hereafter, to speak of an equally striking modification of the " cephalic sound of the voice," which is found to accompany, and which I think is characteristic of a particular affection of the brain. It resembles, as nearly as the nature of the organs could admit, the sound which is known to accompany the effusion of fluid between the two pleure of the lungs, and is never heard, except in those diseases of the brain which are attended with a similar effusion between the membranes by which this organ is enveloped. It is, indeed, no more nor less than a simple ægophony of the brain; and as such, I doubt not, but that hereafter it will be found a valuable acquisition to the category of signs, which belong to this obscure and difficult class of lesions. During nearly five years, in which the observations herein detailed have been made, I have noticed the "cephalic bellows-sound," or some modification of it, in no less than eight different and perfectly distinct lesions of the brain. In some of these, it has been a wellmarked, constant, and invariable symptom; in others, it has been less so, while in all it has been sufficiently striking to render it a valuable and independent physical sign.

The different diseases in which this symptom has been present and characteristic, are thus arranged:

1. In simple congestion or irritation.

2. In acute inflammation of the brain, with or without effusion. 3. In chronic hydrocephalus.

4. In acute or local compression of the brain.

5. In induration, or scirrhus transformation of the substance of the cerebellum.

6. In ossification of the arteries of the brain.

7. In aneurism of the basilar artery.

8. In aneurism, and certain hydrocephaloid diseases.

[The author here gives four cases illustrative of the light thrown on the diagnosis by auscultation.]

I shall now speak, in the second place, of the cephalic-bellows, as connected with an acute inflammation of the brain.

Within the time that these observations have been made, I have noticed this phenomenon in nineteen different and distinct cases of acute inflammation of the brain. It was present in all of them as a prominent and unequivocal symptom; and as such, its progress and development were carefully noted, from the commencement to the termination of the disease in each case. [Three cases are here detailed at length.]

Beside the bellows-sound already described, my attention was, for the first time, attracted to the presence of a peculiar, and to me novel sound, connected with the passage of the voice through the brain and skull. It has a much sharper and shriller tone than that of the natural voice, and seems to strike upon the ear, as though the shrill notes of the clarion were echoing through the vault of the cranium below. It has, moreover, another character which renders it altogether so unique, that when once heard, it cannot easily, the second time, escape recognition; I mean a trembling-brazen-vibratory sound,

which in imagination, resembles nothing so much as the noise produced by singing, crying, or speaking through the teeth of a comb, previously covered with a bit of silk, parchment, or paper. In two or three instances, since recording this case, I have noticed that this sound corresponded almost exactly with the trembling, bleating sound which is so characteristic of the ægophony of the lungs. And, indeed, so nearly does this sound resemble in every essential particular that of ægophony, and so nearly also do the pathological conditions, necessary to the development of these phenomena, resemble each other, that I know of no appellation, by which this can be better designated from that, than by applying to it the term encephalic or cerebral ægophony." But to resume the history of this case, it will be sufficient to state, that the bellows-sound still remained a constant and important symptom, so long as the powers of life were well sustained, and failed only when they had become so much enfeebled, as to render existence, every moment, an improbability. The ægophonic sound of the voice, on the contrary, was equally present and distinct from the time of its first appearance, up to the moment when the last groan told that life had indeed departed from the body.

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I have noticed the cephalic bellows-sound in actual aud local compression of the brain.

This physical phenomenon of the encephalon has been observed also in induration, or scirrhous transformation of the substance of the cerebellum.

I have observed, in the sixth place, the cephalic bellows-sound, as a symptom of ossification of the arteries of the brain.

In the seventh place, the cephalic bellows-sound has been observed accompanying an aneurism of the basilar artery.-Abridged from a long paper in the American Journal of Medical Sciences for October, 1843, and London and Edinburgh Journal.

Dr. Marshall Hall on the Mechanism of Vomiting, in a Letter to Dr. Anderson.-14, Manchester-square, 15th Jan. 1844.DEAR SIR, I beg to thank you for your kind and polite present of a copy of your interesting paper on the Mechanism of Vomiting, which Ireceived this morning. There are three paragraphs in it, on which I beg to make a few remarks, which you will probably do me the favour to communicate to the excellent Journal in which your own appeared.

