phthisical symptoms of late years, render it probable that the physical signs are partly due to dilated bronchi and air-cells, consequent on the original inflammatory lesion.

CASE 131.-Phthisis after Injury to Chest. Arrested Eight Years. Death from Typhoid Fever.

A young gentleman, aged 14, who had lost his mother and one sister in consumption, was first seen by Dr. Williams, June 12, 1860. Four years before, his chest had been crushed by a cart, since which time he had had more or less cough, and was thin, but was otherwise well, till the last four weeks, when it had increased, and was accompanied by expectoration. Deficient breath and motion in upper part of both sides of chest, most marked on the right, where are large tubular and croaky sounds. Tubular sounds above the left scapula.

Oil was ordered in a tonic of phosphoric acid and quinine; and counter irritation with cantharides liniment.

September 29.-Much improved. Cough slight. Gained 5lbs. in a month. Dulness, large tubular sounds upper right chest, and some crepitation in parts.

June 8, 1861.-Wintered well in Madeira, and out daily; but in April brought up three ounces of blood, in May one ounce, and on the voyage home, when a cold wind was blowing, five ounces. Nevertheless, has gained 14lbs., and physical signs are improved, dulness being diminished in the right lung.

June, 1862.-In the autumn gained 8lbs. more, and wintered again at Madeira, but was very sick on voyage to and from the island. Was out daily during winter, walking ten miles a day or riding twenty, but always had cough and expectoration, and once hæmoptysis to the amount of one ounce. Took oil only once a day, and lost 10lbs. in weight. Dulness, dry cavernous sounds in upper right chest, with deficient breath below. Tubular sounds above left scapula.

July 2, 1863.-Passed last autumn in South Devon and gained 14lbs.; afterwards spent the winter in Syria and Egypt, and remained pretty well, except at Cairo, where had diarrhoea, and brought up five ounces of blood in November. Then went up the Nile, and gained flesh, but lost it afterwards. Has taken no oil since March. More breathing audible in right front. Tubular sounds still in upper portion, and some crepitation and obstruction in lower right back.

Was seen again in October. Had brought up an ounce of blood in August, but had taken oil, gaining 9lbs., and was able to walk eighteen miles.

June 9, 1864.-Took a tour through Jamaica, Panama, Cuba, United States, and Canada. Was well and active all the time, but took no medicine, and has lost 3lbs. Pectoriloquy in the right front, and tubular sounds above both scapula.

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September 28.-In Devon, and quite well, walking several miles a day at Free from cough, short breath, and hæmoptysis,

the rate of four an hour.

Physical signs improved.

June 1, 1865.-Wintered in Egypt well, except catching a slight cold, with tinged expectoration, at Beyrout, and since then has been taking oil, Tubular sounds above both scapula, loudest above right, and some crepitant obstruction in the lower portion of the same lung.

July 12, 1867.—Wintered during 1866 in Malta and Algeria, and last year in England, but caught cold when travelling, and had fever, and was much reduced. He nevertheless married in February, and went to Pau; but became very weak, and had slight hæmoptysis. In the spring visited Bagnières, and then Italy, where improved. Dulness, dry cavernous sounds, upper right. Breath weak, with subcrepitus below.

Died of fever in Devonshire, February 1868.

Pneumo-thorax from Perforation of the Pleura.

The occurrence of pneumo-thorax in the course of phthisis from perforation of the pleura commonly causes a serious aggravation of the malady, and accelerates its fatal termination. These cases are sufficiently familiar not to need exemplification; but I record four remarkable cases of recovery after this accident. To explain them, we need only bear in mind that the phthinoplasm which causes the rupture may be the only one, or nearly the only one, in the lungs, its accidental position near the surface leading to this peculiar result. In the same way, a large and fatal hæmoptysis may be caused by a small tubercle or patch of degeneration happening to involve a large blood-vessel and lead to its rupture.

CASE 132.

Pneumo-thorax. Gradual Recovery. Lived
Twenty-one Years.

