^J 
 
 i^i 
 
 ^ ^ 
 
 IMAGE EVALUATION 
 TEST TARGET (MT-3) 
 
 1.0 
 
 i.l 
 
 If IM IIM 
 
 Hi 1^ {11112 2 
 ^ us, 12.0 
 
 1.8 
 
 
 1.25 
 
 1.4 
 
 1.6 
 
 
 ^ 
 
 6" 
 
 
 ► 
 
 "/} 
 
 ^ 
 
 /}. 
 
 .^^ 
 
 
 ^;. 
 
 
 y 
 
 ^^P' 
 
 w 
 
 Photographic 
 
 Sciences 
 Corporation 
 
 23 WEST MAIN STREET 
 
 WEBSTER, NY. 14580 
 
 (716) 872-4503 
 
CIHM/ICMH 
 
 Microfiche 
 
 Series. 
 
 CIHM/ICMH 
 Collection de 
 microfiches. 
 
 Canadian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiques 
 
Technical and Bibliographic Notes/Notes techniques et bibliographiques 
 
 The Institute has attempted to obtain the best 
 original copy available for filming. Features of this 
 copy which may be bibliographicaily unique, 
 which may alter any of the images in the 
 reproduction, or which may significantly change 
 the usual method of filming, are checited below. 
 
 Coloured covers/ 
 Couverture de couleur 
 
 I I Covers damaged/ 
 
 D 
 
 D 
 
 D 
 D 
 
 D 
 
 Couverture endommag6e 
 
 Covers restored and/or laminated/ 
 Couverture restaurde et/ou pellicui6e 
 
 I I Cover title missing/ 
 
 La titre de couverture manque 
 
 I I Coloured maps/ 
 
 Cartes g6ographiques en couleur 
 
 Coloured ink (i.e. other than blue or biacic)/ 
 Encre de couleur (i.e. autre que bleue ou noire) 
 
 I I Coloured plates and/or illustrations/ 
 
 D 
 
 Planches et/ou illustrations en couleur 
 
 Bound with other material/ 
 Reli6 avec d'autres docuntents 
 
 Tight birding may cause shadows or distortion 
 along interior margin/ 
 
 La reliure serr6e peut causer de I'ombre ou de la 
 distortion ie long de la marge int6rieure 
 
 Blank leaves added during restoration may 
 appear within the text. Whenever possible, these 
 have been omitted from filming/ 
 II 86 peut que certaines pages blanches ajoutdes 
 lors d'une restauration apparaissent dans Ie texte, 
 mais, lorsque cela 6tait possible, ces pages n'ont 
 pas 6t6 film6es. 
 
 Additional comments:/ 
 Commentaires suppl^mentaires: 
 
 The 
 to tt 
 
 L'institut a microfilm^ Ie meilleur exemplaire 
 qu'il lui a 6t6 possible de se procurer. Les details 
 de cet exempleire qui sont peut-Atre uniques du 
 point de vue bibliographique, qui peuvent modifier 
 une image reproduite, ou qui peuvent exiger une 
 modification dans la m6thode normala de filmage 
 sont indiquAe ci-dessous. 
 
 D 
 D 
 
 D 
 
 J 
 
 D 
 D 
 D 
 D 
 
 Coloured pages/ 
 Pages de couleur 
 
 Pages damaged/ 
 Pages endommagies 
 
 Pages restored and/or laminated/ 
 Pages restaurdes et/ou peiiicui^es 
 
 Pages discoloured, stained or foxed/ 
 Pages d6color6es, tachetdes ou piqu6es 
 
 Pages detached/ 
 Pages d6tach6es 
 
 Showthrough/ 
 Transparence 
 
 Quality of print varies/ 
 Quaiiti indgale de I'impression 
 
 Includes supplementary material/ 
 Comprend du mat6riei suppidmentaire 
 
 Only edition available/ 
 Seule Edition disponibie 
 
 Pages wholly or partially obscsTed by errata 
 slips, tissues, etc., have been refilmed to 
 ensure the best possible image/ 
 Les pages totalement ou partieliement 
 obscurcies par un feuiilet d'errata, une pelure, 
 etc., ont M film6es d nouveau de fapon d 
 obtenir la meilieure image possible. 
 
 The 
 poss 
 of tt 
 filmi 
 
 Orig 
 begi 
 the I 
 sion, 
 othe 
 first 
 sion, 
 or ill 
 
 The 
 shall 
 TINL 
 whic 
 
 Mapi 
 diffe 
 entir 
 begir 
 right 
 requi 
 meth 
 
 This item is filmed at the reduction ratio checked below/ 
 
 Ce document est filmd au taux de reduction indiqud ci-dessous. 
 
 10X 
 
 
 
 
 14X 
 
 
 
 
 18X 
 
 
 
 
 22X 
 
 
 
 
 26X 
 
 
 
 
 30X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 J 
 
 
 
 
 
 
 
 
 
 
 
 
 12X 
 
 16X 
 
 20X 
 
 24X 
 
 28X 
 
 32X 
 
re 
 
 16tail8 
 es du 
 modifier 
 er une 
 Pilmage 
 
 Tlie copy filmed here has been reproduced thanks 
 to the generosity of: 
 
 Library of the Public 
 Archives of Canada 
 
 The images appearing here are the best quality 
 possible considering the condition and legibility 
 of the original copy and in keeping with the 
 filming contract specifications. 
 
