which all signs of air and fluid in the pleura had disappeared in the course of two months after the perforation. Even when the opening remains pervious, the compound disease is not necessarily fatal. Laennec refers to a case where the signs of fistulous hydro-pneumothorax continued at the end of six years. M. Louis, and the French school, generally, have taken a too unreservedly gloomy view of the prognosis of phthisical perforation; for cases have now been collected in some numbers in this country positively proving that not only may life be prolonged, but excellent health enjoyed, while succussion-sound is well audible in the side: still such cases are completely exceptional.

III. The physical signs of pneumothorax are very significant. The chest-motions suffer more or less extensively in freedom; they may be absolutely null at the lower part of the affected side: when there is any play, the intercostal spaces deepen during inspiration greatly. The vocal fremitus is weakened or annulled; the width of the side increased to the eye and to measure; the interspaces widened, and even bulged outwards, inferiorly, may be natural superiorly. The percussion-sound, increased in clearness, acquires tympanitic quality, retaining this until the accumulation of air becomes so great as to check the vibration of the walls under the blow. Local pneumothorax, at least in front of the trachea and large bronchi, may give an amphoric note. If the quantity of air be moderate, the respiration is of distant, weak type,-if considerable, absolutely suppressed. The conditions of vocal resonance vary: there may be mere nullity of sound; in some cases, the resonance is loud and diffused; and possibly it may be sometimes accompanied with metallic echo. The heart's sounds are, as a rule, obscurely transmitted through the air in the chest; and the mediastina, heart, and diaphragm displaced. The clearness of percussion may extend considerably beyond the middle line.

In cases of simple hydro-pneumothorax the signs are a combination of those of pleuritic effusion and of pneumothorax,the former at the lower, the latter at the upper part of the

side.

When hydro-pneumothorax co-exists (as is the rule) with perforation of the lung, fluctuation may be felt both by patient and observer, when the chest is abruptly shaken; peripheric fluctuation exists to its maximum amount; and Hippocratic succussion-sound is readily produced: these three signs may

exist, although closure of the perforation has taken place. The dull sound of fluid, and the tympanitic resonance of air, are found, in the ordinary posture of patients, the former inferiorly, and the latter superiorly: but the exact sites of both may be variously changed (unless adhesion, which is rare, interfere) by altering that posture; the respiration is amphoric, with or without metallic echo or tinkling; and the cough and vocal resonance are similarly echoed. The phenomena of displacement of organs are carried to the highest possible point. The heart's sounds are commonly weakened in their passage across the distended pleura; but they are sometimes echoed within it. A peculiar inspiratory sibilus is sometimes heard all over the side, and probably depends on escape of air through the chink in the lung.

IV. The treatment of perforative tuberculous pneumothorax is palliative. If the patient be seen immediately, or shortly after the pleura has given way, while his agony exists in all the intenseness of novelty, bleeding suggests itself as a means of relief. The quantity of oxygenating surface has been suddenly reduced, and the sudden disparity between that surface and the mass of the blood might, or would, I think, be somewhat lessened by diminishing the quantity of the latter. Whether this be the explanation or not, venesection does not give very notable relief, and renders subsequent inflammation of the pleura less violent. It should then be had recourse to, where the patient's strength has not been materially impaired by the previous disease. In doubtful cases, moderate cupping of the side may be substituted, or if even this be feared, dry cupping of the chest generally. It is singular what relief, both of pain and dyspnea, is sometimes afforded by the latter process. Repeated flying blisters to the side are also most valuable agents. The bowels must be kept moderately open, perspirable action of the skin promoted, the strength maintained by nutritious animal jellies and broths, or meat, if the patient's digestive powers be not enfeebled, and inflammatory symptoms controlled as they arise.

Various anti-spasmodics are useful in mitigating the dyspnoea, -lobelia inflata, cannabis indica, belladonna, stramonium, aconite, and, above all, opium. I have seen musk, in five grain doses, afford great relief.

In tuberculous pneumothorax, paracentesis can only be regarded as palliative, and, what is worse, temporarily palliative,

Still, as the operation does not obviously place the patient in any way in a worse position than he had been before, and as it often gives new existence for awhile, there can be no objection to its employment (and to its repetition,) when physical sigus show that the mediastinum and the non-affected lung are seriously encroached upon.

It is difficult to lay down a rule for other varieties of perforative pneumothorax; recorded cases are deficient in detail for our guidance, and to me it appears that where recovery has ensued, it would have occurred without the operation. If pneumothorax were suddenly produced in a fit of violent coughing, as in hooping-cough, and the patient had previously exhibited no evidence of organic disease in the lung, I should hold it advisable (especially if the symptoms were urgent) to punc

ture the thorax.

DISEASES OF NUTRITION.

EMPHYSEMA.

