are not only common to both affections, but which, before the appearance of these I have now brought forward, were considered as exclusively belonging to encephaloid disease of the lung. In that described by Doctor Graves, the patient at first laboured apparently under pleurisy; and this view of the case seemed confirmed by the following symptoms: " decubitus on the affected side (the right)-fixed condition of that side-stitches on drawing in deep breath. The physical signs were universal dulness, with bronchial respiration all over the right lung; no rale; no resonance of the voice, diminished vocal vibration. At the post mortem examination, the whole right lung was converted into a mass of encephaloid matter; pleura greatly thickened and dense. In Heyfelder's case, the patient was attacked twice with acute pleuritis. When he first saw him he was labouring under acute pain in the left side; stitch on deep inspiration; inability to lie in any position but on the affected side. The left side was fixed, and was likewise dilated. The physical signs were complete dulness all over the left lung, with absence of respiratory murmur. No œgophony over this side. The heart was dislocated to the right of sternum; and in the situation usually occupied by it, there was a soft, elastic tumour the size of two fists. The right lung sounded clear on percussion, and in every situation, the respiration was puerile, and without rale. At the post mortem examination, the left lung was found converted into a white lardaceous mass, softened in the centre. The external tumour had sprung from this, and proceeded outwards between the ribs; it was also softened in the centre, and a direct communication existed between these two points of softening. In the remarkable case of Mr. J, detailed by Dr. Stokes, the symptoms were at first, solely those of pleuritis, attended at the commencement by dulness, occupying only the lower half of the pleural cavity, but which after some time extended all over the right side; and this side, which at first was of equal size with the left, soon became dilated to the extent of two inches. In addition to these symptoms of empyema, he was affected with oedema of the right

side, and the peculiar varicose condition of the veins of the same side, upon which Dr. Stokes lays such stress, became very evident: he lingered on for some time, and died in great pain. At the post mortem examination, a large quantity of pus, amounting to three pints, was found in the pleura. The lung was converted into a “solid, heavy, fibro-cartilaginous mass of a brilliant, white, brain-like colour, interspersed with black spots, of the diameter of a six-pence each, contrasting singularly with the white portion." The liver was "sound, but somewhat enlarged, and projected about three inches below the cartilages of the ribs, and at the point of contact with them, presented a very deep sulcus, such as Dr. Stokes has described in his observations on the diagnosis of empyema—a condition of the organ evidently the result of congestive engorgement.

From the short description of these three cases of cancerous degeneration of the lung, we may observe that they all began with symptoms of pleurisy. In all, decubitus could not be borne on any, but the affected side. The physical signs were extremely like those detailed in my cases; and in one (that by Dr. Graves) a soft elastic tumour presented itself behind, very close to where a tumour appeared in two of my cases; and in Heyfelder's, a large soft, elastic, tumour appeared in the inframammary region of the affected side, a position which, in my three cases, was occupied also by soft, elastic tumours. Now, supposing that these encephaloid tumours (for such they were found to be) had possessed the pulsation, which every-day's observation shews, that tumours of the kind are extremely likely to enjoy, how could such a case be distinguished from either of my two last? The grounds of diagnosis could not be derived from the history of the cases,-from the sufferings of the patient, -from the physical signs,-or from the nature of the tumours (presuming the encephaloid masses had pulsation),—or from their position, for an empyema may point, and an encephaloid tumour may form, on any part of the thorax. Nor could the comparison of the physical phenomena of the two sides of the chest afford much assistance; for in two cases of the malignant

disease, and in two of the empyemas, the dulness and loss of respiratory murmur were confined solely to one side. The other lung possessed clearness of sound on percussion, pure respiratory murmur, and freedom from rale. In the third case of malignant disease, and the first case of empyema, the physical signs of bronchitis were evident in the lung of the unaffected side, and dislocation of the heart observed in my three cases was also present in the example of encephaloid disease by Heyfelder. But even in these apparently obscure cases, considerable advantage will be derived from an attentive consideration of the points laid down by Dr. Stokes, as diagnostic between encephaloid diseases of the lung, and the ordinary affections of that organ. We have not, for instance, in empyema, the very remarkable varicose and tortuous condition of the venous system, accompanied by oedema of the chest and arm, occurring only on the affected side. For though it is mentioned that varicose veins surrounded the bases of the tumours in two of the foregoing cases, yet such a condition of the veins is widely different from that alluded to in Dr. Stokes's paper, and not likely to mislead the observant physician. Nor have we the remarkably persistent bronchitis noticed in the cases by Dr. Graves and Dr. Stokes, and the peculiar expectoration resembling black current jelly, from its admixture with blood. In the case by Dr. Stokes, these symptoms were not noticed at the time the affected side was dilated, but appeared after it had returned to its natural dimensions; and the liver was found protruding beyond the ribs for nearly three inches, though the sides were symmetrical—a circumstance not as yet observed in ordinary empyema; but to this latter phenomenon I shall return in another place.

