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gurgling could be caught; the complete immunity of the lungsfixed the dependence of the symptoms upon disease within thepericardium, and although the other symptoms may have beenadequate to the diagnosis of effusion, they were necessarily of soequivocal a character that it was satisfactory to have them cor-roborated by so valuable a sign as gurgling. The trivial amountof disturbance caused by so serious an affection was very re-markable ; he had actually been mowing for two hours on theday before I examined him, and could walk for a few miles at aslow pace ; but to walk quick for twenty paces would cause themost distressing dyspnoea; and this explains a very importantfact, that proved the stumbling-block to the correct diagnosis ofmany thoracic diseases before the introduction of the stethoscope.’When a person formerly suffered from embarrassed breathingand dropsical symptoms, hydrothorax was considered to be thefirsf link in the diseased chain; but we now know that it is thevery last, and that disease of the heart is the primary one-disease of the heart producing a relative disproportion betweenthe contents of its cavities. In hydropericardium, this relativedisproportion cannot exist, as all parts of the heart sustain equalpressure, and it is only by sending the blood too quickly to theheart that the dyspnoea is rendered distressingly apparent. Theintelligent gentleman under whose care the case was, adopted thesame view of it that I did. He treated the case by cupping,mercury, and eounter-irritation, with complete success.

.Hyomeo.—On Tuesday last, I had occasion to make astethoscopic examination in a case of obscure uterine enlarge-ment, in which I was assisted by Mr. Morris of this town. Wewere unable to detect any placental or fcetal murmurs ; but thegurgling of fluid was so distinct that it arrested the attention ofboth of us, quite independent of each other; the motion appearedto have been imparted to the fluid by the descent of the

diaphragm, and the contraction of the abdominal muscles. Imention this case, as the hint may be serviceable in other cases,where it may be difficult to diagnose the presence of effusion-no usual circumstance in cases of ascites, accompanied by a I’deposition of cellular tissue in the abdominal walls.

September, 1845. I

CASE OF HYDATID TUMOURS IN THE ABDOMENAND PELVIS.

By JOHN MORLEY, Esq. Surgeon, Burton-upon-Humber.JoHN G-, aged thirty-eiht, waterman, of sallow com-plexion, first consulted me on September 8th, 1843, on accountof spasmodic affection of the stomach, to attacks of which hehas been subjected for many years. He was relieved by themedicine that was administered, in the course of about a fortnight,and I did not see him again untilMay 24th, 1845, when he applied to me on account of great

enlargement of the abdomen, which had increased very rapidlyof late, so as to prevent him following his occupation. He statesthat he has always been high-bodied; his general appearance ismuch altered since I last saw him; countenance more sallow andcachectic. He complains of sickness, flatulence, and constipationof bowels; is unable to walk far, on account of dyspnoea ; pulsequick and weak; urine small in quantity, almost limpid, and oflow specific gravity, being only 1.07 at a temperature of 84° Fah.,not coagulable by heat or nitric acid. On examination of theabdomen, whilst lying on his back, a large tumour was per-ceived, extending from the epigastric and left hypochondriac tothe upper margin of the pubic region, inclined towards the leftside, measuring at its greatest circumference thirty-seveninches. The space occupied by the tumour was dull on percus.sion. The right hypochondriac and lumbar regions sounded re-markably clear. I tried the effect of hydriodic acid and ape-rients for about a month, without benefit. In the beginning of iJuly his abdomen became more enlarged, and he was verydrowsy, his urine contained a deposit, which was convoluted,

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about the length and thickness of a crow’s quill; it looked likepus or semen.

July ]6th.-He was attacked this morning with an epilepticfit, which lasted half an hour. Mr. William Eddie visited him in

my absence, and ordered twelve leeches to be applied to thetemples, sinapisms to the calves of the legs, and purgatives.

17th.-Is more comatose, being almost always asleep, althougheasily aroused. Passes but little urine. Applied a blister to thenape of the neck.19th-Dr. Alderson visited him, and confirmed our opinion

that this was most probably a case of hydatid tumour; sug-gested the idea that it might possibly be a simple cyst, and ad-vised that the tumour be punctured.

