it:-She was inher usual state of health when she retired to rest on Tuesday, the