 L'exemplaire filmA fut reproduit grAce A la 
 g6n6rosit6 de: 
 
 La bibliothdque des Archives 
 publiques du Canada 
 
 Les images suivantes ont 6t6 reproduites avec le 
 plus grand soin, compte tenu de la condition et 
 de la nettet6 de l'exemplaire film6, et en 
 conformity avec les conditions du contrat de 
 filmage. 
 
 Original copies in printed paper covers are filmed 
 beginning with the front cover and ending on 
 the last page with a printed or illustrated impres- 
 sion, or the back cover when appropriate. All 
 other original copies are filmed beginning on the 
 first page with a printed or illustrated impres- 
 sion, and ending on the last page with a printed 
 or illustrated impression. 
 
 les 
 
 Les exempiaires originaux dont la couverture en 
 papier est imprimis sont film6s en commenpant 
 par le premier plat et en terminant soit par la 
 derniire page qui comporte une empreinte 
 d'impression ou d'iliustration, soit par le second 
 plat, salon le cas. Tous les autres exempiaires 
 originaux sont fiim6s en commenpant par la 
 premiere page qui comporte une empreinte 
 d'impression ou d'illustration et en terminant par 
 la dernidre page qui comporte une telle 
 empreinte. 
 
 The last recorded frame on each microfiche 
 shall contain the symbol — ^ (meaning "CON- 
 TINUED "), or the symbol y (meaning 'END "), 
 whichever applies. 
 
 Un des symboles suivants apparaitra sur la 
 dernidre image de cheque microfiche, selon le 
 cas: le symbols — »- signifie "A SUIVRE", le 
 symbols V signifie "FIN". 
 
 Maps, plates, charts, etc.. may be filmed at 
 different reduction ratios. Those too large to be 
 entirely included in one exposure are filmed 
 beginning in the upper left hand corner, left to 
 right and top to bottom, as many frames as 
 required. The following diagrams illustrate the 
 method: 
 
 Les cartes, planches, tableaux, etc.. peuvent dtre 
 fiimds A des taux de reduction diff6rents. 
 Lorsque le document est trop grand pour dtre 
 reproduit en un seul clichd. il est filmi d partir 
 de i'angle supdrieur gauche, de gauche d droits, 
 et de haut en bas, en prenant le nombre 
 d'images ndcessaire. Les diagrammes suivants 
 illustrent la mithode. 
 
 errata 
 Mo 
 
 9 pelure, 
 on A 
 
 1 
 
 2 
 
 3 
 
 32X 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
•iiimm^mfmi<i^n-:/^:'f<t4i'i 
 
 #!'V' „ 
 
 -'f I 
 
 ■«■ W ; . 
 
 
 PULSATING PLEURISY. 
 
 BY 
 
 WILLIAM OSLER, M. D., 
 
 Professor of Clinical Medicine in the I'Kivosity a/ PeiiK^yhania. 
 
 THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
 
 January, 1889. 
 
 t^^^au 
 
 •"'*4-...t ■■'';,!%*■ 
 
 
KxlriK'tc.l from tlic 
 Anicrifiui .Jnnrnul of tlio Mivliriil Sciciu't';' for .laiuiarv, I88!». 
 
 n LSA'JiN(; rLKUitisv 
 
 I!y William 0<li.;h, M.|>,, 
 
 FKHlEUKcri cir II.IVICAI, MEIIICINK IN TMK ININKIISITT nt I'EN NH IH i.V i J 
 
 ': 
 
 Wi 
 
 IM i.s.\iim; |)Kuri.-y is siioli ii ran- I'diidiiiiii) iliat the following cjifle 
 is Wditli pitu'iu;.'' iii>oii rccdnl: 
 
 Strai)! ill /ijliii'/ : /kh'ii in l>jl -^idr ; rnjiiil fffn.tiini, at first .ii ron.s, neces- 
 siiatiiiij two (/.■fjiirnli'ms ; iti/o-pm iiiit'tllnnii.r ; jiii/.^alinn <</' niilc ; free 
 ilraliidiji' ; renivcnj. — James F., airt-il f uciity-llirt'c years, lalcmr, was 
 adiiiitted ti) tlie UnivtTsity ll(W|)ital Mart'li •"1, IM^.S. Family liistorv 
 good; iioiif of liis relatives have !iad plitliisis; witi; [\w. exet'iitioii of 
 an attack ot" rliiiiiiatisiii in liS.S-"). he lias viijoved iiiiit'orndv ifood health. 
 
 (.)ii I'^eluiiary the 2'd, eiLrht days hcl'tire admi;;sioti, \\v sprained liis 
 l)aeiv l)y liltintf a piece of limhei- twi-nty feet in It n;_'th and ten im-hes 
 in diameter. Thi'ee men wire lil'tin;;- it, hut one of them let go his lu»hJ 
 so that the patient had to e.\ert his ntmost strength to snpport liis end of 
 the piece. At the time he did not feel any discond'ort, hut that evening 
 he hecamo sore and stitf. He slept well, and the next <lay, a puhlic 
 holiday, he went about wilii his eomi'ades, hut complained on several 
 occasions that he inid sprained his hack with heavy lifting. During the 
 evening the jiain grew worse and he passed a restle.<s night. The follow-^ 
 ing morning he did not leel well enough to g<^t up ;ind the pain had 
 beeonie almost unhearahle. There was no cough or .sh ./.Iness of l)reath ; 
 he does not know whether he had any i'ever. 
 