20th, eleven A.M.-Mr. William Eddie visited him with me,and after a careful examination of the case, concurred as to the

propriety of the operation proposed by Dr. Alderson. A trocarwas introduced at the linea alba, on withdrawing which thecanula became obstructed with the coats of hydatids ; the incisionwas prolonged about two inches, which permitted two washhand-basinfuls of hydatids to escape, varying from the size of a hen’segg to that of small peas. These were perfectly transparentwhilst warm; there were also myriads of broken-down cysts,some of which were reduced to a pultaceous mass. He bore theoperation remarkably well; the wound was closed by the quilledsuture, and a bandage applied. He took, an hour afterwards, halfa pint of gruel, expressed himself comfortable, and said he shouldsoon be right. In the course of an hour he became comatose, andcould not be aroused.

21st, ten A.M.-Lies on his back, breathing with an apoplecticstertor; has frequent spasmodic twitches of the muscles; pulse120, full and bounding ; jugular veins distended and pulsating;has passed no urine since the operation. There has been a greatdischarge of fetid matter-from the urethra.-Quarter to five P. M.On visiting him this afternoon, to introduce the catheter, Ifound it impossible to do so, on account of an obstruction to itsentrance into the membranous portion of the urethra. Aboutfive minutes after the attempt he was seized with convulsions, andexpired in a few moments.

Examination twenty-three hours after Death.-On exposing theabdominal viscera, a cyst was perceived to the left of the lineaalba, extending from the diaphragm to the iliac fossa, situatedwithin the folds of the omentum, in front of the spleen andkidney ; it was adherent to the peritoneum by false membranethroughout its whole extent; from its lower portion a narrowband passed off to another cyst, situated between the bladder andrectum; the larger tumour contained a few entire hydatids, withabout a quart of debris. Its inner surface was rough and carti-laginous. On the posterior part of its outer coat was a tumour,as large as a walnut, which contained the dry skins of hydatids,firmly packed together. The lower cyst completely filled thepelvic cavity, mounting upwards into the abdomen, and appearedready to burst; it pressed on the rectum and bladder, so as todisplace the latter, and accounted for the difficulty whilst attempt-ing to introduce the catheter. Its cavity was lined by one largehydatid, the inner coat of which was very rough, and containedabout a dozen small transparent ones.The bladder contained about two ounces of turbid urine.Ureters dilated.Left kidney enlarged to twice its natural size; hard and lobu-

lated ; its pelvis enormously dilated, containing urine.Rigltt kidney dilated into a large sac ; its secretory portion did

not appear more than half an inch in thickness.Spleen small, and softened; stomach and bowels did not pre-

sent any morbid appearance, with the exception of the rectum,which was much contracted.

Liver congested.The Gall-bladder contained two calculi, around which it was

firmly contracted; one of these weighed sixty-four grains, theother ten.

CAef.—Pleura; universally adherent; lungs congested ; heartdilated and flabby.The head was not permitted to be examined.

ON THE TREATMENT OF DISEASES OF THEMIDDLE AND INTERNAL EAR.

(Translated from the French by Dr. JOHNSTON.)THE following paper was read before the Royal Academy oSciences at Paris, by Dr. Wolff, of Berlin, on the 6th of January,1845:-The most recent advance in otiatrics is, beyond a doubt, indi-

cated by the introduction of aerial substances, instead of liquid in-jections, into the Eustachian tube. M. Deleau was the first towhom this improvement may be attributed. It was he whofirst demonstrated the inconvenience of liquid vehicles and theadvantage of aerial substances, which, from their gaseous condi-tion, are analogous to the air which circulates in the middle ear,and from that very circumstance, much better suited for intro-duction into the cavity of the tympanum.

But, on the other hand, it must not be forgotten, that aqueousinjections have certain advantages over the douche of air-ad-vantages which seem to have been entirely lost sight of by themajority of aurists since aqueous injections have been replaced bythe air-douche.

Water is the principal vehicle for almost all medical sub-stances. In nature, as in art, it is the fluidem solvens of thegreater part of them. By means of aqueous injections, then,many remedies can be introduced into the middle ear. Thus,Itard injected Barege water, saline and aromatic solutions.