The first of these occurs page 8: "The opinion that the muscular fibres of the diaphragm are actively engaged in vomiting, seems to be supported by two cases related by Boisseau, in which that muscle was torn by violent vomitive efforts. It would, I apprehend, be difficult to explain this occurrence by a reference to Dr. Hall's theory; for the mere fact of the diaphragm's suffering compression in common with the viscera of the chest and belly, many of which possess weaker powers of resistance, would not account for its lace

ration."

My view of this event is, that it occurs in the final, actual, full, and violent expiration which uniformly takes place at the close of

the act of vomiting. The larynx is opened, the air in the thorax escapes; the contraction of the abdominal muscles proceeds, and all the force of that contraction is applied to the diaphragm, and carried upwards to the uttermost. It is the same force, the same violent expiration, which so beneficially empties the bronchial tubes of the redundant mucus in certain cases of bronchitis, in which emetics are prescribed.

The second paragraph to which I have alluded, occurs at page 9: "Violent efforts of vomiting were immediately induced, causing the expulsion of a considerable quantity of milk; and, at the same moment—that is, during the effort by which the milk was discharged, -the diaphragm became tense and rigid, and descended towards the abdomen." And: "on introducing two fingers into the opening which I had now made into the abdomen, I felt the diaphragm to be strongly contracted during each effort of vomiting." That the diaphragm "descended," and became "tense and rigid," during the act of vomiting may be admitted; but that it "strongly contracted," is, I think, more than the mere contact of the fingers could teach us. The account is not, it appears, limited to a detail of the fact, but involves a statement of the mode or rationale of that fact. My view of the case is this at the commencement of each act of vomiting, which is an act of the muscles of expiration, the contraction of the intercostal muscles carries the diaphragm forcibly dowwards, part of the parietes of the abdomen yielding somewhat to this forcible pressure. At this moment it may be found to have "descended," and to be "tense and rigid.”

I have only to add, that if the diphragm does contract during the act of vomiting, it must, in exactly an equal degree, counteract that process, which is one of expiration, whilst the diaphragm is an organ of inspiration. Such contraction is not usual in nature's opera

tions.

The last paragraph on which I beg to remark occurs at page 11. It relates to the fact of the ingurgitation of air into the stomach during the state of nausea which precedes the act of vomiting. You observe : Dr. Hall does not allow the diaphragm any share in the production of this phenomenon." Had I indeed made this assertion, I should certainly have committed a grave error. But you have only partly quoted my statement, of which I must here adduce the remainder. It is this: "It is not improbable, too, that in some instances of vomiting, in which the action of the abdominal muscles was subtracted, a similar effort of inspiration has drawn substances from the stomach into the oesophagus, which has eventually expelled them by an inverted action." It is of these two actions that I have said, "Neither of these phenomena could result from any action of the diaphragm;" and not of the ingurgitation of air into the oesophagus during the state of nausea, which is, as I imagine, effected by an act of inspiration, in which the diaphragm really does take a part.

I should have been glad if you had noticed the subject of vomiting from the oesophagus, and discussed that of vomiting from the stomach, when this organ exists (in the case of hernia), within the cavity of

the thorax at greater length; for the cases of what may be designated hyper-diaphragmatic vomiting appear to me greatly to elucidate this singular act of ejection in general. I am, dear Sir, your's very truly, MARSHALL HALL.

To DAVID ANDERSON, M. D., &c.

London and Edinburgh Medical Journal.

On Dislocations of the Astragalus, with the lower ends of the Tibia and Fibula inwards, illustrated by Cases, by Henry Hancock, Esq., Surgeon to the Charing-Cross Hospital.-The object of this paper is to direct attention to an injury of comparatively rare occurrence-dislocation of the astragalus from the os calcis and scaphoides, the ankle-joint remaining entire. The writer, after alluding to numerous authors who considered that such an accident could not occur, gives an account of the only four cases he has met with in the works of various writers, viz., two in the last edition of Sir A. Cooper's work on Dislocations and Fractures, edited by Mr. B. Cooper; one related hy Professor Harrison in the Dublin Journal, vol. xv., designated Displacement of the Foot outwards, with Fracture of the Fibula;" and a fourth described by Dupuytren in the Leçons Orales, vol. i. p. 225, as 66 a fracture of the fibula with dislocation of the foot inwards." Both these latter titles the author considers erroneous; for it is very doubtful whether, in reality, the astragalus with the lower ends of the tibia and fibula are not the parts displaced; and even if this be not the case, it is only a portion and not the whole of the foot which is dislocated.

