Pulsating pleurisies are essentially chronic; their duration is indefinite; left to their natural evolution, they are frequently fatal, the more so as those attacked oftentimes are tubercular or gradually fall a prey to tuberculosis.

Yet, pulsating pleurisies are curable, and their prognosis is not absolutely dark.

While easy of recognition, pulsating pleurisies remain, both as to their cause and mechanism, a curious and rare phenomenon, to this day unexplained. Likewise, no satisfactory explanation has been given of their rare occurrence.

After this review of the subject as obtained from the study of Comby and of his conclusions condensed in the form of so many aphorisms, proceeding with the report of the writer's case will demonstrate the accuracy of Comby's assertions, although, as said before, some of them fail to receive support.

Thus, the little patient was brought to the office, by his mother, four months after an attack of scarlet fever, not having been free from cough during all this time. Of late, this cough had increased, and although he had been about, yet his mother had noticed that he was easily out of breath and that he frequently complained of pain in his side.

Presently, he had a short continuous cough, an almost livid hue of skin, and a dyspnoea so intense as to cause astonishment at his having reached the office. The pulse was rapid, but regular. On removing his clothing, there was observed on the left side, under the arm, a round enlargement the size of the palm of the hand. This tumor was pulsating; it was located over the seventh, eighth and ninth ribs, about midway between two vertical lines descending one from the pit of the axilla and the other from the angle of the scapula; it was soft and fluctuating, and its beating was synchronous with the pulse. There was no discoloration of the skin over the tumor, no fremitus, no souffle.

On further investigation, the following points were noted: No manifest projection of the intercostal spaces, but quite apparent unilateral chest-immobility. Dullness, general posteriorly, and extending anteriorly near to the collar bone; slight Skoda's tympany. Thoracic vibrations, not existing in front, and but scarcely preserved behind near the vertebral

column. Absence of vesicular murmur. Distant souffle, harsh enough; bronchoægophony. At the apex, breathing somewhat rude, somewhat blowing; in short, supplementary respiration, aphonic pectoriloquy. Adjacent organs displaced; heart apex beating on the other side of the sternum, gastric resonance lowered, and Traube's semilunar space effaced.

Thus, there was every indication of the presence of a large effusion, and of a purulent one since it was pulsatile.

To remove any possible doubt, an exploring aspiration was made with the hypodermic needle, the needle being inserted above and to the rear of the fluctuating tumor, very close to the angle of the scapula. The syringe filled with pus.

This made it evident that nothing but an operation would give relief, and an appointment was made with my confrère, Dr. Featherstonhaugh, for the following day.

As the operation, in pulsating empyema, does not in any way differ from that of the ordinary form (Benlau's method), the only detail worth mentioning is that the incision, instead. of bearing on the classical point, in front of the anterior edge of the latissimus dorsi, in the fifth or sixth space (Moutard Martin) in the sixth or seventh (according to other authorities), was made in the very center of the fluctuating pocket, thus penetrating the pleura between the eighth and ninth ribs (lowest admissible point, says F. C. Shattuck, in Reference Handbook of the Medical Sciences).

The progress of the case after the operation was rather simple; some little shock, but from the very first days the suppuration of the pleura had considerably lessened, the patient was recovering strength, appetite, etc., etc.

Just a month after the operation, the pleural cavity, washed only once in two or three days with an alternate solution of boric acid and potassium permanganate, had contracted so that it admitted but one fourth of the liquid first used. The side was slightly depressed and flattened; the incessant cough had disappeared; the heart had moved half the way towards its normal position; the respiration was weak, unsatisfactory, obscured by cracklings and tubular râles, yet it was not wanting. To all appearances, the tendency of the case was towards recovery. In fact, in the course of the next two months, the patient became practically well; although,

· properly speaking, there was left a sinus, which took a year to close finally.

To obviate the flattening of the thorax, the little patient was subjected in every possible way to a sort of training; respiratory gymnastics, by exercises of deep-forced breathing; muscular gymnastics, by motions of the arms, etc., etc.

It was, however, our impression that, in time, the thorax would inevitably become deformed, inasmuch as in none of such cases can the lung be expected to regain its integrity; Comby having particularly insisted on this point, that "the pulsations synchronous with the heart beats are met with only in old purulent pleuritis, where the lung has become definitely contracted and strongly adherent to the pericardium” (France Médicale).