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The air-douche of M. Deleau, at present almost exclusivelyused in place of aqueous injections, has scarcely been used at all asa vehicle for medical substances. M. Hubert Valleroux, alone,has recently recommended the injection, by a caoutchouc bottle,of atmospheric air, charged with particles of any resinous or bal-samic substances-substances which are volatilized when ex-posed to a moderate heat, and often, indeed, adapted to catarrh ofthe middle ear, but certainly not suited to all diseases of thatorgan.

Medical substances which are only volatilized at a high degreeof heat cannot be introduced into the Eustachian tube by themethod of M. H. Valleroux, yet the majority of the remedieswhich might be employed in the diseases of the ear are in thatpredicament.

Medicated air, recommended by that author, does not, then,completely fill up the void caused in the treatment of the diseasesof the ear by the abandonment of liquid injections for the air-douche. They merely constitute an isolated remedy in an iso-lated disease, (like acetic ether, which is volatilized at 15° Reau-mur, and which was used by Itard.) But the question is-to dis-cover a method by which all sorts of medicines may be introducedinto the middle and internal ear.Long before M. Valleroux, I attempted to make use of some such

procedure, by employing watery vapours as a remedy and vehiclefor more energetic substances. It struck me, that as water in the.fluid state forms the principal vehicle for the different solublemedicines, it might do the same in the gaseous state for gaseoussubstances. There was, certainly, only one circumstance whichhitherto prevented the employment of aqueous vapours in diseasesof the ear, in which they might have been tried with advantage-namely, the high temperature (212° Fahrenheit, 800 Reaumur)required to boil water. ,

One may imagine, that such hot vapours brought into contactwith the Eustachian tube must be injurious; and when it was at-tempted to cool them, by making them pass through tubes, or intomuch lower temperature, they were immediately condensedinto liquid water. This has caused the failure of all attemptshitherto made.What I then wanted was to invent an apparatus by which I

could procure aqueous vapours of a proper temperature, (not toohigh,) and for a suitable time, (not too short.) I think I havediscovered one, and I submit it here for the consideration of theRoyal Academy of Sciences.

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1 shall explain in few.words its construction and action.Water contained in an ordinary tin vessel, and heated by a

spirit lamp, boils. The vapours rise by a pipe into a second vase,much larger than the first, and containing a third vase, filled withcold water in such a manner that the hot vapours which rise fromthe first vase are made to pass over this cold water, and then outby a small pipe at the edge of the lid of the large steam-vase.By this very simple mode I have succeeded in procuring

aqueous vapours at the temperature I desired, and hence I havethe power of introducing the most different medical substancesinto the middle ear.

If it be required to introduce simple aqueous vapours, or a so-lution of any medicine, as, for instance, a solution of a narcoticextract, it suffices, as already said, to pour water, or the solution,into the first vessel, and very cold water into the third. If re-

quired to introduce acetic ether, or any other substance whichvapourizes, at a temperature much below that of water, I pourthat substance into the third vase. The aqueous vapours, onpassing over the liquid, become impregnated with the vapours ofthe ether, at the same time that they are much more cooled thanif they passed over simple fresh water. If it be necessary to

employ balsamic or resinous aqueous vapours, as gum Benzoin, Iplace the Benzoin, well pulverized, in a small vessel, to be placedin the large steam-vase, and the aqueous vapours become also loadedwith the volatile particles of that substance.

In this way I have- employed the most different substances indifferent diseases of the ear with various success.

If the different medicines require modifications in the mode ofevaporation, the method of introducing the vapours into the tubeand middle ear varies according to the state of the tube.

If the two Eustachian tubes be perfectly free and permeable tothe current of air, as in nervous deafness, I do not think it neces-sary to introduce the vapours by a catheter, for inasmuch as the

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atmospheric air enters and passes out freely by the tube, aqueousvapours brought near to its orifice should equally penetrate intothe canal. Consequently, in these vases, I have replacedcatheterism by the introduction of a caoutchouc canula sufficientlylarge, which is thrust into the inferior nasal canal for two orthree inches, whilst the end of the canula projecting outwardlyfrom the nostril is joined to the pipe of the apparatus generatingthe aqueous vapours. The method is very simple, causing.neither pain nor tickling, and requires no experience of such

operations. Any surgeon, or even patient, may ust it, whilstcatheterism of the tube can only be performed by a skilful aurist.

