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A 60-year-old man was observed for 7 years with progressive bullous emphysema that eventually rendered his right lung functionless and resulted in severe dyspnea. Thoracotomy revealed typical periacinar (paraseptal) emphysema. Excision and plication of bullae resulted in prompt relief of symptoms and return of function which were sustained during the next 5 years. The progressive course and recovery were documented by serial clinical, radiographic, physiologic and regional lung function studies. The natural evolution of bullous lung disease is reviewed as are the concomitant physiologic abnormalities and indications for surgerys

Propranolol (I.C.I. 45,520; Inderal) is the second specific adrenergic beta-receptor-blocking drug which has been introduced recently (Black et al., 1964). It succeeds pronethalol, which has limited uses because of its tumour-producing effect in mice (Paget, 1963). Initial work with pronethalol had " shown it to be capable of giving some relief of angina pectoris" (Alleyne et al., 1963). Propranolol exerts a beta-receptor blocking action at about one-tenth the equivalent dose of pronethalol; it does not produce turnours in mice (Black et al., 1964). Patients entered the trial as they presented. Each was given cards on which he was asked to mark down daily the number of attacks of angina pectoris and the number of tablets of glyceryl trinitrate used. All patients were seen by me at fortnightly intervals during the trial. At these visits completed cards were collected and the patients were questioned about the severity of angina pectoris. This was assessed on the basis of effort tolerance. Six grades were used: angina occurring on severe exertion only (grade 1), on moderate exertion, on the flat walking more than 100 yards, on the flat walking less than 100 yards, on watching television, and at rest. The resting heart rate and blood-pressure were also recorded at each visit and evidence of cardiac failure was sought. The bodyweight was measured and an electrocardiogram taken. Blood was collected for haemoglobin, total white-cell and differential count, platelet count, and serum glutamic pyruvic transaminase content. The urine was examined for albumin.Dosage.-The dose used was 30 mg. t.i.d., the morning dose being taken before breakfast, and the others after the midday and evening meals. This dose was chosen because it was the minimum required to block exercise-induced tachycardia in healthy volunteers (S. A. Stephen, personal communication, 1964). No change was made in existing therapy; in particular, patients were instructed to continue using glyceryl trinitrate as before. Though the patients were aware that a new drug was on trial, they did not know in what way this was being done. MaterialThe records of over 100 patients with a diagnosis of angina pectoris were examined. About half of these were eliminated as it was obvious that they did not match the criteria of suitability for trial (see below). The remainder were assessed clinically. ResultsNineteen patients completed the trial and provided the results for analysis. Of the original 23, one defaulted in the third week because his angina improved following unexpected change to a sedentary occupation; another died following a further cardiac infarct (confirmed at necropsy) at the end of the fourth week, having had placebo only; a third was withdrawn in the fifth week of the trial because of dizziness attributed to propranolol. The fourth patient, a 66-year-old woman with a six-year history of angina, was of particular interest. Prior to trial she estimated that she experienced about 12 attacks of angina weekly; some of these came on at rest. During the first ...

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