These two latter circumstances proved an obstruction to the intra-thoracic circulation: the return of the dilated side to its natural dimensions shewed a decrease in its fluid contents, consequently, the obstruction must have been caused either by a tumour pressing on some of the large vessels, or by an important alteration in the structure of the lung itself.

The next feature from which information, in doubtful cases,

may be obtained, is the appearance of soft, elastic, and painless tumours in different parts of the body. These were observed in three of the cases described by Dr. Stokes, and presented themselves at a period long subsequent to the thoracic affection; and in a beautiful specimen of cancer of the lung, exhibited at a late meeting of the Pathological Society by Dr. Law, a soft and large tumour of an encephaloid nature appeared above the right clavicle, shortly before death. From what has been said, the occurrence of such tumours on the affected side, would greatly embarrass the diagnosis; but the situation in which they form appears to be quite accidental. In Bayle's and Dr. Law's cases, they were situated above the clavicle; in Dr. Graves's, one was attached to the ramus of the jaw, one to the epigastrium, and one to the posterior part of the thorax ; in Heyfelder's, one appeared at the infra-mammary region, and another under the left clavicle; and a fifth instance of this coincidence of cancer of the lung, with the appearance of soft, elastic tumours on the different parts of the body, will be found in Forbes's "British and Foreign Review"-No. xxxii., p. 384. The case is extracted from Kerst's Pathology," and is a remarkable instance of the latency(?) of thoracic cancer.

"The patient was a soldier, nineteen years old, who said that about three weeks before his admission, as he was walking, he felt a sudden pain in the ham, and on reaching home, felt a swelling there, which, in twenty-four hours, increased to the size which it presented on his arrival at the Infirmary. At this time, the left knee was much enlarged, but the pain had not increased. There was swelling as large as a goose-egg in the ham, partly compact, partly fluctuating, and on a moderate pressure, distinctly pulsating. Under the notion that it was a false aneurism, compression was employed for some time; but as the swelling increased, and the oedema of the leg came on, the femoral artery was tied; after the operation, however, which in itself was successful, the tumour continued to grow as rapidly as before: the patient began to cough as if from organic disease of the

lungs, and gradually sunk. On examining the body, the internal organs were found healthy, except the right lung, which was completely converted into a brain-like mass. The tumour in the ham was fifteen inches long, and twenty-four inches in circumference, and adhered firmly to the periosteum of the femur and tibia. On its surface were five sacculi, holding between five and six ounces of a sero-sanguinolent fluid." Suffice it to say, that the tumour presented a well-marked example of encephaloid disease, and was curious from the fact that the artery ran over it, lying imbedded between two of the sacculi.

The presence of cancer in any of the other viscera will, likewise, it is hardly necessary to say, afford most valuable assistance, and the persistence of bronchitic rales, not removable by treatment, and continuing after the affected side has returned to its natural dimensions, constitute a point of dissimilarity of extreme value; for in every case of empyema I have seen, in which bronchitic rales existed, they always disappeared as soon as the effusion began to be absorbed, except in some rare cases, where the deposition of tubercle was rapidly progressing.

PURULENT EXPECTORATION IN EMPYEMA.

The case first detailed differs in some points from those which followed, and presents features which demand a separate consideration. The disease ran an unusually rapid course, if compared with those instances, where the matter of an empyema makes its escape outwards, but particularly rapid when compared with the slow progress of the other two cases, which extended over a period of between two and three years each. This circumstance may be accounted for by the difference in the habits and constitutions of the patients. The health of the woman, previous to the attack of pleurisy, was irreparably destroyed by hardship, syphilis and mercury, and in her cachectic and exhausted condition, any acute affection would, no doubt, have exhibited unusual virulence.

Three weeks after her admission into Hospital, she began to