It is obvious then, that, from this circumstance, the treatmentof many diseases of the ear becomes generalized. Instead ofsome few aurists in the capital cities, all physicians and surgeonsmay subject the deaf to a local treatment in their own vicinity.The inhabitants of the country, with those of great cities, thepoor and the rich, may derive equal advantage from it. How-ever, the diagnosis of the disease must ever precede the treat-ment, and it (the diagnosis) demands always the exp-oration ofthe middle ear by the sound. Catheterism of the Eustachian tuberemains, then, the chief means of diagnosis in diseases of theinternal and middle ear, and remains, also, indicated as a thera-peutic means in all diseases of the middle ear, causing a materialobstacle to the passage of air, as in catarrhal obstructions of thetube, contraction or obliteration of this canal. Like otheraurists, then, I exercise catheterism, and venture here to submitto the Royal Academy three new methods of performing thatpperation.

In this short extract I put aside the third method, because itonly serves to facilitate the operation upon persons (as we some-times meet them) who will not permit the introduction of theordinary catheter at all, but as the other methods are preferableto it in every other respect, I only employ it rarely, and do notthink it of much value. ’.

The two other methods, on the contrary, appear to me prefer-able to all the others hitherto in use. We may mentionthat all these methods may be reduced to two, each of which hascertain advantages over the other-i. e., catheterism, by means ofsolid silver catheters, (of Itard, Kramer, &c.) and catheterism, bymeans of elastic and flexible catheters, (of M. Deleau.) -

Inflexible solid catheters have the advantage of greater safetyin the execution of the operation, which is not owing, as com-monly believed, to the solidity of the instrument, but to itscaliber, and, above all, to that of its beak. For as it is muchlarger, it is felt to be well grasped by the orifice of the tube,whilst the thin elastic catheter of Deleau is not grasped by theorifice, and does not give such a sure intimation to the operatorthat he has reached that canal. But the advantage of the elasticcatheters of M. Deleau over the solid ones of Kramer is still

, greater. It consists in the possibility of entering more deeply’ into the tube than that which is retained in the orifice, whilst the

elastic thin catheter can traverse the greater part of the canal,(three-fourths. according to M. Deleau.)

I have attempted to unite those two chief advantages in thetwo methods I have now the honour of submitting to the RoyalAcademy. They only differ in the material of the catheters.The catheters, in the first method, are of silver ; those of thesecond, elastic. Both are double, consisting in an interior catheterof a caliber as great as that of Kramer, and an interior one assmall, and even smaller, in caliber than that of Deleau. Theexterior catheter is of the ordinary length of those used for theear (six inches); the internal catheter is two inches longer. Theformer are graduated along their whole length, the latter areonly so at their lower end, which projects from the externalcatheter. The internal catheter, in the first method, is of pure,or almost pure silver, and hence, flexible, whilst the external oneis of ordinary silver,-i. e., mixed with copper, and hence, in-flexible. The internal catheter, of the second method, does notrequire to have a wire, because its passage is sufficiently securedby the outer catheter which contains it. It is obvious that thisgives it an additional advantage over the catheter of M. Deleau.But the principal advantage of my catheter is, as I have alreadysaid, that it gives the same security in the execution of theoperation as the large solid ones of M. Kramer, and that it goesquite as deep, and even deeper, into the tube, than the thin elasticcatheters of M. Deleau. For whilst the external catheter isstopped by the orifice of the tube, the internal one goes deeperinto that canal.

Each of these two methods has its advantages over the other,and consequently its indications. The double silver catheter ispreferable for the exploration of the ear; it is safer, and permitsof exploration directly by touch as well as by hearing. In con-tractions, or even obliterations of the tube, it is still more useful,as it may often be used to force a passage, whereas the elasticcatheter cannot. But the elastic catheter on its side has theadvantage over the inflexible silver one, that it is much betterborne by the patient. Above all, when the catheter is to beadapted to an apparatus cumbersome in transport as that of Mr.Deleau or mine for the production of vapours, and when thepatient is obliged to remain some time in the same position, theelastic catheter is very useful. When using the caoutchoucbottle, one is as useful as the other.

