last, such a quantity of intestine escaped through the opening, that the unfortunate man was unable to return it; the surgeon who was called in was equally unfortunate. In this state the poor man came to Paris, and immediately sought relief at the Hôtel-Dieu. The following was the appearance of the parts on his reception into the hospital:-A tumour as large as a double fist, and lined with injected mucous membrane, occupied the whole of the right inguinal region; the vermicular motion of the intestines was manifest over its surface; at the inner and upper part was seen an opening of an elongated shape; a great quantity of liquid fæcal matter was discharged through this opening; no evacuation took place through the anus, and the patient was extremely reduced in flesh.

After careful and long-continued pressure for more than a quarter of an hour, the everted mass of intestine was returned to the cavity of the abdomen; this consisted of the ascending colon, the lower portion of the ileum, and a part of the cœcum. The opening in the abdominal parietes was now found to be nearly circular, and of a diameter of an inch and a quarter; a strong compress and bandage were applied to prevent a fresh escape of the intestine. This was attended with very considerable success; the fæces were no longer discharged through the abnormal opening, but although mechanical means were employed the size of the opening could not be sufficiently reduced to lead to the hope of a final cure. M. Blandin therefore determined on refreshing the edges of the wound, and uniting them by suture; this was done on two several occasions, but failed; a portion of integument was then dissected off from the neighbouring parts and laid over the artificial opening, but united along an exposed surface at a little distance from the edges.

On the fourth day the flap was found to be united all round the wound, except at the upper part. After the lapse of fifteen days this upper edge, and the corresponding border of the flap were again refreshed, and united by a few more points of suture: this was successful; the fissure united, and one or two minute openings readily closed on being touched with the nitrate of silver.-Bul. de l'Acad. de Médecine.1

Indications of Tracheotomy.-At the end of a memoir in the Archives Générales de Médecine, on the Indications of Tracheotomy, by M. Barth, we find the following conclusions:

First. The respiratory vesicular murmur may be either diminished, or entirely suppressed on both sides of the chest, by any lesion which is capable of reducing the calibre of the air passages, at their upper part, in a considerable degree. This arises either because the passage of the air into the bronchi is impeded, or because it arrives merely at the superficial portion of the lung.

The lesions alluded to may occupy different points of the larynx and trachea, but they are most commonly situate near the glottis. They act either by contracting or by blocking up the cavity of the air-tube. As examples, we may cite syphilitic vegetations; various sorts of tumour; tuberculous ulcerations with prominent edges, and accompanied by thickening of the submucous tissue; oedematous tumefaction of the amygdala. Under the same head we may also, with probability, range polypi of the nasal fossæ, which project into the pharynx; polypi of the trachea; foreign bodies in the air passages; and tumours compressing the trachea.

The knowledge of this fact is of great utility in the diagnosis and treatment of certain affections of the respiratory organs. Thus, as the existence of several of these affections cannot be determined by the sight or touch, they might be confounded with pulmonary emphysema; an error which might induce the medical attendant to abandon his patient to his fate, while

1 Lancet, Sept. 1, 1838, p. 816.

a more accurate diagnosis would enable him to rescue him, by the performance of tracheotomy, from certain death.

On the other hand, the persistence or absence of the vesicular murmur enables us to distinguish spasmodic suffocation from that produced by oedema, or any other physical obstacle, and thus to avoid the unnecessary performance of a dangerous operation.

In cases where a foreign body has fallen into the air passages, the same fact permits us to determine its position in the trachea, or in either of the bronchial tubes, according as the respiratory murmur may be absent throughout the whole of the chest, or at one side only.

Finally, in cases of croup, the diminution of the respiratory murmur may perhaps enable us to determine whether the false membranes are confined to the larynx, or extend thence into the bronchi.

Second. The degree of diminution of the respiratory murmur furnishes the measure of the obstacle. This also is an important fact towards determining the prognosis and treatment of affections of the respiratory system.

In some cases, which are in appearance very dangerous, as in those of angina, attended with false membrane, the more or less complete presence of the respiratory murmur will indicate the degree of danger to be trifling, while, on the contrary, its absence denotes that the chances of recovery are much diminished.1

Medical Dictionary.-Messrs. Lea & Blanchard have in the press a second edition of Dr. Dunglison's Medical Dictionary, in one volume,

octavo.

BOOKS RECEIVED.

From the Author.-An Essay on Scarlatina. By James Conquest Cross, M. D., Professor of the Institutes of Medicine and Medical Jurisprudence in the Medical Department of Transylvania University. 8vo, pp. 48. Lexington, Ky., 1838. [A good paper.]

Annual Circular of the Washington Medical College of Baltimore, July, 1838. 8vo, pp. 16. Baltimore, 1838. [Containing a list of the students who have attended the school since its commencement.]