 From the "JGth to the ;>d, the date of his atlmi.ssion, he was " up and 
 down;" in hed part of the time, and part of the time hy the kitclien 
 tire. The pain in the back was his only complaint. He is positive he 
 had no cough, l)ut lie was short of breath. 
 
 On admission, the pati<iit looked very ill ; liu/e flu-tiei|, tongue drv 
 and coated ; lespiratioiis oC., temperature I'XIi . H( was able to lie 
 down in bed. The importance attached to the lifting on Febriuirv 
 2od mav be gathert'd from the fact that he was adnult ■(! to the suTLfic^al 
 ward as a ca.-^e of injury to tlie back, and sub.se(juently ransllrred. The 
 dav after adnussion he had nnich pain, of a cutting la'ure, in tin; left 
 side, in the axillary region outside the nipple. Tliere nas als(j extreme 
 tenderne.>^s on palpation. 
 
 I saw the patient for \\\o first time on >rarch oth, and was struck with 
 his ilistressed aj)peai'an<'e. He lay propped up in bed, had slight 
 dyspniTa, dry tongue, puise 100, temperature lOO . He complainc^d of 
 
 ■ U'-uil liv titla Bt (lif meetinn I'l the Assuciatiun uf Aiiicrii uii I'lijsiiiuii:', Wii-iliiiigtun, 1888. 
 
' p '/ 
 
 '■>) 
 
 OMLKU, rri,S.VTIN(l TLKUKlsy, 
 
 severe pnin in tlii' left liack. just below the senpiihi. On exniniimtion 
 the existence ot' ;i hir;,'*' flf'ii.-idii in tlif left plfiira was n'jxlily (h'leriiiiiicd. 
 The eanliae iinpiil.-if was in the tiiiril ri;.'iit inierspuit; in tlie para-sternal 
 line. 1 iiotiet'd one or two special f'tatiires in the case; the riudilen onset 
 utter the strain, llie rcniarkahle rapidity with which the ell'iislon had 
 taken place, and the uniiHiial amount of pain on palpation. 
 
 March (Itli, a more thoroii;rh examinatiiK was made: exfmnsion was 
 almost iiej.'ati\e on the lefl side; the intercostal s[)aces indi.-<tin;.niishal)Ie. 
 The only cardiac impulse visihie was in the third ritrhl interspace. Ta<'tilo 
 fremitus was dimini.-lu'(|. There was unilorm duine.ss on the lett side 
 reachiiii,' to the clavicle and exlendin;^' a little lieyoiid the riirht mari,'in 
 of the slerimm in thest>.on<i interspace. Hv a hvpoihrmic |)ii. ctnrc the 
 flui<l was .shown to he serous. On the principle that a full pleiini 
 {U'liiands immediate aspiration this operation was performed hy Dr. 
 Daland Ixd'ore the ward class, and titty ounces of clear serum removed. 
 
 On the .")th and (llh, the patient seenied nmch relieved, liy the Dth 
 the Ihiid had reaccumuhited and the heart heat wasaj.'ain visihie to the 
 rinjht of the steriuim, the tlulness r(>achin|j: to the level of the clavicle. 
 A.'tpiralion was aj^ain pertoriucd and two (piarts of slij^htly tiirhid serum 
 removed, lie seemed to improve very much after this. The tempera- 
 ture kept below 9!) \ the dyspncea was relieved the appetite improved, 
 and with the exception of pain in the iell side he telt very eomfortahle. 
 The sijrns of effusion persisted and the heart beat could be seen in the 
 third left and the third rijflit interspaces. 
 
 Jfith. The following note was made; Condition of patient has im- 
 pi" xl, pulse 84, respiration 2f<, temperature D-S^; dyspniea seems quite 
 od, sleeps with his head low, comj)lains onlv of chest pain; leftside 
 s,. .cely moves, and looks somewhat bulged. Cardiaeimpul.se seen in the 
 seeond and third spaces on both sides close to the sternum. The lett 
 interspaces not specially promiiuut. Tactile fremitusfelt at the extreme 
 apex, but nowhere el.se mi the left side; jiercus-ion ii'.te clear to the 
 seeond rib, dull below this. On the right side normal. 
 
 Auscultation; Ins|)iratioii is loud and breezy in the subclavieular and 
 /supra-scapular regions. Helow these points the respiratory murmur has 
 a distinctly ain[)horic character, e<jntrasting remarkably with the breath 
 sounds over the upper part of the lung. The xu'wc .«ounds in the lower 
 regions are very ariieuiate ; no me.alli<' tiidcling on coughing. No bell 
 sound, nor could succussion be tibtained. 
 
 l!>th. Tt)-day for the first time it was observed that the percussion 
 note in the Iell subclavicular region was distinctly tympanitic. I)ul- 
 ni!ss extended from the upper border of the third rib, ami was distinctly 
 movable. This was very nuirktd \\ hen he lay on his rig'ht side, in 
 which j)osition the ])ercussion note in the axilla became hyper-resonant 
 Avithout tym]ianitic (piality. Posteriorly in erect position at outer angle 
 of the scapula the percus.sion note was distinctly tympanitic. To-day, 
 for the first time, the bell sound was obtained with the coins. 
 
