or four places, near the extremity, which is to be inserted into the chest. It should then be marked with ink at distances of about six and nine inches from the same end, so that when introduced, we may know how much of the tube is within the pleural sac.

The operation is performed in the following manner: The patient being ready, the tube is filled with water, its distal end closed by the ring, and placed in a basin of water beside the bed. The trochar is thrust through the centre of the small piece of rubber, which is to act as a valve, and this is drawn over the canula. Having oiled the trochar, it is to be thrust into the chest, at either of the points usually recommended for the operation.

As the stilet is withdrawn, the thumb should be placed over the end of the canula to stop the flow of pus until the drainage tube can be reached. The tube is then crowded through the canula for a sufficient distance, and the canula is withdrawn; as it leaves the chest walls, the rubber valve is slipped off upon the tube close to the surface of the chest. The extremity of the tube may now be opened under water, the canula slipped off, and the pus allowed to flow.

As the stilet is withdrawn, the pus escapes in a full stream, and during the passage of the tube through the canula no air can enter, on account of the pressure of pus from within. In this way the operation can easily be completed without the entrance of a single bubble of air.

After the tube is inserted, an aspirator can be attached, or the pus may simply flow out through the siphon. The latter method is sometimes preferable, as the aspirator is liable to cause too great atmospheric pressure upon the expanding lung, and consequent rupture of some of the smaller blood vessels. After the pus has ceased flowing, the cavity may be washed ont with a one or two per cent. solution of carbolic acid, at 100° F., or the cleansing may be deferred for twenty-four or forty-eight hours.

After the pus has been discharged, a slit a couple of inches in length, should be made in the middle of the elastic bandage

for the passage of the tube, and the bandage should then be pinned snugly about the chest, over the rubber valve.

In the after treatment, the pleural sac should be cleansed once or twice daily with a weak solution of carbolic acid. During the treatment, if the cavity ceases to diminish in size, other injections may be substituted.

In cleansing the cavity, the end of the tube should be placed under water, in a basin, which can be raised to any desired height. The fluid flows into the chest through the siphon and then out by the same means.

Between the visits of the physician, the end of the tube may be left under water, to which a little carbolic acid has been added, or it may simply be bent upon itself and closed, by slipping over it the little ring. Though the former method is preferable, the latter will sometimes be found necessary with restless patients. If the latter plan is adopted, the cavity should be cleansed twice a day.

For two or three days after the operation, the soft tissues in the intercostal space grasp the tube firmly and keep the cavity hermetically closed, but at the end of this time, the tube becomes loose in the opening through the chest walls, so that air would enter, or the tube would fall out, were it not for the piece of rubber, which was placed on it when the canula was withdrawn.

This rubber not only acts as a perfect valve, when held by the elastic band, to prevent the ingress of air, but it also holds the tube in position, with sufficient firmness to prevent its being withdrawn by any ordinary force. The tube may be still further secured, if thought best, by a bandage placed about the chest.

The force with which the fluid flows into the cavity may be perfectly regulated by the height of the column of water in the siphon. As soon as the cavity becomes slightly distended, the patient will complain of uneasiness or pain in the chest, and then the tube should be at once lowered, to stop the flow. This has the advantage over methods usnally recommended of occasioning but a trifling wound, and consequently slight

constitutional disturbance from that cause-of preventing the entrance of air-of simplicity in the operation and convenience in after treatment of painlessness after the soreness from the puncture has subsided, and of comfort and neatness for the patient. It is nearly as simple as paracentesis with the aspirator, and is attended with little if any 'more danger to the patient.

It might be used in those unyielding cases of chronic pleurisy with serous effusion, where the cavity rapidly refills after paracentesis.

In illustration, I subjoin the reports of two cases operated upon by this method.

