PULSATING PLEURISY is a rare phe nomenon. Sixty-eight cases have been collected, mostly on the left side, and only one was sero-fibrinous, the rest being purulent. The impulse may be heaving and limited to the sternal region, or dif fused and most marked in the axillary and scapular regions. In some of the cases pulsation did not occur until per foration of an intercostal space led to the formation of an abscess-sac beneath the skin,amempyerna necessitatis,—the pulsa tion being confined to the subcutaneous abscess.
pleurisy is much more fre quent than is ordinarily supposed. The x-rays have considerably facilitated the diagnosis of this condition. Ten cases personally observed. It is frequently confounded with gangrene of the lung. Sciagraphic examination gives the same results in cases of interlobar pleurisy and of aortic aneurism. Bk!R•re (Gaz. Heb. de Med. et de Chic., Feb. 2, '99).
Course and Termination.—The affec tion presents a very variable course. In dry pleurisy the inflammation may rap idly subside and recovery take place in a few days. In some there is persistence of pain for some time and fresh attacks in other parts of the pleura. In these the pleurisy is secondary to other affec tions, chiefly pulmonary tuberculosis.
In cases of sero-fibrinous effusions the fluid may increase for a week or ten days, when, the active process ceasing, absorp tion sets in and rapid recovery follows. Or absorption may not begin until after the lapse of a stationary period of in definite duration. Recovery is rarely complete in less than a month; in cases of considerable effusion it requires a much longer time, especially if aspira tion is required. Absorption rarely be gins during the continuance of the fever.
A sero-fibrinous effusion may persist for months, especially in tuberculous cases, notwithstanding repeated aspira tions. Scro-fibrinous pleurisy is rarely fatal, yet excessive effusion is not without risk. Even though the effusion causes little discomfort while the patient is at rest, sudden death is liable to occur, espe cially on exertion. Death may be due to thrombosis or embolism of the pulmo nary artery, to clot in the right ventricle, to degeneration of the heart, or to oedema of the uncompressed lung. Displacement
of the large thoracic vessels with com pression, especially of the inferior versa cava, has been regarded as a cause, but at most is only an improbable one. Dull ness often persists after the effusion is absorbed. It may be due to unexpanded lung or to copious fibrinous exudation. It may persist throughout life.
Retraction of the chest sometimes fol lows absorption; it may be local or gen eral.
In purulent cases the duration is much prolonged. The exudation is occasion ally absorbed when due to the pneumo coccus; but this is rare and never occurs in streptococcal cases. Left to itself, the exudation may discharge by external rupture, by rupture through the lung, or into some other cavity or organ. With early and effective drainage recovery may be complete without any retraction of the chest or impairment of expansion. Such results have been obtained even after the exudation has existed for six months or more. The degree of interference with expansion of the lung, and consequently of retraction of the chest, is determined by the amount of thickening of the vis ceral pleura resulting from organization of adherent lymph or from changes in the pleura itself and subjacent lung-tissue. The defect may be compensated for by enlargement of the upper part of the af fected lung as well as of the opposite lung; so that dyspncea does not result.
Bronehicctasis sometimes develops in the contracted lung, and may affect the opposite lung also.
In neglected cases the pus will usually in time perforate the chest-wall: em pyema necessitatis. The opening most commonly occurs in front in the fifth in terspace, where the chest-wall is thincst, but it may take place anywhere from the root of the neck to the buttock. The course in such cases is very tedious,— often the opening never closes. In a young girl under my own observation it lasted eleven years. There was extreme retraction of the chest. Rupture may also take place into the oesophagus or the pericardium. The diaphragm may be perforated and the pus discharged into the stomach, intestine, gall-bladder, or even the pelvis of the kidney. Or it may pass down the spine and appear as a psoas or lumbar abscess.