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puerile respiration), and below in a zone extensive enough but very narrow; behind, the breathing was free over the entire back, no crepitation, perfect resonance. Hence, pleural sac was in a normal condition, and pleuritic effusion out of the question. Was an aneurism to be thought of ? On the surface of the swelling, the skin was red, tense, thin and quite warm. It seemed suggestive of an abscess. Such was the opinion of my old and regretted friend, the late Dr. Boudrias, whose well tried and extensive experience was of much value to me in this instance as on many other occasions. "I admit an abscess," he argued, “for if it were aneurism, it should be of the internal mammary artery, or of the intercostal. But those arteries are too small to furnish so voluminous a tumor. Moreover, it cannot be from the aorta, as then it would be located higher up. Neither can it be an aneurism of the apex; no observer has ever taught that such an aneurism had perforated the chest wall; as a conclusive sign, there is no murmur. In proof of abscess, there is the existence of previous pains." To assure the diagnosis, a capillary punction was then made at the base of the tumor, selecting a point where the skin was sound; a considerable amount of pus escaped. The pocket was now freely open so that a possible subcostal collection and diseased condition of the ribs might be looked for. After a little search, there was found a perforation located at the union of the intercostal cartilage with the sixth rib and which had afforded communication between the anterior purulent collection and another one located beneath the thoracic wall. The pus was inodorous and carried flocculent particles and pseudo-membranous shreds; there was denudation of the edge of the rib and of its posterior face, but to an extent which remained undetermined. Thus, it had become clear that it was a case of costal periostitis with "shirt-stud” abscess. One may infer that the posterior pocket of this abscess was in contact with some point of the ventricular part of the pericardium As Le Dentu remarks, "the heart impulse does not belong solely to the apex, every portion of the ventricle imparts the same sensation during the cardiac systole." The heart was pushing the liquid forward by compressing the retro-parietal pocket; by this compression, a certain amount of pus was forced into the external abscess, and hence occurred expansion and impulses. After the operation, fistulous tracts persisted for about three months, but finally cicatrization took place without our having recourse to resection. On October 23, 1890, a little more than a year later, this child contracted diphtheria, which became laryngeal. I had to intubate, but in 28 hours the child was dead. Some time ago, I gave you a parallel between tracheotomy and intubation; I had this case in mind when I spoke of “an instance when I had to intubate with no other help than the father and a neighbor" (Medical Annals for May, 1898, page 252).
This digression has perhaps carried us a little too far from our subject, but no detail is insignificant which can guard against error.
Thus, the utmost care has been taken to make sure of your diagnosis. Yet, to clear up a last doubt, as in the case just referred to, you practice an exploring punction. It gives pus.
Should you now proceed to empty the pleural cavity by aspiration, you will cause the formation of a pneumothorax, which takes the place of the aspirated Auid. The atelectasis of the lung is such that this organ is incapable of dilating rapidly enough to fill the vacuum left by the punction. Hence the pneumothorax is almost inevitable; in very few cases has it failed to appear.
This pneumothorax is latent; for its detection, you can depend neither on the amphoric breathing nor on the metallic tinkling; the Hippocratic sound alone can reveal its presence.
The thoracic pulsations disappear after the evacuation of the pleura; they recur after aspiration as soon as the accumulating liquid is again abundant. Even in this case, they may finally disappear.
The heart is deviated and, so to say, transposed to the right; it is held by adhesions which prevent its return to the left after the punction. The cardiac impulses are regular; there is no enlargement, no dilatation, no valvular lesions.
Sometimes, a slight pericardial effusion has been detected, even adhesions extensive enough to produce cardiac symphysis.
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 dyspnoa 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. Featherston haugh, 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 fattening 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