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CHARING-CROSS HOSPITAL.TWO CASES OF FRACTURED RIBS, WITH WOUND OF

LUNG; EMPHYSEMA; PNEUMOTHORAX; HYDRO-THORAX; RECOVERY.

(Under the care of Mr. BARWELL.)CASE 1.-Thomas BV -, aged fourteen, was admitted, on

the 21st of May, 1873, having been struck from behind bythe shaft of a waggon, and jammed against another vehicle.On admission, the ribs on the right side, from the upperpart of the axilla downwards, were found to be fractured,and the right side of the chest collapsed. There was some

haemoptysis, and the patient was in a state of shock. Next

day the haemoptysis was somewhat less; but there was em-physema, extending from the occiput to the ilium, on theright side only. Respiration 50; pulse 130; temperature1013°. Ordered one grain of mercury and chalk powder,with five grains of compound ipecacuanha powder, everyfour hours. The side to be strapped and bandaged.May 23rd.-Emphysema rather more extensive, but it

nowhere passes to the left of the middle line. Has greatinclination to cough, but restrains it on account of thesevere pain. For the same reason he speaks only in analmost inaudible tone. Sputum frothy, frequently stainedwith, and sometimes consisting entirely of, blood. Per-cussion-note of right side dull; alae nasi move considerably;tongue furred, moist; pulse 144 ; respiration 50; tempera-ture 1024°; bowels confined. Ordered two grains of calomelnight and morning, and to have six ounces of brandy daily.May 24th.-Passed a good night, and seems better.26th.-Last night the boy was very ill, almost in a state

of collapse, attributable to his having been over-excited bythe visits of too many friends. He says that he has painin breathing. The right chest is, however, less dull, and therespiratory sounds are clearer. Pulse 150; respiration 62,very shallow; temperature 103 3°. Bowels have acted twice.To discontinue the calomel; and take five grains of car-bonate of ammonia with some tincture of ginger three timesa day.28th.-There is some excess of resonance on the right

side, most marked at the upper part of the chest down toabout the third rib. The bowels act rather too frequently.Tongue cleaner; appetite better; pulse 130; temperature1012°. Slept better last night. Ten-drop doses of tinctureof opium to be added to the mixture.30th.-The space of excessive resonance has increased,

and extends to the lower border of the fifth rib and reacheslaterally to the middle of the axilla; otherwise the patientis better.June 1st.-Very much better. The tympanitic condition

is less; the respiratory murmur and the percussion noteelsewhere are normal. Pulse 94; temperature 100°. Tongueclean.5th.-The pneumothorax is gradually diminishing. To

take two grains of sulphate of quinine three times a day.8th.-Last night the patient woke np coughing very vio-

lently ; this caused some temporary pain, but he soon fellasleep again. The air in the pleura, which had almost dis-appeared, has now returned, the area of hyper-resonancebeing as extensive as ever. Pulse 80.

15th. - The excess of resonance has all but disappeared.To get up for an hour or so daily.

20th. - The patient has rapidly gained strength. The

pneumothorax has quite disappeared, and he is in all re-spects well, save that the percussion sound of the rightside about the axilla is slightly dulled. Discharged.CASE 2. - R. H-, aged forty, coachman, was admitted

March 28th, 1873, having been knocked down by an omni-bus. He was tipsy, and no positive diagnosis could bemade, but severe chest injury had evidently been inflicted.On careful examination next morning at 10 o’clock, five

ribs from the second downward on the right side were foundbroken outside the angles. There was considerable emphy-sema, and he complained of severe local pain, as well asmuch general suffering. Ordered five grains of compoundsoap pill every four hours. - At 8 P.M. haemoptysis began,and continued more or less for twenty hours.March 31st. - Subcutaneous emphysema over the right

chest laterally and posteriorly as high as the neck ; clear,rather low-pitched percussion-sounds over the front of theright chest; respiratory murmur entirely absent; subeuta-

neous crepitation very audible over emphysematous por-tions ; cubitus (left) ; respiration 2S ; cough occasional;sputa of dark sanguineo-mucoid masses, scanty and non-aerated ; pulse 100, rather small and hard; temperature99-5°; tongue furred, rather dry; appetite fair; bowels beenrelieved once slightly ; pain in the chest, even withoutmovement, is severe, and is greatly increased by any volun-tary or respiratory movement. He says he has had no

sleep since admission. To continue the opium; the bowelsto be kept active by enemata.

