FROM THE AUTHOR. 
PULSATING -EMPYEMA. 
REPORT OF A CASE. 
J. C. WILSON, M.D., 
LECTURER ON PHYSICAL DIAGNOSIS AT THE JEEFERSON MEDICAL COLLEGE, ETC. 
REPRINTED PROM THE TRANSACTIONS 
OF THE PHILADELPHIA COUNTY MEDICAL SOCIETY, 
may 8, 1889. PULSATING EMPYEMA. 
REPORT OF A CASE. 
Read before the Philadelphia County Medical Society, May 8, 1889. 
By J. C. WILSON, M.D., 
LECTURER ON PHYSICAL DIAGNOSIS AT THE JEFFERSON MEDICAL COLLEGE, ETC. 
The following case of pulsating empyema is worthy of record, not 
only because it illustrates a rare clinical condition, but also because 
it sheds light upon some points in the pathology of that condition 
which have been the subject of debate: 
Strain in lifting ; pain in left side ; pleural effusion, at first serous, subsequently 
purulent; extensive pulsation of side ; pyo-pneumothorax ; paracentesis thoracis, 
free drainage interrupted by removal of tube ; tense pneumothorax ; resection of 
ribs; drainage.—Daniel McL., aged twenty years, unmarried, Irish, laborer 
in a dye-house ; admitted to St. Agnes Hospital March 16,1889. His parents 
are living and in good health. Three years ago the patient had an attack of 
chest-trouble, which continued for four weeks; since then his health has been 
good. He has been in this country about a year. His present illness began 
about six weeks prior to admission to the hospital. In lifting a large roll of 
cloth, he gave himself, as he says, a twist in the left side ; immediately suf- 
fered severe pain, which was increased on deep breathing. There was at first 
no cough. After a time he began to suffer from shortness of breath and from 
cough unattended by expectoration, but worse at night; was able at all times 
to lie down in bed. The difficulty in breathing becoming urgent, his chest 
was tapped on three occasions during the nine days prior to his coming into 
the hospital, a large quantity of fluid being removed. This fluid, he says, 
was at the first two tappings clear, but was on the last occasion turbid. 
Upon admission, the patient presented the appearance of severe illness; 
tongue furred, no appetite, bowels constipated, great oppression, respiration 
shallow and difficult, 52 per minute; no orthopnoea; face and hands slightly 
livid ; is restless at night, sleeping very little and sweating freely; tempera- 
ture 99.5° F., pulse 140, small and feeble. Urine free from albumin. 4 
WILSON, 
The presence of a large pleural effusion upon the left side was determined 
without difficulty. The respiratory movements were much restricted; the 
intercostal spaces obliterated; vocal fremitus feeble in the infra-clavicular 
region, elsewhere scarcely perceptible or absent altogether. The cardiac 
impulse was felt in the right side in the nipple line, and was visible in the 
third and fourth intercostal spaces to the right of the sternum ; there were no 
murmurs. There was percussion dulness over the whole left chest extending 
to the right border of the sternum at the level of the second intercostal space. 
There was a distinct impulse having the cardiac rhythm over the whole of 
the left side anteriorly and laterally as far as the line of the posterior axillary 
fold. This impulse, which was very distinct upon palpation, was not visible ; 
it was not felt posteriorly. Upon auscultation below the clavicle, feeble 
respiratory sounds of indeterminate quality ; elsewhere absence of respiratory 
murmur and diminished vocal resonance. 
On the 20th aspiration was performed, the needle being introduced in the 
eighth intercostal space slightly in advance of the line of the posterior axil- 
lary fold. About three pints of foul smelling greenish-yellow pus were with- 
drawn. Patient then complaining of great pain along the spinal column on 
the left side, the pulse becoming small and thready, and the distress urgent, 
one-sixth of a grain of morphia was administered hypodermically and the 
aspiration discontinued. 
In the original notes made at the bedside appears the following statement: 
“The retraction of the intercostal spaces and the extreme distress of the 
patient render it probable that the pus cavity is smaller than the physical 
signs would indicate.” After this operation the patient was somewhat re- 
lieved ; respiration was less labored; the temperature fell to 98° F.; but 
sweating at night continued, and the tongue remained dry and brown. 
On the 22d it was noted,] that the pulsation on the left side was no longer 
observed to the left of the nipple line, save in a restricted area in the third 
intercostal space. The impulse of the heart was still felt below the right 
nipple, and was visible in the third and fourth intercostal spaces at the right 
border of the sternum. There is tenderness upon pressure over the whole of 
the left side of the chest. 
On the 25th the signs indicated rapid reaccumulation of the fluid. The 
intercostal spaces were again obliterated; dyspnoea became urgent; the 
lividity of the face and hands, which had to some extent disappeared, 
returned. The patient complained of severe and continuous substernal pain. 
The whole antero-iateral surface of the left chest became, as before, the seat 
of distinct cardiac pulsation. Fever had redeveloped. 