Mr. D. A., æt. 26, surgeon, March 17, 1846; seen with the late Dr. John Taylor. Sister died of phthisis. Declares that he was quite well till seventeen days ago, when, riding a very restive horse, he was suddenly seized with severe pains in the whole left front of the chest, catching the breath. This has continued more or less ever since, with short dry cough and quickened breath. Pulse 120, weak. No heat of skin, and other functions natural. Left chest tympanic and tender on percussion. Loud amphoric breathing, metallic tinkling with voice, and sometimes with breath and heartbeat, which is a little to right of its proper place. Intercostal spaces not de

pressed in inspiration. Dulness for about three inches in the lower part of left back. Breath-sound puerile in right lung.

This patient remained in a weak state for twelve months, suffering still from short breath and pain in the left chest; very little cough. He visited me in the spring of 1848, when he had improved in flesh after taking cod-oil, but was still weak and breathless, and with sore feeling in left chest. Now, however, the stroke was generally dull; breath-sound very obscure, with subcrepitus. No metallic or amphoric sounds.-To continue oil with tonic, and paint the side with iodine.

I heard that his health improved after, sufficiently to enable him to go as surgeon to an East India merchant ship, when further amendment took place, and I heard of him some years after as conducting a small practice in Kent. Death announced in Times,' 1867.

CASE 133.-Pneumo-thorax. Recovery.

Living Ten Years after.

A gentleman, aged 48, first consulted Dr. Williams, December 11, 1861. He had lost his mother and a sister from consumption, but, with the exception of a sore throat four years ago, he had no ailment till last May, when he was attacked with pain and throbbing in the left side, and with cough. In July the breath became very short; in September the expectoration was sometimes tinged with blood, and Dr. (afterwards Sir James) Simpson, on examining his chest, found the left side fixed, but clear on percussion, and the heart beating at the sternum. Dr. Williams, in addition to these signs, detected over the lower half of the left side, back and front, large amphoric blowing sounds, and metallic tinkling with voice and cough, and with any occasional clicks; also tubular sounds in the upper portion of the lung. Breathing puerile in the right lung. Pulse 100. Skin cool. Oil was ordered, with quinine phosphoric acid and tincture of orange, and counter-irritation with cantharides liniment.

April 19, 1862.-After seeing Dr. W. the cough increased, but after being some time at St. Leonards, taking quinine and oil, he improved wonderfully; gained 18 lbs. in weight. Pulse normal and regular. Dulness, deficient breath in lower half of the left chest, but no trace of metallic tinkling or undue resonance. Large tubular sounds at and above the scapula, and some friction sounds in front, and at the side, where there has been some pain. Left chest contracted, measuring three-quarters of an inch less in circumference than right.

July 2.-Is in town frequently, attending at the House of Commons, and remains well. The pain and friction-sounds have ceased on the left side.

December 20.-Was well till September, when he had a severe attack of measles, accompanied by cough; but was convalescent in a fortnight, and since then has been free from cough, and with the exception of breath being short, is quite well, and able to walk and hunt. Some breath-sound now heard in left front, as low as fourth rib, except near sternum, where the heart

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dulness and pulsation remain. Dulness and little breath below; bronchophony above both scapula.-To continue the oil in phosphoric acid tonic. November 18, 1863.-Quite well, and free from cough and expectoration, though often exposed to wet and night-air in yacht. Is able to shout as loud as ever. Deficient motion and stroke-sound in whole left side, which is still contracted, but loud and vesicular breathing in front and at the side. Loud tubular sounds from the middle of scapula upwards. Tubular sounds above right scapula.

October, 1869.-Generally well, and has become stout, but more or less cough. Wintered at Caithness. Still dulness and large tubular sounds at left scapula and above.

The signs of pneumo-thorax were unequivocal in this case, and must have arisen from perforation of the pleura, by partial disease of the lung in the summer of 1861. Happily this disease was arrested, the air effused was absorbed, and the lung was gradually re-expanded.

CASE 134.-Pneumo-thorax. Complete Recovery. Well Four

Years after.