CASE I. A patient of Dr. P. H. Mathei. Seen in consultation with Drs. Mathei and E. Ingals, December 1st, 1876. E. G., aged four years, was attacked with rheumatism four weeks ago. A few days later complained of pain in left side, evidently of a pleuritic character. To-day the patient complains of severe pain in left side of neck, he has lost considerably in strength and weight,-appetite poor, thirst considerable, digestion fair, bowels loose, urine scanty at times and profuse at others. Pulse small and quick, 130 per minute; respirations, 40. Frequent hacking cough with no expectoration. Curvature of spine with immobility of left side and bulging, especially of left mammary region. Flatness over greater part of left side, with feebly transmitted respiratory sounds. Apex beat of heart within half an inch of the right nipple. Just below the nipple the right side measured ten and five-eights, and the left nine and five-eights inches. Introduced needle of aspirator, near the angles, between the eighth and ninth ribs, and withdrew five and a half ounces of thick yellow pus, when coughing came on and the pus ceased flowing; although the cavity was not empty, the needle was withdrawn. After the operation the apex beat could be felt about three-eights of an inch nearer the sternum. Soon the child became quiet, and he subseqnently did well for several days. The severe pain in the left side of the neck was perfectly relieved by the operation.

Dec. 7th. Pain in neck has returned. The patient very restless and suffering from dyspnoea. Punctured the chest again near the same point as before and withdrew eighteen ounces of healthy pus. A few drachms of blood flowed with the last of the pus. The impulse of the heart changed in consequence of operation from a position near the right nipple, to the left side of the sternum. The respiratory sounds became quite distinct in left lung. The child did well for two or three days after the operation.

Dec. 12th. Respirations, 44; pulse, 150. Patient very weak. Apex beat near right nipple. Performed paracentesis near the point of the last puncture and withdrew fifteen and a half ounces of pus. The heart returned nearly to its normal position and the left side which had measured eleven and onefourth inches before the operation, measured only ten and three-fourths inches afterward.

Dec. 21st. The patient did well for four or five days after the last operation, but for a few days has been losing; suffering greatly from dyspnoea and pain. During last night he took, beside several grains of bromide of potassium and several drops of laudanum, a grain and a half of morphia in doses of a quarter of a grain each, yet he did not sleep. There is oedema of the left side of the chest, as low as the last rib where it abruptly terminates. The struggles of the child in opposing another operation, caused the wound of the last puncture to reopen. From the opening, thick pus slowly escaped.

In the afternoon of this day, I operated in the method described, excepting that air was allowed to enter the chest. The aspirator was applied after the dressings had been secured and the air withdrawn with the remaining pus. Twenty-three ounces of a thick, greenish-yellow pus were obtained. About half an ounce of blood flowed after the aspirator had been attached. The pleural sac was not cleansed in this case, until the following day, afterward it was washed out every day with a one per cent. solution of carbolic acid. The tube was bent upon itself and kept closed, except morning and evening

when it was opened under water and the pus allowed to flow out. The pus remained more or less bloody for several days. The cavity was rapidly obliterated so that in two weeks it would hold only two ounces. Three weeks after the operation it was noted that the child had been suffering for several days with rheumatic pains, and that he had just passed through an attack of varicella. Not more than half a drachm of pus had escaped morning and evening for several days, and the cavity would not hold more than two drachms.

Jan. 13th. The bandage having been removed, the tube fell or was crowded out to-day-cavity entirely obliterated.

Four weeks after the operation, the patient was discharged by Dr. Mathei as cured; the opening in chest was healed, the lung expanded freely, the impulse of the heart was normal and there was no dyspnoea. A month later there was slight curvature of the spine and depression of the left side, but after a few weeks the child presented a normal appearance of the chest and was in perfect health. During the treatment, from two to three grains of quinine werc administered daily, and Dover's powder or morphia were administered when needed to relieve pain and secure rest.

March 18th, 1877. CASE II. Mrs. P., aged 30, mother of two children, youngest about three years of age. Has been sick about eighteen months. From the history, seems first to have had pleurisy. Was attended for several months by regular physicians, and then fell into the hands of a quack, who maltreated her for nine months.

The patient is very feeble; harassed by an almost constant cough, and frequently expectorates a considerable quantity of grayish white sputa, of a nummular form. Complains of severe pain in the right side, for which she is obliged to take frequent doses of morphia. Pulse, 118; respirations, 28.

Dullness on right side above fifth rib in front, and above sixth behind. Flatness below these points, and extending one inch higher in axillary region. When lying upon left side a slight degree of resonance extends about an inch lower in the axillary region. Heart one half inch farther to the left than