 ■:'!lh. Since the 20th he has had irregular fever reachmg 102' in the 
 evening, lie has, however, felt much better. The physical signs persist; 
 in the recundieiit posture the note is hyper-resonant to the low(u* border 
 of the third rib. dust below the nipple it is disiinctiy tympanitic, from 
 this point into the axilla there is dulness. When he turns on his right 
 side the entire left axilla is resonant. There is amphoric breathing 
 from the third rib, best marked in the lower axilla, where the percussion 
 
 *////^?C 
 
08LEK, ITLSATlNi; I'l.KlUIS' 
 
 8 
 
 note, is (lull. TliiTc WHS iintircd today in llif iMiirtli, liftli. ami sixth 
 iiitci>|t:ic»'s ill tlic mid a\illarv liin' a nniark^iMr piilsalioii. Tlif wliol.- 
 side rt'ccivcil u very [tositivr sliock, systolic in liincand syiicliroiioiifl with 
 thf cardiac itn|tidso in tiic third rit,dit intcrsparc just altovc the ni|)|)le ; 
 th<' haml |)hi<'i'(l on tin- left .-idi' isdistinitly lilted with each impulse. 
 When he lies toward the; riiilit side tlic iinlsatinn in the U'f'l axilla is ii 
 little more marked thtiii when he i-i Hat on Ids l)acl';. 
 
 .'?//i. The e immmi dccid'itiis is on the left >ide and in this |>osiiioi) 
 the heart im|iidse is well seen just ahove the riLrht nipple. The pidsa- 
 tio'i in the left mammary and axillarv reiriMiis is vers- miirl\e(l. The 
 maximum intiMisiiy is outside the led nipple. NVIien he turns on the 
 ri;.dit side the |)ulsati'iM is most marked in the lifili and sixth interspaced 
 in the midaxillai'y !iue. Palpation ^I'wv^ a very deeided heave and a 
 distinct shock is felt. In the erect posture, the pulsation is not so forcihlc, 
 th()ujj:h still very tniilent. The coin sounds are now unusually distinct. 
 Siiccussion is not ohtainahle. 
 
 J!'lh. Tin; left chest looks lari,'er and fuller than the rin'lil ; it is com- 
 |)Ietely immobile. The intercostal spaces are olditerattnl with the excep- 
 tion of till' sixth, which is still visihie. The svstoiic im|)ulse on the Ictl 
 sidtt is very niuiked, and can readily he seen by the students in the 
 distant seals of the amplutheatre. McasiuHMiient on the rij^ht side j^ives 
 sixteen and one-eiirhth inches, expansion one-half inch ; on the left side, 
 seventeen and (ine-i|uarter inche-. j)ractically no tixpansion. 
 
 Piil/iiitldii. — Tactile fremitus i^ absent on the left side. Heaving 
 ini|)ulse in the mammary and axillary rcfjions well felt with the hand. 
 
 I'fiTii.'inioii. — Clear, hyper-resonant note to upper border of tin; third 
 rib. From the third to the llfth it is distinctly tympanitic. Below this, 
 in the axillary re^doii there is duliiess. When ho turns on his riizht side 
 till! iiulsatioii in the mammary and axillary re;riiiiis is more marked. 
 Where the percussion note was dull, it is now tympanitic. 
 
 AiLscnlbttioH. — In the left infra-clavieidur retrion the breath sounds 
 are loud and distinct, not amphoric. In the third and fourth inter- 
 spaces tlu' respiratory murmur is ;4(areely audible. In the axillary 
 rei^ions there is distant but distinct amphoric breathinir, very clearly 
 heard win n a deep breath is taken. No special amphoi'ic echo aliout 
 the voice, the vibrations of which are not c(numunicated to the ear; pos- 
 teriorly there is distant amphoric breathing. 
 
 '7/,i/. The irreLCular fever has persisteil and tlx; presence of pus was 
 demons! rated with a hypodermic iK.'cdle. It was decide<l to open the 
 pleura, which was done by Dr. Ashhurst ; fully three pints of [)us 
 escaped. A lar^-e drainage tube was inserted in the ciLihth interspace 
 b(>low the angle of the scapula. After the operation, the heart did not 
 return to its normal position, though it beat to the left of the sternunj. 
 Patient stood the o])eration verv wfll, the eveninu: temperature was only 
 98.'J'. 
 
 April S. Pulse 92, respiration 24, temperature !).S'. Inspection showed 
 a remarkal)le change on the left siile of ihe chest; it ali'eady looks 
 smaller than the right, and there is flattening in the second, third, fourth, 
 and fifth intercostid spaces ; there is very marked pulmonary res<inanco 
 to fourth rib. Tympanitic in th(> fifth, sixth, and seventh interspaces. 
 
 With the exception of the fif'ih, when the temperature rose in the 
 evening to 102", the patient's condition was most satisfactory, lie sle|)t 
 
OSLKli, IT I.SATI NO IM.Kl'UISV 
 
 well, appetite jjood. U'm|M'riilnn' (lid ikiI lisr uIidvc W ; tliero wiih f'rc« 
 <lraiiiii;r«' tluKiiL'li lultc. 
 
 y>///. ( 'licst tiH'iisiircfi tu-dav: ii).dit siilf, til\<M ii mid a liall" iiudu'** ; 
 \iii\, tirtccn and oiic-cijrliili. l)in('liar;r<' very li;:lit. Fntin tluH time the 
 patient improved verv rapidiv ; leinpefatnre lins iml ri.oen almve 100''. 
 
