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by absorption; which permitted of its expectoration throughthe bronchial tubes, the mucous membrane of which took ona sort of compensative inflammation, if it may so be called, orvicarious action, to produce this result. Absorption, therefore,has predominated over effusion, adhesion between the surfaceof the lung and chest took place, and contraction of the cavityensued. In such a case as this, the liver would encroach uponthe contracted chest, and thus account for the dulness in asitnation which otherwise would have been occupied by healthylung.

Cases like the following are full of practical value to thestudent, and are well worthy of study. Our readers who de-vote themselves to accurate clinical study associated with soundreflection, will do well to consult Dr. Robert L. Macdonnell’sContributions to the Diagnosis of Empyema, in the DublinJournal of Medical Science for 1844, which afford a fund ofvaluable information in connexion with this subject. He hasbeen the first to point out the modes by which the cure of anempyema is accomplished through the aid of the bronchialtubes: "In one, the membrane takes on a vicarious action, bywhich large quantities of pus are discharged without any dis-tinct evidence of inflammation being set up in the membrane,or communication being established between the bronchial tubesand the sac of the abscess. In the other form, direct commu-nication exists between the bronchial tube and the sac of theempyema. They are both efforts of Nature to get rid of thepurulent collection and effect a spontaneous cure." "

R. C-, aged twenty-three, a journeyman baker, and byno means of robust appearance, was admitted April 25th, 1856,suffering under a well-marked attack of plenro-pneumonia ofthe right lung, the pneumonic symptoms, however, notablypredominating over those of pleurisy. He was taken ill withpain in the side &c. on the 2*lst; had, on admission, the usualsymptoms of pneumonia involving four-fifths of the right lung,and on the 29th had the base of the left similarly affected.Under a stimulating plan of treatment, with the application ofturpentine to the chest, and opiates at night to allay the cough,the more urgent symptoms yielded; still the improvement wasnot so rapid as it might have been. On May 8th the reportwas as follows:-Respirations 40; pulse 88; appetite good;skin of moderate warmth. Physical signs: Dulness on percus-sion remained over the lower two-thirds of the right lung be-hind, and in front below as high as the third rib; in thesesituations coarse regular crepitation was audible; elsewhere thebreathing was vesicular, but rough. On the left side there wasno dulness; but at the base a little coarse crepitation. A blisterwas ordered to the right side, and three grains of blue pill, withone-third of a grain of opium, given every six hours, the patient at tthe same time taking meat diet, and a few ounces of wine. Onthe 12th he was not so well; the respirations were 44; thepulse 96, and he was much troubled by the cough, which cameon in violent paroxysms, lasting ten to fifteen minutes, withscanty white frothy expectoration; he perspired also muchduring sleep. On the 14th the general symptoms were muchthe same, but the physical signs had somewhat altered; reso-nance was returning at the lower portion of the right lung be-hind, but in front the dulness from below up to the tlaircl rib wasmore marked than ever, and in this situation neither naturalbreathing nor morbid sound was audible. On the 17th therespirations were 28; his general condition otherwise the same;his mouth was slightly sore from the mercury. The pills wereomitted, and the following draught ordered:-Dilute nitricacid, and dilute hydrochloric acid, of each eight minims; com-pound tincture of cinchona, half a drachm, and ten drachms ofdecoction of cinchona, every six hours. On the 23rd the respi-rations were 36; the pulse 90, and his nights were bad; he hadalso much perspiration, and his cough was also very trouble-some. Physical signs: Right side-anteriorly resonance as lowas third rib, over which space the breathing was harsh; belowthis point there was complete dulness, with manifest bulgingof the mammary region, absence of vocal fremitns, and silentbreathing. The lateral region was dull with vocal fremitus,and coarse crepitation. In posterior region there was resonancethroughout, with rough vascular breathing over the superiorhalf, and coarse crepitation inferiorly. On the 31st his generalcondition was much as at the last report; the physical signswere also the same. It was moreover ascertained that the rightside of the chest measured across the nipple an inch more thanon the corresponding side, and the obliteration of the fourth,fifth, and sixth intercostal spaces was very marked. Underthese circumstances Mr. Brooke was requested to pass a groovedneedle through the fifth intercostal space at a spot two inchesto the right of the sternum. A drop or two of healthy pusescaped, and about an ounce more followed the subsequent in-

troduction of a small hydrocele trocar and canula in the samesituation. The patient suffered very little inconvenience fromthe operation, and immediately after, the affected side wasfound to measure very little more than the opposite one. Faintirregular crepitation was also at once audible over the mam-mary region, though the resonance had not returned. Repeatthe mixture.June 3rd.-Slept well; pulse 92; respiration 30; skin warm

and moist; complained only of a little pain in the situation ofthe puncture. Repeat the mixture.

