264 to twenty ounces, which caused him to faint; sennse draught. I Evening: Has been much relieved by the bleeding; blood cupped and buffy; twenty leeches; enema; calomel and opium. In the night, at two o'clock, the dyspnæa returning, twentytwo leeches were applied, and thirty minims of solution of opium given. l9th.-Eight A.,11.: Easier, quieter, better; pulse 110, soft; can lie quite flat on his back. The wound discharged so little, that the external parts were dilated inwards towards the

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... num, until the pulsation of an artery could be seen, perhaps the internal mammary, which it was not thought advisable to disturb; respiratory murmur not distinct at night; enema; calomel, opium, and twenty leeches. 20th.-At three in the morning, being greatly oppressed, thirty leeches were applied, and at eight o'clock twenty more, which quite relieved, but left him in a state of great exhaustion, sick, and faint. A little arrowroot relieved the faintness ; discharge from the wound free and accompanied by air,' bowels open. -Ten at night: Calomel, and forty minims of the solution of opium. 21st.-Eight A.M.: Has now, for the first time, a hope of life; pulse 112, soft; no pain; can turn on his side, but fears to hurt himself; wound discharges freely; has had a small piece of bread for the first time.-Four P.M.: Restless, but better; senna and sulphate of magnesia mixture.-Eight P.M.: Oppressed; pulse 120; twelve leeches; calomel, and thirty minims of the solution of opium, at night. 23rd.-Oppression at night relieved by six leeches; slept afterwards; breath slightly affected by the mercury, which was now omitted; ten grains of the compound extract of colocynth given at night, with thirty minims of the solution of opium. 25th.-Free from pain; breathes easily and without difficulty; can turn in bed with ease; slept well; the discharge from the wound is free; takes farinaceous food, oranges, tea, &c. He gradually improved until the 13th of March.-On the previous Friday, the 9th, lie removed from Bond-street to Mount-street; and on the 13th, amused himself by washing all over in a small back room without a fire; caught cold, and, acquired a troublesome congh, which was quieted on the 14th, at night, by opium.-On the 15th, A.M., it was evident that some mischief had been done; pulse 120; breathing difficult; was bedewed with a cold sweat; respiratory murmur indistinct on both sides; on the left, not heard below the fourth rib; although the whole side sounded sonorously, it evidently contained air, the tintement metallique being very remarkable. The wound having closed very much, and the distance to the left cavity of the pleura under the sternum being considerable, a piece of sponge tied around the eye of a small gum-elastic catheter was introduced, so as to enlarge the track of the ball, and give passage to the air from the left side of the chest. This was done at five o'clock P.M.; and at ten, on its being withdrawn, air rushed out in a very manifest manner, and to his great relief. The metallic tinkling which was distinct before the instrument was withdrawn instantly ceased, but could be reproduced by closing the opening. The small gum catheter was therefore re-introduced with the eye projecting beyond the sponge, and retained, air passing through it; cough very troublesome. March 17.-Better; pulse 100; bowels open; cough easier; expectorates freely a rouillée, or reddish muco-purulent matter. 18th.-Easier and better; breathing on the left side not heard below the fourth rib; discharge free; the permanent gum catheter taken out, but passed in daily. After this he slowly became convalescent, and is now (1853) in perfect health, being an admirable instance of the treatment to be followed in such cases. When there is not an opening to enlarge, one should be made with the trocar. It has been stated by the latest writers on pneumo-thorax, that tympanitic resonance on percussion, and the absence of respiration, are not pathognomonic signs of pneumo-thorax, as these physical signs may exist without it, and pnerumo-thorax may exist without them. The metallic tinkling, in addition to the absence of all appearance of disease in the abdomen, will be conclusive of the presence of this disease. APPOINTMENTS. -Mr. Charles Gardiner Guthrie has been elected surgeon, and Mr. Carsten Holthouse assistantsurgeon, to the Westminster Hospital.-Mr. Mercer has been elected house-surgeon to the Essex and Colchester Hospital. Mr. Taytor, who retires, received an unanimous vote of thanks from the governors, and a solid testimonial to his worth, in the shape of a purse of sovereigns.