 Mill/ !>. Tlie discliaf;.^' is now sli^lit. A smaller drain.i;/e liii>e wan 
 introrliiced ; the discliar^e Lrradnally diminished, and he improved rupidlv • 
 in stren^^fli and wei;:hi. I'"arlv in .lime the tiihe was removed. 
 
 June 10. 'Ph( note is that the siinis has enlirelv healed. He lel't the, 
 hospital on the l)th, weij^hinj.' 140 pounds, a ^ain of twenty-two pound.'* 
 since i\ \)v\\ Ijth. 
 
 The condition of his chest on disehar;;e was as follows: There was 
 tnarked flatlenin^' of tin; left sidt', particularly in the axillary and mam- 
 mary regions. 'I'he circiimti'rence was: riLrht. fifteen ami three-ipnirters; 
 left, fifteen anrl oiie-ipiarler inche.s. The percussion note was clear to 
 the fifth rii» and the spine of (he scapula hehind. hclow tlusi- points t hero 
 was dulne.«s. Loud hreath sounds in the clavicular and mammary 
 rei'ions, feeble and distant in lower axillarv, and ;it hase. 
 
 
 I believe that this wa.s an instance of pneumothorax from the oiiLset, 
 one of tlin.se inferestine; ca.ses to which Pr. Samuel West' ami Dr. de 
 Havilland Hall' have called attention, in which the condition has lo|- 
 low('<l strain in a person previously healthy. It is very improhabh' that 
 on the eififhth day of an acute plcnri.sy there would be a serou.s exuda- 
 tion of such extent as to reach the claviele and encroach on the pleura 
 of the oth(>r side. On the other haml, the perciissioji note, as is well 
 known, may be dull in pneumothorax when the icnsion of the thoracic 
 
 wal 
 
 is verv i^reat, and I tliiid< that in this wav the mi^take arose. Tl 
 
 le 
 
 node of onset in a healthy man, the course of the disease, and the rapid 
 
 ain hiid induced 
 
 and comi>lete recovery lavor tiie view that tlie sir 
 pneumothorax which excited the pleurisy. 
 
 The chief interest of the case lies, however, in the curious phenomenon 
 which developed in the fifth week after the attack. 
 
 Instances of tumors of the thoracic wall, w hich pulsated synchronously 
 with the heart, are mentioned by several of the njdi-r writers —Baillon 
 (1040), T^e I'"y ' 177<i'. and IN;lletan '1810 — but the first ca.ses of pul- 
 satint;; empyema, recoirnize(l as such, were repurte(| by the late Dr. K. 
 [j. Macdonnell,' I'rofWsor of ('linical .Medicine in Mc(.iill Universitv, 
 
 Montreal, who, at the tii 
 
 ne, \vi 
 
 IS clinical a.ssistant to Drs. Graves and 
 
 .Stokes, at the Meath Hospital, Dublin. 
 
 In the first of these cases a larjifc tiiiiHU" appe:vrcd in the cardiac re^rion, 
 which, after pulsating for si>me time, became red. tense, and shluiuir, 
 and then burst, giving exit to a large quantity of pus. 
 
 se tw(t tumors appeared in the lower part of the let't 
 
 In tl 
 
 le ^^ccond en 
 
 ' Cjiii. S..C, Ti-aiisncti"iifi, viil, xvii. 
 
 ^ Inil'liii .I'liuii. -Mini. Si'iciiio, Murcli, 1H4}. 
 
 ! Uild., 
 

r. 
 
UHI.KU, I'L'I.SATINO I' I,K i: Kl « Y. 
 
 t; 
 
 r. 
 / 
 
 niilf, pri'Mi'tilitiK fliirtniitinn mnl |iiil.<«iitioii. Wlun o|m nni |)iiriil«>iit 
 tiiiiiU'r criciipcil ill Imi'i::)' 'iiiiiiiiiiiiM. 
 
 Ill i!if fliiiil ciiHc :uM lurjj;(> tiitiKirs a|»|H'iii' •'! in llic luwti |iurtiiiii nf 
 tlif \i't\ rti'l"' iif tin- rUiHt, iirfHrriiiii;,' tliictiiiitiMti ai|i| |iiiUiitiiiM. Tlify 
 were < pi'iicd niiil tli."i('liur;,Mil a Istru'r (|iniiiiit\ "t" |'ii.«. iJcaili liillnurd 
 ill nil till .xc ca^'t'M. 
 
 Dr. Macijiiiim'jl r*'iiiat'k(Ml that lliis riiiHliiKiii ua.- inw in tlu' liiotniy 
 i>\' cnipyt'iiKi. 
 
 SrviTuI ('arrrni Htu<lit'.>< nt' pnlsafin;: |ilciiri-*v liiivf rci-i'iitlv lircn huhIo. 
 < )ii<' l)V '.Jiiiiiliy,' who cdllci'tiMl 'J7 ra.xi > ; miuI ri -tccMiiil l»v Kt|ii»r,' wlin 
 liiis cnlloctctl .'IS cn.tcr*, miiy '2 ><{' wliirli arc rc|nirtt'il liv .Anit'riciiii 
 aiitli'irs — Dif*. l-'liiit^ and l)illiiij_diani,* iVniii ilii> wanU of Dr. iF, il. 
 Uipii'y at S|. I'miicis IIi»|>ital, New ^'lll^;. 
 