4th.-Physical signs: Posterior region resonant throughoutwith vesicular breathing; posterior lateral also resonant withcoarse crepitation; anterior-lateral and anterior region, fromthe third rib downwards, still dull with faint, irregular crepi-tation of moderate size.

llth.-The physical signs were the same as at the last re-port, except that vesicular breathing was audible over thewhole lateral region. He coughed slightly, and expectorateda small quantity of frothy colourless mucus; he perspired muchat night, and did not gain flesh. To have a drachm of cod-liver oil, thrice a day, and fifteen minims of muriated tinctureof iron, also thrice a day in an ounce of water.18th.-During the last three or four days, symptoms of

general bronchitis had manifested themselves; the cough hadbecome more troublesome; the expectoration profuse andmuco-purulent; and moist, irregular rales were audible overboth sides of the chest. A blister was applied, and the com-pound cascarilla mixture ordered.

This attack gradually passed away, and on the 27th thecondition of the anterior portion of the right side of the chestwas found much improved. It was now resonant from clavicleto nipple, the intercostal spaces had become quite flattened,and the side now measured a quarter of an inch less than theother. Under the clavicle, the breathing was roughly vesicular,over the upper half of the mammary region mixed with largecrepitation, and posteriorly and laterally it exhibited the irre-gular rales of bronchitis. He still coughed much, sweated agood deal at night, and was rather losing than gaining flesh.Cod-liver oil increased to two drachms three times a day.

July 2nd.-Resonance now extended to an inch and a halfbelow the nipple, and distant vesicular breathing was audiblethroughout the mammary region; his cough was much dimi-nished, and the perspirations had greatly abated.7th.-The cough was nearly gone, and the expectoration

scanty; he slept well, and perspired scarcely more than inhealth. The whole of the right side was now resonant on per-cussion, with vesicular breathing audible, except anteriorly,from the sixth intercostal space downwards; here it was dull,and no sound, either morbid or natural, was to be heard, thisbeing dependent probably on the liver rising somewhat aboveits natural level.At this date, the patient left for the country, where he re-

mained until September 18th, when he came to the hospital.He had taken cod-liver oil during his absence; had now nocough nor expectoration; had gained greatly in flesh, andlooked upon himself as quite well. Nothing morbid could bedetected by auscultation or percussion, except that the sameundue amount of dulness remained in the right infra-mammaryregion as was observed on his leaving the hospital two monthspreviously.

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ROYAL FREE HOSPITAL.

DOUBLE PLEURISY AND PNEUMONIA TREATED BY DIAPHORETICS,BRANDY, BEEF-TEA, AND FISH; RECOVERY.

(Under the care of Dr. BRINTON.)THE foregoing case was not only of interest from the compli-

cation of an empyema which terminated satisfactorily, but the-treatment was different from the old plan, briefly commentedupon in a previous " Mirror." The subjoined instance is oneof pleuro-pneumonia of both lungs, pursuing a steady coursetowards cure with mild treatment, supporting the patient withbrandy and beef-tea, subsequently changing the latter for fish,the details of which have been furnished us by Mr. W. Curran,the house-surgeon to the hospital.