But the case did not realize this expectation. Frequently seen later on, and again quite recently (Febr., 1899), its condition and appearance may be summed up as follows:

The boy, now nearly 12 years old, has grown up rapidly; he is tall for his age, but slim and slender; though not strong, has never since coughed nor been sick. On being divested, his chest shows symmetry and dilates equally well on both sides, both as to inspection and palpation. A careful auscultation reveals no abnormal sign and no difference in the respiratory murmur of the left side as compared with the right, either as to force, quality or extent; everywhere is found good vesicular breathing. This condition is further corroborated by percussion and mensuration.

Thus, that lung has not been sclerosed.

Thus, again, sclerosis is not an essential condition of pulsating pleuritis, or of all large pleural purulent collections. Again, it does not appear essential that the disease be chronic for this phenomenon of pulsation to occur.

Watkins has quoted a case where every indication was in favor of an acute course.

In our case, the indications seem to demonstrate that it was not chronic. The child begins to cough towards the end of his scarlet fever and continues coughing until he comes under treatment, that is, four months later. But the fact that quite rapidly after the operation, the lung regains its elasticity and that its functions are restored ad integrum

appears as a fair indication that the disease remained throughout of an active form. It is likely that the breathing apparatus became involved in the lung tissue first. The pleura became diseased secondarily, because the lung, beneath, was diseased. And as the pulmonary lesion was septic-the infection, probably streptococci, having been brought in the footsteps of the scarlatinous infection-this caused the pleuritis to become rapidly purulent. Regardless of the four months elapsed, it may therefore be quite possible that the empyema was of rather recent date. In support of this hypothesis, you might remember that, before operating, we had observed a souffle quite sharp, though distant, and that, soon after the operation, râles could be heard; which would show that the lung was not carnified and unable to dilate. As a last proof, it might be mentioned that the heart, as we remarked, at first pushed over to the right, then receded under the sternum during the month following, did not, however, symphyse itself there; in course of time, it returned to its normal place. Moreover, later on, it exaggerated its position to the left, and this on account of grave structural changes.

Indeed, this deviation to the left is striking. The apex to-day is seen to beat three and a half centimetres below the nipple; in other words, the apex is lowered a whole intercostal space, and beats outside the nipple vertical line; the impulse is strong and, if felt with the hand, it communicates to it a decided thrill, which reminds of the "purring tremor" of Laennec. At percussion, the area of dullness is considerably increased. Thus, this heart is hypertrophied. The hypertrophy is compensatory to a double valvular lesion. During systole, there is at the apex a marked murmur: mitral insufficiency; and during diastole, at the base, a louder murmur, but soft and prolonged: aortic insufficiency. It is quite natural that the unfortunate young patient, while growing rapidly, should have remained delicate; he is on the way to a cor bovinum

In the beginning, we alluded to this valvular lesion when we compared this case with the first one related, and pointed out that both had a similar organic affection of the heart for their ultimate outcome. To what period does the pathogene

sis of this lesion date and what is it to be connected with as to causation? At the moment of operating-we have insisted on this point-the heart was deviated, but appeared healthy. Scarlet fever can then hardly be incriminated; except remotely, on account of its debilitating influence. Most likely the lesion has been the outcome of the infectious pleuritis, although it is difficult to determine the time at which it may have set in and when it became apparent. To settle this point would have required a closer observation than was possible.

If it be granted that the myocardial changes have been the direct consequence of the suppurative pleuritis, then this case differs from the first in that respect; for in the first case the cardiac affection seemed to have developed between the retropharyngeal abscess and the empyema, unless we admit that it coexisted with the later disease.

Thus, in one case (the first), the heart is affected before or at the same time as the pleura; while in the other (the second) it is affected after; but in both, it becomes affected after a suppurative disease of a very severe type.

Thus again, both cases have an eruptive fever for starting point (remote causes), and both terminate in a most grave alteration of the circulatory center (ultimate consequence).

Finally, such cases-as well as the other one reported (of pulsatile abscess of the præcordia)—are not unfair illustrations of the sad systemic influence of severe suppurative diseases; defective health or untimely death, under any ulterior provocation, however slight, being their natural result.

For the ANNALS.

A NEW METHOD OF TREATMENT OF CARCINOMA CESOPHAGI.

BY DR. WALTER ZWEIG,

Assistant in the Policlinic of I. Boas, Berlin.

In February of 1899 Rosenheim (Therapie der Gegenwart) described a new method of treatment for the dysphagia of patients with carcinoma œsophagi and its effects have been determined on the patients in our policlinic. The difficulty