 I am alilf In add tli<' ifportH of a few addilioiKil im.^cs tViiin tiiis «idi> 
 of the Atlantic, hnt I'rniii in(|nirii>s wiiidi I li:ivr made truiu tin- lios|)ii:i| 
 j)liysi(i;ui«* i>t' tliis ('(iniiliy the I'linditinn !i|i|ifiirs tn he cxtrciiicly rare. 
 Dr. ( i('(»r;.'c Il<)s.-j, |'rnt('.xr<Mr of Cliiiii-iil Mcdiriiii' in M(<iill I'liivfr-ity, 
 Mniitnal, has "fivcii an aci'Diinl nt an cxtn intly iIltt'l■('^<tillg cu-se,* wliicli 
 clottcdy sinnilati'ii jiiiriirisiu ; 
 
 .\ iiiiiii, iifit'd ill rty-si'vcii yi'iirs, wsih adiiiitliij In tlic ilfiiiTai llcisjoiai 
 Hiiflcriiiir I'roiii piiiii in llir side, coiiv'li, mid CcMr, w iiii li In-ltd atmui tivn 
 <l:iy.s, iiiid wliicli iMlhiwi'd a severe weitiii::. I'lid'e \v iirt (leliciciit (•x|iaii-'iiiii on 
 the left (*ide wilh dnines'* to iho aiiL'ii <>[ the sea|»nl.i and diiniiiiHlied rii'inilus. 
 W'itinn ten davn the e.KpiiiisiNe inoveiii'iit (d' lln' hd't side lieeaiiie iimro 
 inipairiMl. Tlie second and third intercostal Hpaees in t'ririt hecanie proini- 
 lienl, presentini;' perceptible pnisatii'n Mynchronons wilh systole (d' the heart, 
 ,\iiiint live d.iys alter tlic onset (d' llie illness lie iiad a severe til lA' e<>iii;|iiii;r, 
 in whiih lie iirniiL'ht up, at leiisf, a pint of pure pus. thiik, ireainy, ioid odnr- 
 les.s. The couirh eontiniU'd lor a lew days, with expfctniation d piis. The 
 percussion note an the hd't. side became clearer and the pulsatinir tniimr 
 entirely dis ippeared. Tiie teinprrauire tell to iiornial and the man's slren.rtli 
 retiirneil Teu week's I'roiii the onset the man hit tlie hospital strDiit,' and '.veil. 
 
 Dr. I'\ 1'. Henry, <d' IMiiludclpliia,'' rfpurts a ea.-c IVoin the l^J)i^co|)al 
 Hospital : 
 
 \\'nina:i, ajjed thirty years, aduiiHed in liie spring; ot' 1 SSU, On the hd't side 
 ot' (lie thorax there were three stroir^ly pulsatin.,' minors— uiie al)out the si/e 
 of half u larjre oran.i^e, in the h ft maiuiiiary re;.:ioii, diicrily over the central 
 portion of the heart; a second, imich smaller and acnminated — '. '., with 
 apex nuidi Hiualler than the h.ase was situated on the left antero-iuferior 
 j)orli(m of the lliorax ; and a third, the larues; of the ihrn', on the left onstero- 
 inferior portion, il> !i>M'.i' diamet'T, al>i>iit I'niir iie Ins. eorrespMudin.' wiih th.it 
 of the vertebral t"duiiiii. All these ttiiii'irs po^sissed a s'rniiir expausih>. sys- 
 tolic pnisatimi. '{"he day after mimissiim pus was wiiiidrawn hypoiiermi- 
 callv from the smaller tiiinnr. The tnaiir over the bent co.jtaiiied air, w liich 
 
 ' Ard'lvcs Oriii'TaifS, I's:; 
 
 t I)fut..lic!, .\n-lnv riic-kiiii. >l.'li. in, IM xl. |HS7 
 
 • I'liiiini! Iti'iHiO nil I'll p.. nil- I'liMUJli-, |i. IT , .iml On tin' H.-npint iry Oisaiis, p. 18 1, IS'.ii. 
 
 « Now Ymk .M.'.linil !;-■., ,nl, I8>l, 
 
 '' ChiihiIh Jlfil. iiiiij Sure. ,l,.iini , Miiy, IhS.'i 
 
 ' I'rcM llll^!■. ipC til- I'liil.i. Co, Mf'l. So. ii't.v, vul. iii, \i. S'l, 
 
6 
 
 OSLKfi, I'(M;SAT IN'G I'LK UlUSY, 
 
 WiiH very cvidi'iit on !ii:i:ii|iiil;ttiM'i. A-ijiii'iilimi was |n'rfi)riiu'il, iunl, 8 ime 
 tiiii(> ;iltcr, :i (IfiiiM i'j;(' tiilic vv.is iii-iiriol liy Dr. A-ililiursl 'I'lir wninan was 
 roiiiDViil liy Ihm' rricii'ls, Imt, was alivr a vi'ar ai'liT the uMcra'iiii. 
 
 Dr. luiH'way, (»(' Ni.'w York, writes that lii- has iii"t with one casi; of 
 ninpycina wt' the h'I't si,!,., in which the tii:ii <r wa> sitiiali'il in iho left 
 s:'cniiil interspace, uhii'h uiilsaleil when lie' patieiii stnml ere(;t, !>ut. w hi;ii 
 the patient was IviiiL;- diwii air liUeil t!ie sae. 
 