M. A. S-, single, dressmaker, admitted March 3rd, 1857;about the middle height, rather corpulent, and of nervous tem-perament. Is a person of good health, and has never been thesubject of any serious ailment, though for the last five years, orwhilst engaged as a needlewoman, she has suffered from cough,headache, giddiness, occasional vomiting, and nausea; had noparticular pain, but complained of irregular appetite, bad taste,dysmenorrhcea, and failing strength; is nervous and hypochon-

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driacal, and says that the " least thing sometimes puts her out of sorts." About five days ago she felt severe throbbing, and Ifrontal pain of intermittent character, which was aggravatedby movement or exertion. Sharp pain in the back of the neckand under the right shoulder-bone, which letter became muchworse on Sunday, and affected her as if " sharp knives" werepassing through her. She became very sick ; the headache andfever increased; the breathing was very hard, rapid, oppressed,and painful, especially in the recumbent posture ; and failingin obtaining relief from her ordinary attendant, she applied andwas admitted in the following condition :-" Face flushed, ex-cited ; alae nasi rapidly dilating; visible heaving over thorax;jactitation ; involuntary sighing, and some slight dysuria;tongue thickly coated; bowels confined ; pulse 150; respiration48. Respiration sounds, harsh, forced, catching, and bronchialin front. Expiration scarcely detectable; large blowing andloud liquid crepitation at either base; occasionally also heardapproaching mamma on left side, with dry grating friction andpectoriloquous oegophony in both. A large blister was appliedon the right side, which was the first most affected, and a dia-phoretic mixture, containing ten minims of ipecacuanha wineand five of laudanum, every four hours; and beef-tea, arrow-root, and two ounces of brandy, a dessert-spoonful of which,with two of water, every three hours.March 5th.-Eleven A.M.: Breathing on both sides markedly

tubular, especially oa the left; voice oegophonic and whis-pering ; occasional gurgling and coarse redux crepitation allover the right base. Sputum viscid and dirty red, not rusty,but of prune-juice or apricot hue. Pulse 150; respiration 50.6th.-Sputum more viscid and sticky, not so copious or dis-

coloured, easier. Pulse 144; respiration 46. Both sides nowalmost equally involved, but pain more persistent in the left,and pleural rubling advancing towards mamma on that side.Ordered two drachms of castor oil immediately.

7th. - Respiration dry, noisy, superficial, and markedlytubular; grazing friction all over the right side; no crepitation;voice-tone shrill, osgophonic, and pectoriloquous on both sides,but very little moisture in either. Pulse 130 ; respiration 44.To increase the brandy to three ounces, and have boiled fishinstead of beef-tea. Bowels fully open; generally improved.8th.-Pulse 110; respiration 36. Improving; chest sounds

much as above.9th.-Respiration still blowing; very tubular and quasi am-

phoric on both sides, but most so on the right, where also thereis some large crepitation; voice continues pectoriloquous andwhispering; less oegophonic and not so superficial in either.Pulse 126; respiration 29; progresses favourably.10th.-In every respect better. Breathing on both sides

much less bronchial ; no friction fremitus ; some liquid sub-

crepitant bronchus at the right base, where the voice is stillsomewhat shrill and whispering. Otherwise the condition of thepatient is so much improved, and the chest symptoms so favour-ably disposed to subside, that she may be now regarded as quiteout of danger, and in a fair way towards a speedy convales-cence.

CLINICAL RECORDS.

A FIELD DAY AT KING’S COLLEGE HOSPITAL.

So anxious is the desire of pupils and strangers to witnessthe more important operations in surgery, that we are

not surprised to find large numbers present at some of ourhospitals when it is known what is going to be done. Thiswas the case at King’s College Hospital on the 3rd inst., wherewe saw familiar faces from almost every hospital in London, aswell as a number of strangers and others. On that day Mr.Fergusson completed the operation for a severe case of doublehare-lip, in a girl about seventeen years of age. She had hadthe right side remedied about three weeks before, and on thepresent occasion the deformity was removed on the left side,under chloroform. Notwithstanding the great deformity here,it was unassociated with fissure of the palate. A fatty tumourwas next removed from over the upper part of the rightscapula of an elderly female, by Mr. Fergusson. A youngwoman, aged twenty-three, was now brought into the theatre,with a large tumour of the left side of the lower jaw-a thingrarely to be seen now-a-days, because tumours of the jaw aregenerally removed at an early period, before they have attainedto anything like magnitude. Five years ago this poor womanhad a tumour of the lower jaw, which was removed a yearafterwards by Mr. Pettigrew. Some time after, a new growthappeared in the site of the old cicatrix, although a considerable