April lst.-Pulse 80; respiration 28; temperature 995°.He is easier, and suffers less. Cough and expectoration asbefore. Side to be strapped.2nd.-Pulse 96; respiration 28; temperature 100°. Cough

as before; sputa more abundant, with black and red clots.Still complains of not sleeping.4th.-Pulse 90 ; respiration 25; temperature 983°. The

man is improving, but to judge by his complaints, which, ashe is not allowed stimulants, are very dismal, he is now atthe worst. To discontinue the opium, except one pill atnight.

5th.-Respiration 20; pulse 98, stronger and fuller. Onthe right side the percussion sound is hyper-resonant fromthe clavicle to below the nipple, and an inch beyond theedge of the great pectoral muscle, with a low-pitched, blow-ing respiratory murmur, which seems distant, almost in-audible. The base of the lung cannot be examined on ac-count of the loud and harsh subcutaneous crepitation. Theright chest as a whole is nearly motionless. Emphysemastill up to the neck. The sputa consist of mucus and somepellets, about the size and with the appearance of raisins;not frotbv.9th.-He has been gradually improving. To-day the sub-

cutaneous emphysema was found to have entirely dis-appeared. The raisin-like sputa have ceased, save an oc-casional pellet; the pneumothorax the same. Pulse 87 ;respiration 20; temperature 96°.

12th. -Yesterday, towards evening, pain in the chestbegan again, and was severe. The cough also became moretroublesome; very little expectoration. These symptomscontinue to-day. The pulse is small and hard, 98; respira-tion 27; temperature 1015 . The hyper-resonance has butslightly diminished in extent. The respiratory murmur isnot well-marked; especially at the base and back of thelung can this be more clearly ascertained. Percussionsounds are slightly dull. The right chest very immobile.To take five grains of carbonate of ammonia three times aday.

17th.-For four days the pain and cough improved, buthas returned.19th.-Complains of greater weakness and difficulty of

breathing. On examination the lower and back part of thechest on the right side was found dull on percussion. Theregion of this dulness shifted, according as the patient layon his back or side, or sat up ; the rest of the right thoraxwas hyper-resonant. This condition was best observed whensemi-recumbent on the back. Then a line extending froma little above the angle of the scapula to above the nipple,corresponding roughly to the third rib, could very easily betraced; all below this was dull from pleuritic effusion, allabove it tympanitic from pneumothorax. Pulse 112;breathing 26; temperature 1012°. To take ten drops oftincture of digitalis in a diuretic draught three times a day.23rd.-He is better. Pulse 100; breathing 24; tempera-

ture 99.7°. The effusion is rather less in extent. Tocontinue the mixture, and to take ten grains of compoundipecacuanha powder at bedtime.27th.-Is getting better. Ordered four ounces of gin daily.May 1st. - Pleuritic effusion disappearing. He now

complains of pains in several joints, especially in the rightknee and ankle, which are somewhat swollen. Pulse 96;respiration 21; temperature 963°. Ordered three grains ofiodide of potassium in a diuretic draught three times a day.15th.-The chest symptoms have been getting better, and

now, with the exception of some slight general dulness onthe right side and a little tubular sound in the breathing,he has recovered. The rheumatic condition of the limbs,however, remains ; but as more urgent surgical cases re-quired beds, Dr. Pollock kindly took charge of the patient,and was able to send him out in three weeks, breathingperfectly well, although with still a little percussiondulness on the right side.