 The>" ca-es, with the tliirt \ -ei^hi cjneeicil tV'iiii iiteraiiire l)y Coinliy 
 imd Kepler make a total of" fortv-tww casrs. The coinlitioii is aliiio.st 
 iuvaria!>ly met wiihoiilhe h'I't si'h'. In lailvtlii'ee iii-tai\ces, those of 
 Kepler, HcyfehhT,' and (JeiLTel,' was the enipvenia in the ri^dit side. 
 Keph'r thinks tiiere niav have Ixh'Ii h donht in [ levt'ehler's ease, l)Ut the 
 report see. is perftM-tly cU'iir. The innior appeared hetween the .second 
 1111(1 third ribs oil the riudit side, and pnlsated di.siiiiet!y. It rnay po,^.sihly 
 have heeii a mediastinal al)f>('ess. as it was close to the plenrul margin. 
 Onlv eiL,dil ounces of pus flowed ont wiicii pnnelnri d. 
 
 In the cas(; of (TciL'^el, a man. ;et. Iifi\-scven, had in the riulit mam- 
 mary rcL^iiiii a prominent projection winch pulsated riynchroiioiisly with 
 the heart. The case terminalt'd iatalK'. Iletwe ai six and .icven pounds 
 (•f pus were found in the pleura. 
 
 ICnipyema exi^^teil in all the cases, with the exec'ption of (uie reported 
 Ity Kepler, from I-aclihorst's clinic, in which the fluid was solou^^. It 
 ociairred in a hoy a't. f.urteeii, who, fourteen days ht'fore his admi.ssion, 
 liad been .seized with a severe pain on the ri^dit .si<le, and shortly after- 
 ward i^reat tenderne-is at the .seventh rih. There was dulness at tlie 
 rit^lu base, which rapidly incre:ised until it reached the aiij^lc of the 
 i<ca|iula, and within a few davs thei'e wen' siixns of efliision in the right 
 tliorax. On first examination the riudit side was enlarge 1, intercostal 
 spaces prominent. There was active pulsation over the antero-lateral 
 reLMon of tlu; right side of the chest reachiiiLr as hi^h as the third rib, 
 and .'-vni'hroiiou-^ with the movements of the heart. The a[iexd)eat of 
 tile licait wa'^ 1.5 c:n. ab.ive the nipple in the left mammary line. On 
 account of sullocalive svinptoin.- aspiration w;i> pcrt'oniied and 'SOO c. cm. 
 of pure serous fluid removid. \\ a second pnncturt: 20(1 c. cm. more 
 were removed. I'nlsalion ceased after the witiidrawid of the fluid. In 
 fourteen davs t he tluid reaccumuiatetl. An e>:[)loratory puncture showed 
 it to be pus, and the operati>'n i'n euijiyeina was made. TJie seventh 
 rib wa> resected and •">i>i) c. cm. ol' pus i'( iiovcmI, 
 
 In only two instances of Iveplei-'s series was pvopiieiniioihorax present. 
 One rep M'leil bv [•'('•re'il,'' a man ;et. I weiiiy-t wo, had, in dulv, 1 "^'"^"i. left- 
 sided serous (>ll'usion, which was tappi'd, and he recovered. On ()ctol)er 
 27th there was auain a lar^i' hl'i sidt' etfu>ion with air. The beat 
 \va.^ at the right nipple, ami ai) out llh' end of Xoveinber pulsation of 
 
 i .Mj.-tr.i-t !■}• K.-i'lcr, I. v. - i,iii..tH.I l.v Kc|ilcr. 
 
OSLER, I'ULSATINc; I'LEURISY. 
 
 the wholo lot't side was notie(!(l, syiu'IironDiis witli the licart. It waa 
 most marked bcliind and in tho axilla. Tlic as[)ii'iiti m of 2] litres of 
 pus al)olirilied the pulsation. In Dillingham's ease tiie man luul pneumo- 
 thorax. 
 
 To these cases nuist he adih.'d tlie one which I hero report, ami the 
 ca.ses of Henry and Janeway, in both of which there was evidentlv air 
 in the pleura. 
 
 Two groups of cases may he recognized: ],the intra-pleural pulsat 
 ing pIouri.sy ; 2, the pulsating empyema nec(>ssitatis. in which there is an 
 external pulsating tumor. The latter conliti m, die mo-t common, 
 occurred in twenty-five of the forty-two cases, pri'halily also in a lart'i-r 
 proportion, as there are several repoi'ts with very scanty details. The ex- 
 ternal tumor is nsiudly single, hut in five cases tliere were two tumors, and 
 in one, Dr. Henry's case, three. Tlie perfora'ion of the pleura usiuilly 
 occurs in the anterior aspect of the chest, from tlie second to the sixth 
 rib, sometimes (dose to the sternum. In three cases the tumor a|)i-,eared 
 posteriorly — at the spine, at the angle of the sca|)ula, and in the hunlmr 
 region. In the intra-pleural cases the pulsation is usually in the antero- 
 lateral region of the afiected side, and may he evident on palpation only, 
 or, as in the case here reported, it may l)e visihlc even at a distance. 
 
 Pulsating pleurisy usually occurs in ca,<e.- in wliieh tlu! tlui<l has 
 existed for some time, hut that it may occur in acute ca.ses, even with 
 a serous exudation, is illustrated hy Kepler's patient. In I toss's case 
 and in mine the coiidition was also acute. 
 