I My methods possess one more advantage over the others-viz., the facility of introducing the catheter by the opposite

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nostril. This operation, but rarely indicated in cases where the Inasal canal of the corresponding side is too narrow to admit the Ipassage of the catheter, cannot be performed at all with the icatheters of Itard, or of Kramer, because their beaks are tooshort, and only with difficulty by Deleau’s method, and by par- iticular catheters with long beak, (8-10 lines.) The difficulty ofthe operation arises from the length of the beak of the catheter,since we know it cannot pass so easily as the ordinary catheter. ’,Thus, my double catheters obviate this disadvantage entirely,for during the passage of the instrument through the nasal canal,the internal catheter remains within the external; the beak of theinstrument is then as short as that of the ordinary catheters, andwhen it touches the Eustachian tube, it is turned to the inside,and then the internal catheter is thrust out of the external intothe tube.

In the memoir I had the honour to submit to the RoyalAcademy, I have mentioned a case in which catheterism by theopposite nostril was necessary; that case corroborates what Ihave just said. The results obtained in the other cases I havementioned cannot be given in few words, and therefore I take theliberty of referring to my memoir. I have already treated abouttwo hundred patients by this method, some of which cases arementioned in the memoir.

I have the honour to request of the Royal Academy of Sciencesthe nomination of a commission to judge upon the method heresubmitted.A commission was then accordingly named, composed of

MM. Roux, Velpeau, and Breschet.

INTUS-SUSCEPTIO SUCCESSFULLY TREATED BYTHE INJECTION OF TEPID WATER THROUGHTHE RECTUM.

By W. HENDERSON, M.D., Perth.W. H———, aged sixty-four years, of spare habit, while walkingin the street, on the 2nd of August, was suddenly seized withacute pain in the left epigastric region, accompanied with vomit-ing, and got home with difficulty. His wife applied to a druggist,who gave her castor oil, which was returned soon after havingbeen taken. The druggist was again consulted, and gave sulphateof magnesia and senna, to be repeated until the bowels weremoved. Doses of this were repeatedly taken, and as often re-jected.

I did not see him until the 4th, when I found him complainingof acute pain and extreme tenderness to the touch in the left epi-gastric region; sickness at stomach; countenance expressive ofgreat anxiety and suffering; pulse 86, strong. Ordered him tobe put into a warm bath, and to take one of the following powdersevery hour-viz., three drops of croton oil, to be rubbed up withone drachm of loaf sugar, and divided into four equal doses.Eight o’clock P.M.: experienced considerable relief from the bath;has taken all the powders, and only vomited once. To have aturpentine enema, and if the bowels are not relieved by it, tocontinue the powders. Ten o’clock P.M.: enema was returnedwithout any feculent discharge; no vomiting ; thinks the painrather easier. To take five grains of calomel, and ten grainsof scammony, directly, and continue powders every hour.5th.-Was called early in the morning; had passed a very rest-

less night; the pains in side and back, and hiccough, which cameon during the night, are very distressing; has vomited two orthree times. Repeat enema. Twelve o’clock, noon : enema wassimply returned ; stercoraceous vomiting. The symptoms werenow so urgent, and the sufferings and prostration so great, that Imade him aware of the danger he was in, and the necessity ofhaving recourse to more powerful means for relief The patienteagerly declared his willingness to submit to anything, and beggedof me to proceed. I then had a tin tube, thirty-four inches longand three-sixteenths wide, fitted into the nozle of a large enemasyringe, and a short piece of wider tube soldered on the otherend, and fitted to receive the pipe of a small funnel. Throughthis I injected tepid water into the bowels through the rectum.The tube with the funnel was thirty-seven inches and a half inlength, and when raised upright, produced a pressure upon thebowels of a column of water that height. When a little morethan the second quart of water had passed, and the patient wascalling out to stop, or he should burst, I observed a shock in thetube, accompanied with a gurgling noise, and a quicker descent ofthe water through the funnel. I now withdrew the tube, and atthe patient’s earnest desire had him lifted to the night-stool, whenthe water was speedily ejected mixed with liquid feculent matter,with complete remission of the pain. In about twenty minutesafterwards he had to be again lifted to the night-stool, when theremainder of the water was thrown off, mixed with feculentmatter as formerly. Ten o’clock P.M.: the pain and sickness at