From the Author.-Elements of Medical Jurisprudence. By Theodoric Romeyn Beck, M. D. Professor of Materia Medica and Medical Jurisprudence in the College of Physicians and Surgeons of the Western District of the State of New York, &c. &c., and John B. Beck, M. D., Professor of Materia Medica and Medical Jurisprudence in the College of Physicians and Surgeons, New York, one of the Physicians to the New York Hospital, &c. &c. 6th edit. 2 vols., 8vo, pp. 670 and 743. Philad., 1838.

From the Author.-On the Influence of Caloric on the Living Animal Body. By Robert Peter, M. D., Professor of Chemistry and Pharmacy in Transylvania University. 8vo, pp. 22.

[The clinical lectures of Dr. Graves, Dr. Peter will find, were published in the "American Medical Library."]

Circular of the Trustees and Faculty of the Albany Medical College. 8vo, pp. 34. Albany, 1838.

From Mr. Waldie, the Publisher.-Practical Surgery; with one hundred and twenty engravings on wood. By Robert Liston, Surgeon. With notes and illustrations by George W. Norris, M. D., one of the Surgeons to the Pennsylvania Hospital. 8vo, pp. 374. Philada., 1838.

1 Lancet, Aug, 25, p. 783.

1

Otorrheal discharges arise either in the external or internal ear, or in parts foreign to that organ; in the last case, purulent collections in the skull consequent on caries, from suppuration of the brain or its membranes, may open for themselves a way through the external ear; then this organ not only forms a passage for the exit of pus, but becomes also changed into an ulcerated or purulent surface, and thus enters into communication with the substance of the brain. This communication is not very rare, especially if we reckon those cases in which the disease commences in the ear and extends to the brain. Notwithstanding the importance and frequency of this disease, which we shall designate cerebral otorrhea, MM. Itard and Willemier are the only authors who have studied the subject as it deserves. Before proceeding further in the researches on this disease, we will detail some cases so as to simplify by autopsy the progress and phenomena of the affection.

According to the point from which suppuration proceeds we admit two forms of the disease, either the suppuration being propagated from the brain to the ear (primary cerebral otorrhea), or from the ear to the brain (consecutive cerebral otorrhea; there is also a third form, in which both organs are diseased, when it is impossible to point out with certainty which of the two was first affected.

Primary Cerebral Otorrhea. CASE 1.-A man, ætat. 42, being chilled after exposure to the rays of the sun, complained of a fixed acute pain on the right side of the sagital suture. The next day a high fever broke out, with chills, nausea, anxiety, insomnia, and then violent cephalalgia, eyes glistening and injected. On the 5th day phrenitis supervened, and in spite of every remedy which could be put in requisition the patient died on the ninth day. As an excessively fetid pus had been discharged from the mouth, nose, and right ear, for a short time previous to his death, Bailly, who observed this case, made the dissection. On raising the skull, a tumour of the size of a filbert was found filled with an excessively fetid pus. The dura mater and arachnoid were in a state of putrefaction. The subjacent cerebral substance itself was morbid and very fetid.

The auditory organ does not appear to have been examined in this case. CASE 2.-A mason, ætat. 41, was seriously wounded about eight years ago, on the right angle of the lower jaw, by a wall falling upon him; bruises and swelling followed. With the exception of hemicrania on the

1 Gazette Médicale, No 21, Mai 26, 1838.

2 Dissert. de Otorrhea, Trajecti, 1836.

3 As M. Willemier's thesis, from which the majority of these cases is extracted, is not for sale, we thought proper to give them in detail. (Note of the French editor.) 4 Lallemand. Recherches anatomico-pathologiques sur l'encéphale et ses dépendLettre IV.

ances.

VOL. II.-15

right side the patient was well. About three years ago, without any known cause, this pain became gradually more frequent, and so acute as to prevent rest either day or night; it occupied the forehead and occiput. Different remedies were unsuccessfully used by the various physicians whom he consulted. Now and then the pain was very great; the mouth turned to the right; incomplete paralysis of the upper eyelid, so that the eye was half open; delirium; subsequently deafness, with a sensation of hissing and roaring.

At his entrance into the hospital of Utrecht, M. Schroeder describes him as in the following condition :

Conformation of the body delicate; leanness; face red; mouth evidently turned to the right; paralysis of the right side of the face; conjunctiva of the right eye, which was half open, very red and oedematous; pain on separating the eyelids; eye moveable, but slightly turned to, the right, occasioning slight external strabismus; intellectual faculties enfeebled; stools normal; appetite good; and pulse strong. Deglutition rather difficult.

After some days the patient felt so well that he was anxious to resume his occupations; did not complain of any pain; but cephalalgia soon returned with fresh intensity. He uttered cries during the night, jerking back his head.

On the 11th of February he had an attack of apoplexy; on the recurrence of consciousness his speech was difficult, and deglutition constrained, with tottering gait; conjunctiva injected and cornea tumefied. February 21, had a fresh attack of a more violent character. The body had become stiff, and motion difficult.

March 2d. Although debilitated he appeared to exercise his íntellectual faculties better; he announced his approaching death, and wished to settle some affairs. He died in the night.

