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such a train of symptoms, the patient was put on stimulat ing plan of treatment, with bland nourishment, and anodyne enemata to control the rapid diarrhoea.

The second or third day after she came in, and when she had reacted a little, a slight cough attracted the attention of one of the pupils, who told me that my colleague, Prof. Flint, had diagnosticated slight effusion into the left pleural cavity. We examined the lung carefully; but the physical phenomena, and the absence of any general symptoms indicative of an acute attack of pleuritis (the patient having only a slight cough, and complaining of no pain whatever), induced us to incline to the belief that the feeble respiratory murmur and dull percussion were rather owing to adhesions which were the result of old pleurisy. Examination of the anterior part of the chest, however, revealed most clearly the existence of emphysema of the superior lobe of the same lung. No feature of this condition of disease was wanting, and the attention of the class was directed to the same day after day. For several days after the question of effusion was raised, there was no apparent increase of the supposed fluid, but suddenly it began to accumulate, and in thirty-six hours the entire left cavity was so filled that all the intercostal spaces were level with the general surface of the chest, and the heart was completely dislocated-its pulsations being distinctly visible through the emaciated thoracic walls entirely on the right side of the median line of the chest. There could now be no doubt of the correctness of Professor Flint's original diagnosis and the error of our own.

While the chest was rapidly filling with fluid, considerable dyspnoea existed, but when the effusion seemed complete all dyspnoea disappeared, and the respiratory act wss conducted with so much ease that no stranger passing the bed would have for a moment imagined the existing state of

things. After a few days, however, difficulty of breathing appeared, and with much reluctance the patient submitted to the operation of thoracocentesis, which was skilfully performed by Prof. Flint before the class, on the 4th Jan., and fifty-four ounces of serum were withdrawn. Next morning all dyspnoea had subsided, but all the bad train of symptoms at first detailed were present, (as they had ever been), and the prognosis was, of course, unaltered.

During the ensuing week the patient gradually grew weaker, the diarrhoea being wholly unmanageable, and, at last, oozing of blood from the gums appeared. In the meantime, the chest filled with fluid again, and on the 12th Dr. Flint repeated the operation for its withdrawal, taking away about a tin wash basin full. Only temporary relief ensued, however, and the patient died on the 13th. Other pressing engagements prevented us from making a post mortem, which we very much regret. Dr. Grall received the body in the dissecting room, however, and then all the usual conditions of a pleuritic chest were found, together with enormous fatty enlargement of the liver. We regret very much that the bowels were not closely examined, as we were inclined to believe that the patient had long been the subject of ulceration of the bowels before coming in.

We should not omit to mention that in this case the diagnosis of fluid in the cavity of the chest could be clearly established by the phenomenon of fluctuation elicited in the intercostal spaces. We have always been surprised that particular attention has not been directed to this means of diagnosis in works on the diseases of the chest, as the means of diagnosis of any important affectiou cannot be too freely increased.

CASE 4.-Hydropneumothorax.-M. W., native of Hanover,

æt. 28 years, in New Orleans four years, single, was admitted to the ward December 22, 1859. On approaching the patient's bedside we found her laboring under intense dyspnoea, so that it was with the greatest difficulty she could answer our questions. She was lying on the right side, her pulse was very quick and feeble, there was lividity of the surface, and general tendency to dropsy. Physical exploration of the chest not only readily revealed an old case of pulmonary tuberculosis, but all the striking phenomena of hydropneumothorax were prominently elicited. The treatment in this case was, of course, stimulant, but with no idea of effecting any permanent benefit, as the prognosis was clearly of the gravest character.

She lived five days, during which time the members of the class had the fullest opportunity for studying, practically, all the phenomena characterizing her disease. After death Dr. Flint examined the body before the entire class in the amphiteatre, and the diagnosis was thoroughly confirmed.

CASE 5.-Diffuse Capillary Bronchitis, with Fallacious Signs of Heart Disease.-C. H., native of Germany, æt. 39 years, married, entered ward December 24th. Saw her first on 25th, at 9, A. M. She had been sick one month, but became rapily worse three or four days before entering. Had an infant of a few months at the breast. Appearance of the woman was most striking. Her face was livid, her lips absolutely purple, countenance indicitive of the greatest distress, dyspnoea extreme. Her skin was cool, the pulse 130, and very feeble (even the carotid arteries pulsating with no force), and general tendency to dropsical effusion. Physical exploration aiscovered the whole posterior portion of both lungs the seat of intense subcrepitant râle, and the

anterior portions already being involved. The closest scrutiny could determine no signs of pneumonia. The prognosis was of the most unfavorable nature, as the patient really seemed to be on the verge of the grave. She was, however, placed on stimulants, with anodynes to induce a little rest, which she had not experienced for many days. Next morning there seemed no change in her general condition, and the subcrepitant râle was now pervading the lungs in every part. Stimulants and nourishing diet were ordered to be urged freely, and next day (December 27th) there was snch an amendment of the general sypmtoms (the patient having slept several hours too) as to induce strong hopes of her weathering the storm. The treatment was continued from day to day, the patient gradually improving, until the 3d, when, on visiting the ward, we found her almost in collapse, and everything indicating certain dissolution; and, on the afternoon of the 4th, she died.

We shall always believe that this patient was lost in consequence of the want of that careful attention at night, which is so indispensable for cases of the kind, and which will, probably, never be afforded in any hospital.

During the course of her disease all the class had the fullest opportunity to study carefully the phenomena of uncomplicated capillary bronchitis in its gravest form, and, by comparison with cases of pneumonia, they could readily establish the differential diagnosis. In the course of these explorations several very intelligent graduates in the class. called our attention to the existence of a very distinct valvular murmur at the apex of the heart, and they clearly agreed on the existence of mitral disease. Several years ago we had met with a similar case, and had made a similar diagnosis, which post-mortem observation forced us to abandon. We, therefore, declined to agree with them on

the present occasion, and asked a suspension of opinion until the case should end in either death or recovery. A post-mortem was conducted by Dr. Flint in due time; the diagnosis of the pulmonary disease was established, and the heart was found perfectly healthy. In subsequent conversation with Prof. F., he suggests that the sound was, probably, to be attributed to the tricuspid valves, as he could not otherwise account for regurgitative sound. For our own part, we leave the question sub judice, suggesting that herein is a field for future study-viz: the abnormal sounds of the heart under the influence of severe and acute pulmonary disease.

CANCER OF THE TONGUE REMOVED BY THE ECRASEUR.

By Dr. S. CHOPPIN, Visiting Surgeon to Charity Hospital, Prof. of Surgery in N. O. School of Medicine. (Reported by Gustavus Devron, Resident Student, Charity Hospital.)

George Lobstein, a Frenchman, aged fifty-two years, was admitted in ward No. 9 of the Charity Hospital on the 13th of December, 1859, complaining of lancinating pain in the tongue, and of general debility. Dr. Choppin found the left half of the tongue the seat of ragged ulceration, and giving to the touch an unyielding, inelastic resistance. The patient presented the peculiar color and cachectic appearance indicative of a cancerous diathesis. He stated that the disease commenced by a small tubercle on the left side of the tongue, and that he had now suffered constantly for the last nine months, having had only slight relief some six months ago, after the application of caustics. During the last three months the disease had progressed steadily, and so great had the pain been, that he had not been able to enjoy a single complete night's rest. During

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