 Various explanations of the phenomenon have been oHiM'ed. P- 
 Broadbent' suggests that it occurs when adhesions exist between the 
 hiyers of the pericardium and in'twecn the [k ricardium and the chest 
 wall. Ihit tliat this cannot hold good in all cases is shown by ixports 
 of post-mortems in which such adiiesioiis were not present. Traul)e 
 I'cgardcd destruction of the costal i)ieura. and marked paresis of the 
 intercostal muscles as the conditions which rcnderi'd pleurisy po.ssible. 
 In the case which 1 have rej>orted, there was persistent tenderness of the 
 thoracic walls, suggestive, to say the lea.'-l, of invuhcment in an unusual 
 degree of the parietal structures, but there was no (edem:i or special 
 protid)erance (d' the spaces, and the cniidition came on too eai-ly to have 
 been due to destructive I'hanges in the pleura. It was probably due to 
 extreme distention oi' the side. Bouveret, in lii-^ rei-ent monogra])h on 
 empyema,^ hohL- that the i)ulsalion is met with wlienev< r tlu' re.-istance of 
 th(' thoracic wall is greatly rtiluced. as in the way Traubi- suggests, or 
 when the resistance on the part of the diaphragm is heiLditened, as by the 
 <leposition of a thick layer of fd)riii. The fact that the al)straction of a 
 very small quantity oi' fluid will at once abolish the pulsation, indicatt>s 
 
 I Liduit, 1881. 
 
 - Traiti' ill' I'l'niii.vomi', |iiii I.. Iloi:viMnt, I'ariM, IfchS. 
 
8 
 
 OSLER, PULSATING I'LKUKISY. 
 
 %i 
 
 that a certain ilogree of pressure is a necessary condition. Coniby thinks 
 that the pulsation only occurs when ti>e lung is compressed and adhe- 
 rent to the pericardium, so that the heart movements are communicated 
 through it to the pleural fluid, and so to the chest wall. Fereol makes 
 a somewhat similar suggestion, holding that in every instance the condi- 
 tion is one of })neumothorax, in which air forms an elastic cushion 
 between tlie pericardium and the lluid through which the pulsations 
 of the heart are directly transmitted to the chest wall. 
 
 The cases have been mistaken for aneurism, and tlu' situation in 
 which the pulsating enipyt'ina ncces.^itatis usually (!• elops renders the 
 error very ])ardonable. The doubt can readily hv solved with a line 
 hypodeiuiic needle. 
 
 The prognosis in puis;\ting pleurisy is not very favorable. Of the 
 thirty-eight cases in Iveplcr's series, seventeen died. But we must 
 remember that most of these cases occurred before the tlays of safe and 
 fre(|Uont operations upon the chest wall. 
 
 Complete evaciKition of the fluid with free and pernuinent drainage 
 meets the indications for treatment. 
 
 *M 
 
% 
 
 1 I'i 
 
 99w 
 
THE AMERICAN JOURNAL 
 OF THE MEDICAL SCIENCES 
 
 ■X.'-,:!:*^ 
 
 
 V ..■"N'' 
 
 Is the oldfst and hrst-kntncit medical pcriodii<il of Ama'ua, haTinj^ 
 been founded in rSso. It nuwlwrs among its contributors the most 
 eminent names in Ike profession, and, ae,ordii'^ to unqiiestionable 
 uutlivrity, *^/t contains many orit^inal fafers of the higiiest value ; 
 nearly all the real criticisms and rcviexvs lidtich we />ossess : and 
 such carefully prepared summaries of the progress of medical 
 science and notices of foreign works, that from this fie alone, roere 
 nil other publications of the press for the last fifty years destroyed, 
 it lootild be possible to reproduce the great majority of the real 
 contrihutions of the world to medical science during (hat period.^* 
 Published monthly. $4.00 per annum. 
 
 THE MEDICAL NEWS 
 
 Is the leading medical neitispaper of this co.ntry. Started in 1S4J 
 as a Monthly, it 7oas changed to a H^ekly ■■11 /S^^. It haj been 
 shaped to furnish the profession at rapid intenuils ruith the latest 
 ir formation on all medical subjects. During thr year /S^3 THE 
 AMERICAN JOURNAL and THE MEDICAL NEWS published 2160 
 articles on Progress alone, and, in addition, one ami three-quarter 
 vnllion wordi 0/ original matter, the equivalent of 9 octa7>o 
 volumes. THE NEWS is sent postpaid for $S-00 per annum; 
 THE AMERICAN JOURNAL for $4.00, or both at $730. 
 
 •y" :' 
 
 THE YEAR-BOOK OF TREATMENT FOR 1888 
 
 
 • iNow in press for its fifth annual issue, gives a classified statement 
 of the value and uses of all remedies vjhich have been introduced 
 and practically tested during the year. Pi ice, $1.23 ; or in com- 
 bination with either or both the above Journals, y^c. 
 
 n 
 
 THE MEDICAL NEWS VISITING LIST 
 
 'yV 
 
 r.:- 
 
 4.\' • 
 
 Contains 48 pages of indispensable data and lyb blank pages, 
 ruled to accommoiiate all records of practice. Handsomely bound 
 in r-:d seal, $r.2j. In combination 7oitn either or both aho'oe 
 periodicals, 75c. Or JOURNAL. NEWS, YEAR-^BOOK and VISITING 
 LIST. .$H.jo. 
 
 Lea Mlhn \ Co., publisher?, 
 
 PHILADELPHIA. 
 
 706 & 708 
 -Sansom Street. 
 
 
 .«vi,i'tv iV*, V^ajfa't i*',«''*'^>44.