portion of the jaw had been removed from the angle close tothe condyle. It was quite clear that unless the tumour wasagain removed it would cause the patient’s death; so this pro-ceeding was accomplished by Mr. Fergusson while she wasunder the influence of chloroform, administered by Dr. Snow.The incision in this instance extended from near the angle ofthe lip, (but not through it,) around the margin of the jawtowards the right car, the flap being dissected up, the jaw-bonesawed across near the symphisis, and finally withdrawing thediseased mass. There was a good deal of haemorrhage, but asthe operation was quickly performed it did not signify. Thetumour broke short off near the angle, but the condyle andattached portions were subsequently extracted. This isgenerallv a very difficult proceeding, but was done with easeby the aid of the lion forceps.A knee-joint was now excised, also by Mr. Fergusson, from

the right leg of a young man who had come in to have it am-putated ; but as amputation is the last thing to be resorted toin this hospital, and the case seeming a fair one for excision,that measure was adopted. There had been disease of thejoint nearly the whole life-time of the patient, and lately anabscess formed over the joint which communicated with it, thejoint being anchylosed. The excision was performed in theusual manner, but the patella had become displaced laterally,where it had attached itself; it was therefore left to form asort of natural splint.The operations were concluded by the deliga.tion of the right

femoral artery by Mr. Bowman, of the man whose case we re-ported in our " Mirror" of last week, and was performed in anequally quick and satisfactory manner as when the left femoralwas tied a few weeks ago in the same patient.

MULTILOCULAR OVARIAN CYST.

IN our last number (p. 452) we recounted the particulars ofthe injection of an ovarian cyst with iodine, in a girl agedtwenty-one, at University College Hospital, under Dr. Garrod’scare. She gradually sank, and died on the 28th April, withoutany symptoms of peritonitis. The autopsy at once revealedthe cause of the failure of the iodine injection. The entireabdomen was occupied by a large cyst, with thin walls, filledwith a purulent fluid much loaded with lymph and fibrine.This, we have no doubt, had other circumstances been favour-able, would have formed a solid growth, with eventual absorp-tion, had the tumour been able to contract upon itself after thetapping; but unfortunately this could not take place, from theadhesion of the upper part of the cyst to the diaphragm andone or two other places, and moreover its proving to be a mul-tilocular ovarian tumour--two or more pretty large cysts occu-pying its superior and left lateral aspects, with numbers ofcysts of varying dimensions springing from its inner walls. Theuterus was that of a virgin, the right ovary and Fallopian tubebeing normal, whilst the lefc formed the tumour, with a smallpedicle. There was no trace whatever of peritonitis, nor didthe patient during life complain of any pain to indicate it.The result in this case proves, what has been stated by writers,that multilocular cysts do not admit of the iodine plan of treat-ment, unless, as we have heard Mr. Brown state, a cathetercan be passed into neighbouring cysts, as well as the parentcyst, in injecting the iodine. A single cyst, not too large, withgood health, is the suitable form of case for injection withiodine; and we may add that the pure strong tincture shouldbe used, undiluted with water, and allowed to remain in.Iodism is certain to set in, which is associated with more orless prostration, to be met by the free exhibition of wine andbrandy, and a radical cure may be anticipated.

FUNGOID DISEASE OF THE HAND; AMPUTATION OF THEFOREARM.

AT page 63 of this volume we mentioned the removal of asuspicious fungus-like ulcer, by Mr. Hilton, at Guy’s, from thefleshy part of a man’s thumb. It extended beneath the annular

ligament, and was pronounced at the time to be recurrentfibroid disease. The fungous ulcer supervened in the incisionmade some months previous to let out pus, the hand havingbeen in a swollen state for twelve months. To our surprise,on the 7th April, we saw the same patient brought into thetheatre at Guy’s, to have his forearm amputated. It appearsthat, shortly after the removal of the disease in January, heperfectly recovered, the wound healed, and he left the hospitalquite well. Latterly, however, the old disease reappeared invarious parts of the hand, protruding in the palm, and espe-

cially near the thumb, in a prominent fungous mass, leaving