-Dr. Minchin has been appointed medical officer to the North Dublin Union Workhouse. IN a former paper (see THE LANCET, Oct. 30, 1852) I endeavoured to show that epilepsy depended upon a decided and unequivocal deficiency in the due amount of that stimulus which is supplied to the muscles from the blood, nerves, and other sources, and not upon an increased afflux of such stimulus. In the present paper I propose to extend the inquiry, and demonstrate that other muscular disorders depend upon the same want. In order to this, I shall endeavour to prepare the way by some preliminary considerations respecting the temperament and predisposition of such of these disorders as are of a chronic character. I. All muscular disorders admit of being divided into three categories-the tremulous, the convulsive, and the spasmodic; and this division forms the groundwork of the subsequent remarks. 1. In ordinary tremulousness, the temperament or predisposition is obviously distinguished by delicacy; it is the feminine, in contradistinction to the masculine habit of body. In palsy, the shaking goes hand in hand with unequivocal marks of decrepitude and decay-the listless wish, the snowy head, the fireless countenance, the wasted limb, the feeble pulse. IN chorea, and in very bad tremulousness, the general condition is very similar. This affection is almost peculiar to females, and to females whose parents were infirm or aged, or who themselves had become enfeebled by improper or injudicious habits. It often originates during some severe and exhausting disease, or in the period of convalescence, and is always attended by signs of debility. In old cases these signs are very decided: the muscles are soft and pale, so as to bear some resemblance to the muscles of white-fleshed animals; they are also easily tired and tardily repaired. The face, lips, and tongue are pale; and not unfrequently the atony of the circulation is further indicated by pastiness of the skin, effusion in the serous cavities, rheumatic deposits, and other indications of a watery and depraved blood. In mercurial trembling the general state is intimately akin to that of general palsy or aggravated chorea; and in bad cases every faculty of the body and mind is completely shattered. In ague, the general strength is much impaired, and this impairment is in proportion to the severity and frequency of the paroxysms. 2. The hysteric convulsion is connected by its name with women, and by facts with women who are more than usually delicate, or with men who are in the same predicament. The convulsion of teething is equally connected with delicacy, for it is certainly true that this symptom manifests itself in weakly rather than in strong children, and in weakly children almost in proportion to their weakliness. 3. The state of system in chronic spasmodic affections is virtually the same. The liability to cramp is always associated with tremulousness. It increases with the advances of age, and is almost permanent, when occasional tremors are prolonged into palsied tremors. The cramps of lead-poisoning are connected with a remarkable degree of wasting and atrophy, particularly in the muscles. The subjects of catalepsy, in like manner, are much more delicate and impressible than they ought to be. Their skin is usually pale or dingy, their pulse readily disturbed, their general appearance either hysterical or apathetic. A cataleptic boy, lately under my care, (the particulars of whose case were reported in TIIE LANCET at the time,) was as irritable, uncertain, and fretful as an infant. His apprehension was slow, his memory weak, his head large, his eyes staring, his pupils dilated and sluggish, his complexion sallow and venous, his hand cold and clammy, his pulse slow and feeble. As with epilepsy, therefore, so with these forms of chronic muscular derangement, the conclusion is, that the disorder is manifested in a state of general weakness and atony, and not in one of health and vigour. II. In order to arrive at the knowledge of the real nature of the J several affections allied to epilepsy, we now proceed to examine the condition of the vascular, nervous, and muscular systems in, and the nature of the causes operating upon, these affections. I. What, then, is the condition of the vasc2clar system ? 1. In ordinary tremulousness, in palsied shaking, in mercurial , tremor, and in choraic agitation, the circulatory powers are ! always depressed. A flushed face and a bounding pulse are never ' present'. So also with the tremulous movements before and after fever. Rigor is coincident with a sense of coldness, a feeble pulse, a sunken countenance, a corrugated skin; subsultus, with a