During the last days, the conjunctiva of the left eye was equally red and swollen. After death the right paralysed eye was open, the left closed. The treatment had consisted in the application of leeches and cauteries to the pained part.

Autopsy. Dura mater strongly adherent to the right side and injected; arachnoid of the right hemisphere inflamed, posterior lobe of that hemisphere strongly adherent to the dura mater. The whole of the fossa of sylvius, as far as the edge of the cerebellum, was distinctly softened and mixed with pus. This pus was especially collected in a large quantity in a cavity situated at the lower part of this lobe, the extremities of which appeared almost entirely destroyed. The edges of this abscess were separated from the posterior and healthy part of the medulla by a sanguinolent, almost black, edge; there was also an effusion of purulent serosity under the arachnoid of all the base of the brain, which extended as far as the crura cerebri, to the pons varolii, and meduila oblongata; fourth ventricle and cerebellum sound; lateral ventricles filled with a large quantity of serum; dura mater anterior to the petrous bone almost cartilaginous, of more than two lines thick. The inflammation of the dura mater reached laterally as far as the sella turcica. The third pair of nerves were inflamed in a space of half an inch, and reddened to a considerable depth. The sixth, fourth, and fifth pairs, as well as the optic nerve, were sound. The part of the dura mater which is in contact with the petrous bone was sound, but slightly red towards the base; on opening the cavity of the tympanum, it was found completely filled with coagulable lymph. The ossicles of the ear very red, as well as the vestibule itself; the blood-vessels of this part, and those in the canal, were more distinct than ordinary. Nerves sound; not inflamed. The left ear was healthy, and the cavity of the tympanum filled with air. Facial nerve on both sides normal

If this case is not an example of the passage of suppuration from the brain

1 Schroeder van der Kolk, in Willemier, Diss. de Otorrhea, Traject. 1836, p. 59.

into the ear, it proves what is much less frequent, the propagation of cerebral inflammation to the internal parts of the ear.

CASE 3.-A man, aged 40, received a serious wound on the right cheek and arm, of which he was soon cured. Nine months after, he was seized with cephalalgia; delirium; face and eyes red; tongue parched in the middle, red and moist at the edges; skin not dry; pulse hard, but not very quick; abdomen hard, shrunk, not painful to the touch. Answers sometimes correctly. Pains in the right temple; lies on his left side; no pains in the integuments of the cranium; comatose and deaf.

On the twenty-first day a white puriform matter was vomited. The next day skin was dry and hot; pulse irregular; respiration laboured and accelerated; copious expectoration of a whitish matter, similar to that which was vomited; breath fetid; voice indistinct; chest sonorous; died at the expiration of a few hours.

Autopsy. All the thoracic organs normal; caries of the superior surface of a part of the petrous portion of the temporal bone. All the petrous bone, as well as the meatus auditorius externus, destroyed. In the cerebellum was an abscess surrounded by a complete cyst.

CASE 4.-J. R. de M., ætat. 29, of Groningen, soldier, well made, of a lymphatico-sanguine temperament, had enjoyed good health until his twenty-third year, at which time he began to suffer from bilious attacks. The father died of phthisis; the other relations were healthy. Since the above period he had been well until March 1833, when, immediately after taking cold, he felt a hissing în his right ear, accompanied by a discharge of viscid matter.

In January 1834, he entered the hospital for pains of which he was soon relieved. He remained well till the month of June, when he had a fresh attack of his first complaint, accompanied with deafness of the right ear. After seven weeks' treatment the patient was entirely cured and returned to his regiment.

Another relapse, about October, with pain and swelling of the tongue and surrounding parts. A flattened abscess, formed chiefly at the helix; pains ceased.

The

November 27th.-The patient entered the hospital of Utrecht. internal superficies of the concha of the right ear was filled with a flat abscess of a yellow colour and red edges, which discharged a grayish yellow pus, fetid and mixed with blood. The external auditory passage, which could not be examined on account of the swelling, was suppurating and excoriated, and the parts adjacent to the ear were red and tumefied. A yellowish, viscid pus, was discharged from a small abscess behind the ear; in examining which, neither the bone was found denuded, nor was there a fistulous orifice. On this side the hearing was entirely destroyed, and diminished on the opposite side. The patient complained of pain of varying intensity in the interior of the ear and in the head, particularly above the diseased part; then he was annoyed with a hissing and rolling sound; all the other functions were normal. There had been stupor to greater or less extent for some days.

December 1st.-A purulent discharge was observed to flow from the left ear, followed on the second by violent pains in the head and ears and by painful insomnia..

11th. The side of the face was slightly red and the concha of the right ear painful to the touch; the purulent discharge acquired a better character.

12th.-Pains in the head insupportable. Respiration distressing, and pulse scarcely perceptible.

Night disturbed. Motions automatic; eyes half open; pulse slow, feeble, fluttering; moaning respiration; in a soporific state. Died about two o'clock. Autopsy, made twenty-four hours after death. After raising the cranium, the brain and its membranes on the external surface were found to be