Mr. F., æt. 24, October 2, 1867.-Several half-brothers and sisters have died of consumption. Except a pain in the chest last November, from which he was well in a fortnight, has had no illness till the second week in August, when he again had pain in the front of the chest with a cough, which entirely ceased in two weeks; and in September was well enough to make a tour in Switzerland, and ascended the Eggischorn with no other inconvenience than short breath, and occasional pain in the left side. No cough. In the last three days he has noticed a splashing noise in his chest, but says he feels well. Seems nervous and anxious, and with quickened breathing. Pulse 90; heat natural. Left chest distended, tympanic on percussion, and with no breath sound. Heart pulsation seen and felt to right of sternum and in epigastrium. Tubular breath and voice at left scapula; and below speaking or laughing is accompanied by a tinkling echo, which can be produced also by succussion. Dulness in lower third of left back.-To take oil in tonic mixture. Left side to be painted with tincture iodine.

October 14.-Much the same. Complains only of short breath, and of the splashing noise on every quick turn of his body. Cough and expectoration slight, induced by change of posture. Signs the same.

October 22.-Continues pretty well, but breath short, and occasional pain in left chest, which is tender, especially in lower part. Hears noise less. Left side smaller, with less tympanic distension. Tinkling and splashing sound higher in axilla and back. More breath sound above left scapula.

November 18.-Weaker, and feverish at times, with pain in side. Sometimes faint on exertion, and breath short. Dulness, and absence of breath in lower half of left chest. Stroke clearer, with some breath sounds above. Bronchophony above_right scapula. Heart now in place, or a little higher

and more to the left than natural. No tinkling, splashing, or other sign of cavity, nor flattening of walls.

February 10, 1868.-Has continued steadily taking oil and tonic, and has much improved till the last week, when there has been much more pain in side, with feeling of weakness. No cough, but breath is shorter again; appetite bad. Left chest more natural in shape, but lower third contracted; still dull, while in middle is less dulness, with obscure breath. Tubular sounds at and above scapula. Friction with deep breath in middle front (where has been pain). Heart to left of sternum, with its apex beating above fifth rib. Nitromuriatic acid mixture, belladonna plaster to left chest.

June 9.-Quite well, except pain catching breath on exertion; felt since leaving off plasters. Strength good, and up to usual weight, 10 stone. Same signs, except slight crepitus below left axilla.-Continue nitromuriatic mixture, opium plasters to left side.

June 8, 1869.-Well all winter, without pain or cough, but breath oppressed by cold. Lately been a walking excursion, several miles daily, and uphill with a knapsack on back. Weight 10 stone 8 lbs. Lower half of left chest rather duller, and moves a little left than right, but breath sound heard everywhere except at base, where is crepitus on deep breath.

September 3, 1869.-Heard that he had been walking 30 miles a day, shooting, rowing, &c., without inconvenience.

In this case the discovery of the disease causing natural alarm, a late President of the College of Physicians was consulted, and expressed doubts as to the nature of the case. This led the patient to seek a third opinion, which was that of the present President of the same College, who fully confirmed the diagnosis first given.

CASE 135.-Pneumo-thorax. Rapid and complete Recovery.

Mr. M.- -æt. 48; seen with Dr. Stutter, of Sydenham, May 16, 1868.Lost a brother in phthisis. Has been quite well and gaining flesh lately. Has been in the habit of going quickly up and down a long flight of stairs twenty times a day, up to five days ago, and lately had found the exertion cause pain in the right side, and a feeling of oppression. On that day he consulted Dr. Stutter, who ordered a mustard poultice the side. This relieved the pain, but the breath remained short, and then Dr. Stutter found signs of pneumo-thorax on the right side. Now complains of nothing but shortness of breath, and a feeling of fulness in the right side. Pulse quiet, urine scanty. Lower half of right chest tympanic on percussion down to lower margins of ribs, below which liver dulness reaches down four or five inches in abdomen. Breathing amphoric, with metallic tinkling on coughing in lower half of chest. Above breath sound obscure and stroke rather duller than on left side, particularly on the scapula.--An effervescing saline was given for a few days, and tincture of iodine to be painted on the right chest. Afterwards oil to be taken.