stomach are much relieved, but the hiccough has been incessant,and is often accompanied with a sensation in- the throat as ifimmediate suffocation would take place ; nothing from the bowels.To take a tea-spoonful of vinegar in a wine-glass of water everytwo or three hours during the night should the hiccough notabate. Repeat calomel and scammony.6th.-Though the hiccough was relieved for a short time after

taking the vinegar, yet it has been very distressing, and conse-quently, the patient has passed a restless night. Bowels have notmoved; the pain in the back and side, and sickness at stomach,but without vomiting, have all returned, although not to theirformer extent; complains of great exhaustion, and looks ill. Thetepid water was then had recourse to, as formerly, but when abouta quart and a half had passed, symptoms of syncope made me de-sist. He was lifted to the night-stool and the water was speedilyreturned, with some traces of liquid feculent matter. Fouro’clock P.]B!.: except the hiccough, has been rather easier sincelast visit; nothing further from bowels ; complains still of painin his side, which he cannot bear to be touched; upper portion ofabdomen tense and very tender; countenance expressive of muchsuffering; complains of exhaustion; pulse 100, feeble. Satisfiedthat hitherto the obstruction had not been fully removed, I again hadrecourse to the tepid water. When two quarts had been intro-duced, no more would pass; I then removed the funnel, and ap-plied my mouth to the end of the tube, and with all the power Icould exert, forced air through until the patient called out hefelt it "boiling in his stomach," and that he should certainlyburst. When placed as formerly, water and air, mixed with moreconsistent feculent matter, were returned very freely, with com-plete remission of all former symptoms, except hiccough, and theuneasy sensation of suffocation in the throat. Ten o’clock r.M. i

perfectly relieved, except hiccough; allows the abdomen to befreely handled without complaint. To take a draught containingone drachm of tincture of hyoscyamus and ten drops of Battley’ssolution of opium.

7th.-Passed a tolerable night ; no pain except from hiccough,which continues to distress him; passed a scanty, consistent, andhighly offensive stool this morning. To continue mild aperients,and be put into a bath at 950 Fahrenheit for forty minutes. Teno’clock P.M.: greatly relieved ; hiccough still a little troublesome ;.nothing from bowels.8th.-Had a good night; no pain anywhere; abdomen soft and

free from tenderness ; nothing from bowels except flatus, of whichhe had passed an enormous quantity. To take four grains ofcalomel, and, an hour after, infusion of senna. Nine o’clock P.m. ebowels have not yet acted, but complains of no pain, nor isthere tension or tenderness of abdomen. Hiccough still a littleannoying.

9th.-Passed a quiet night, but did not sleep much on accountof hiccough; had a very free and copious stool this morning,since which the hiccough and squeamishness at stomach, fromwhich he has never been altogether free, have completelyleft him, and he has taken a little breakfast with relish.Convalescence from this time progressed without any untowardsymptom.

Remarks.-I record this case, not on account of anything newin the mode of treatment, but to show the necessity of perse-verance, and to encourage others not to suffer themselves to bediscouraged by partial failures. It is true, that the pressure ofthewater, on its first application, forced back (partially, at least) theintus-susception. Of this I had distinct and palpable evidencefrom the vibration of the tube, the gurgling noise, and the increasedvelocity ill the descent of the fluid, but the continuance of sub-dued pain in the original seat of the disease, and the tension ofthe upper portion of the abdomen, indicated that the relief hadbeen either partial, or that the bowel had speedily resumed itsformer position.On the second introduction of the fluid, the alarming state of

the patient made me desist before I was satisfied that the obstruc-tion had been overcome.When the injection of the water was had recourse to the third

time, the exhausted state of the patient showed that full relief ordeath must speedily be the alternative, and consequently, that this.time it must be pushed to a satisfactory result, at all hazards. Itwas for this reason that when the water ceased to flow, having nomeans at hand to increase the height of the tube, I had re-

course to the mechanical expedient of my own lungs to force thefluid forward; and notwithstanding all the power I was capableof exerting, it was a few seconds before I felt the obstructiongive way, and even then I did not desist until the patient screamedout that he felt it ,. boiling in his stomach," and that he should cer-tainly burst.The only other point of interest in this case is the length of

time that elapsed after the obstruction was overcome, before the