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The following cases are related by the author.

John Middleditch, a strong, healthy man, æt. 24, was admitted into the Charing-Cross Hospital, under the author's care, on the 5th of December, 1840, with an injury to the right ankle, having fallen from the top of one of the vats in a brewery. Four days afterwards, when the swelling was reduced, it was found that the fibula was fractured about three inches above the ankle; the axis of the tibia, instead of falling on the centre of the foot, was thrown inwards and slightly forwards, giving the leg the appearance of being twisted in that direction. The position and direction of the foot were not materially altered, further than by its projecting considerably on its outer side and the toes turning slightly outwards, but its dorsum looked upwards as in the natural condition. Upon carrying the finger along the outer edge from the heel forwards, the anterior extremities of the os calcis, where it unites with the cuboid bone, could be felt distinctly, whilst above there was a considerable cavity instead of the prominence formed by the astragalus and external malleolus. By pressing the finger along the dorsum of the foot, a depression could also be distinguished behind the posterior margin of the scaphoid bone. On the inner side of the foot was a prominence corresponding to the internal malleolus, of which the inferior margin could be distinctly defined; and anteriorly and inferiorly, another projection, more prominent, evidently caused by the head of the astragalus, over which the skin

was tense, thin, and vesicated. The distance between the internal malleolus and prominence of the os calcis was somewhat greater than in the sound foot, and that between the lower end of the inner malleolus and the sole of the foot diminished above an inch. The anklejoint was still capable of flexion and extension, and there was very considerable motion in the centre of the foot, corresponding to the calcaneo-cuboidal articulation, forming as it were a double joint. It was concluded that the astragalus had been forced from without inwards, off the upper articulating surfaces of the os calcis, carrying with it the lower ends of the tibia and fibula, most probably resting upon the lesser process of the os calcis. The various steps by which reduction was effected are next described.

The integuments over the point of pressure sloughed and separated on the third day after the reduction, leaving the anterior part of the astragalus exposed in its proper position; and this was succeeded by considerable discharge for several days, in the course of which, the internal calcaneo-scaphoid ligament sloughed and came away; the astragalus being now no longer restrained in that direction, gradually twisted round upon the calcis, until at length a large portion of its head protruded through the opening in the integuments: this prevented the wound from closing, and, as the bone could not be kept in its proper position, but had lost its articular cartilage, and was passing into a state of necrosis, he subsequently, with a small saw, removed its head to the extent of about three quarters of an inch; after which the wound gradually healed, the parts became consolidated, and the man left the hospital cured in July, just seven months after the accident.

Ten months subsequently the following report was made :-He walks as well as he did before the accident, without stick, or artificial support of any kind. The leg is larger than the opposite one, and there is some thickening around the ankle; but the motion of the joint is good, and the direction of the foot and the situation of the malleoli natural: he is able to do his work, which at times is very heavy, as well as ever he did, his leg being entirely free from pain.

The particulars of the last case are taken from the surgical notes of the late Mr. Howship, and relate to a preparation in the possession of the Royal College of Surgeons. It appears, from the position of the bones, that the same accident had occurred as that described in the former case; but that the dislocation had not been reduced. The author enters into a detailed account of the bones. He then concludes his paper with some observations on the treatment to be pursued in these accidents, giving the opinions of various writers on dislocation of the astragalus.

Mr. Lloyd made some general observations on the subject of the paper, and particularly combated the propriety of amputation, save in extremely rare and desperate circumstances. In the vast majority of instances of dislocation of the astragalus, amputation, as it was not required, so was it altogether inadmissible. In former days, indeed, the operation was even commonly had recourse to; it was one of the