I. THE disease, inconveniently termed vesicular emphysema by Laennec (and which it might be better, perhaps, to call rarefaction of the lung,) is essentially characterized by enlargement of the air-cells, obliteration of their vessels, and atrophy of their walls; occasionally oil (as first pointed out by Mr. Rainey,) is discoverable in the walls of the vesicles, but it is not constant, and when present, its relationship (of cause or of effect) to the existing atrophy is uncertain. A state of hypertrophy of the inter-vesicular structure occurs in very rare instances.

II. The sole symptom of atrophous emphysema per se is dyspnoea. Often commencing in early youth, or even infancy, at first slight in amount, and only felt on some unusual exertion, such as running up-stairs, &c., when once developed, dyspnoea is permanent, but subject to great variations in intensity. It is true, many persons labouring under emphysema will affirm that their dyspnoea is only occasional,-that habitually their respiration is perfectly natural. But I have never known an instance of this kind where the patient was not the victim of a delusion; the truth is, that a moderate amount of dyspnoea had become to him second nature, a state of comfort and health,—and ex

cessive difficulty of breathing alone gave him annoyance. The dyspnoea is increased, from time to time, either through spasm, through abdominal infraction, or through intercurrent bronchitis; the former two causes produce sudden paroxysmal attacks, requiring the patient to rush to the open window for air, or pass the night in the sitting posture out of bed; the latter is less violent, but more protracted, in its action. The amount of persistent dyspnoea is generally proportional to the duration of the disease. The paroxysm is occasionally accompanied with a fit of palpitation, but not unless some cardiac disease co-exist. Cough preceding, commencing with, or following dyspnea, exists in almost every case; the habitual sputa are frothy, liquid, and mucous or watery. It is matter of doubt whether the state of the lung itself, independently of that of the bronchi and pleura, may give rise to pain; my own observation leads me to doubt it. The facies of emphysematous patients is pe⚫culiar: of dusky colour, and anxious melancholy expression, it is full, out of proportion with the chest and body generally, -a probable result of thickening of the cellular membrane and muscles of the face, as suggested by Dr. Stokes,-the former from repeated venous obstruction, the latter from respiratory effort. The nostrils are thick, and very often the lower lip full, and venously turgid: I have, however, not seen the latter state without heart-disease. The muscles of the neck enlarge, and its cellular tissue disappears. The patient's gait is stooping; Dr. Stokes has known the acromial, interscapular and lower scapular regions almost horizontal. The strength is inversely as the dyspnoea: in aggravated cases, bodily exertion becomes an impossibility. The flesh of the body generally and slowly fails,-each attack of bronchitis diminishing the weight pro tempore, or permanently. The pulse is not accelerated,far from this, it ranges below the average of health in a considerable number of cases, except when intercurrent bronchitis is present. The respiration also (with the same qualification) is less frequent than in health; in fact, the act is so laboured a one, that it cannot be often repeated in the minute. The pulse often strikes the observer by its weakness, as compared with the amount of cardiac impulse. This want of accordance comes of the frequency with which the right heart undergoes enlargement (while the left does not suffer,) as a consequence of the pulmonary disease. No conceivable amount of emphysema of both lungs will necessarily entail the smallest amount of

dropsy, even oedema of the ankles. If dropsy occur, there is something else (generally tricuspid regurgitation) to account for it. The bowels are habitually constipated; the urine aqueous.

Emphysema tends, in the course of years, to produce dilated hypertrophy of the right heart, Bright's disease, and habitual inclination to venous congestion within the head. It is rather protective than otherwise against tubercle, has but slight influence in producing dilatation of the bronchi or pleurisy (Louis,) rarely leads to interlobular emphysema, and still more rarely, by rupture of a sub-pleural sacculus, to pneumothorax.

III. The physical signs of emphysema are numerous and positive. Inspection discovers bulging of the infra-clavicular, mammary, and central sternal regions, or of the anterior surface generally. General expansion of the chest occurs very rarely; M. Louis observed it only once in ninety-six cases: when it exists, it gives the chest a globular form.

The state of the interspaces in the bulged portions of surface has been matter of dispute. Dr. Stokes has taught that in emphysema, "even after great dilatation of the chest has occurred, we see the intercostal spaces, so far from being obliterated, deeply marked;" and that the single malady in which this obliteration really occurs is pleurisy in its advanced stages. The conditions directly conducive to its production are paralysis of the intercostal muscles and excentric pressure, one being as essential as the other; this paralysis is presumed to be the result of inflammation extending to the muscular tissue. For the same reason, the intercostal spaces will not be obliterated in cases of simple hydrothorax, nor in all instances of pleuritic effusion; because muscular inflammation and paralysis do not exist at all in the former, and are not necessarily present in the latter. The question here started is strictly one of observation; and it must be confessed that the experience of physicians generally does not accord with that of Dr. Stokes in respect of the bulging of emphysema. MM. Louis and Woillez (not to mention others who have paid less special attention to the form of the chest in emphysema) are wholly opposed to Dr. Stokes on this point. Both maintain that the intercostal hollows are in this affection either effaced or manifestly less marked than in the natural state; and even point out this implication of the muscular plane of these spaces as one of the distinctive marks of emphysematous prominence. In point of fact (as mentioned