The chest-wall was perforated in the seventh intercostal space in advance 
of the line of the posterior axillary fold by a large trocar and canula, and 
after the evacuation of four pints of fetid pus, a soft rubber drainage tube was 
introduced, and the chest dressed antiseptically. Rapid improvement in the 
patient’s general condition immediately followed; the temperature fell to 
normal; the pulse became slower and fuller; the respirations less frequent; 
the tongue cleaned; appetite returned; sweating at night ceased, and the 
patient slept fairly well. In a week he was up and about the ward. The 
discharge from the tube amounted to a few drachms only daily, and was no 
longer fetid. PULSATING EMPYEMA. 
5 
On the 12th of April, the drainage tube having become clogged, was 
removed. The resident physician was unable to replace it. 
Owing to absence from tbe hospital, I did not again see the patient until 
the 18th. I found him then very weak and feeble; skin slightly cyanotic 
and mottled ; respiration 48; pulse 120; temperature 98° F.; no orthopnoea; 
appetite good; no sweating at night; the right lung resonant throughout; 
no rales. The impulse of the heart was felt near the right nipple, and in the 
third and fourth intercostal spaces, where the sounds were distinct. The left 
chest was distinctly flattened in its antero-posterior diameter, though the 
intercostal spaces were prominent, and the surface of the chest throughout 
tender upon pressure. There was pulsation, as before, over the antero-lateral 
surface of the chest, extending to the line of the posterior axillary fold. This 
pulsation was synchronous with the systolic impulse of the heart to the right 
of the sternum. It was most distinct in the second and third intercostal spaces 
to the left of the nipple line, but could be faintly perceived to the base of the 
chest. The percussion sounds were tympanitic anteriorly above the level of 
the fourth rib, and flat below. Posteriorly percussion resonance was flat, 
except at the extreme apex. 
Upon auscultation the heart sounds were faintly heard all over the left 
chest, anteriorly and laterally; posteriorly they were inaudible. Above the 
fourth rib anteriorly, in the region yielding tympanitic percussion resonance, 
the respiration and voice signs had an obscure amphoric quality, and the coin 
test yielded the bell sound. There was no metallic tinkling upon coughing, 
nor was there succussion. There was no change in the relative distribution 
of tympany and dulness upon change of posture. 
The dyspnoea increasing and the substernal pains being more pronounced, 
it was decided to open the pleura freely. This was done April 27th, by Dr. 
Mears, after the resection of an inch each of the sixth, seventh, and eighth 
ribs in the axillary line. Upon puncture of the pleura, there was an escape 
of air, and the wound being enlarged to permit of an examination of the 
cavity, it was found free from pus. The finger perceived the compressed 
lung, which transmitted the cardiac impulse; and a large probe being carried 
into the wound and gently brought in contact with the lung, was perceived 
to move synchronously with the cardiac systole. After the operation, the 
heart did not return to its normal position, but continued to beat to the 
right of the sternum. A large drainage tube was introduced. 
The medicinal treatment consisted from the beginning in quinine and 
Basham’s mixture. Whiskey, in the form of milk-punch, was administered 
in moderate amounts. 
May 7. Active fever followed the operation. On the third day there was 
a purulent discharge, which continues until the present time, amounting to 
two or three ounces in the course of twenty-four hours. The chest is mark- 
edly flattened, as well in the infra-clavicular region as at the level of the 
resected ribs. The respirations have ranged between 30 and 40; the pulse 
between 98 and 140; the temperature, which reached 103° F. upon the fourth 
day after the operation, is this morning normal; the appetite is fair; the 
bowels are regularly moved ; slight sweating at night. The pleural cavity is 
washed out twice daily with a solution of salicylate acid and borax. The case 
has been transferred to the surgical wards. 6 
WILSON, 
In the left infra-clavicular region there is vesiculo-tympanitic resonance 
with a feeble inspiratory murmur. There is here also distinct vocal resonance 
and vocal fremitus. Below the level of the third rib there are characteristic 
amphoric signs. In the second intercostal space, to the left of the nipple line, 
there may be still perceived, upon careful palpation, a faintly transmitted 
cardiac impulse. 
The sequence of events in the foregoing case appears to have been 
the following: Strain in lifting causing laceration of the pulmonary 
pleura (whether pleural adhesions, set up during the sickness three 
years ago, had any part in determining such a lesion or not cannot be 
decided); pneumothorax followed by serous effusion; aspiration in 
the fourth week, twice repeated at short intervals; pyo-pneumothorax 
with firm compression of lung, the lower lobe of which is completely 
airless, and probably adherent to the pericardium ; slight expansion 
of upper lobe after aspiration; heart dislocated and retained in its 
new position by inflammatory adhesions ; transmission of impulse from 
displaced heart through contracted left lung, at first to fluid contents, 
later to tensely confined air in the pleural cavity, with pulsation of 
the chest-wall; this pulsation more distinct and persistent opposite the 
second and third intercostal spaces, probably there transmitted through 
the compressed lower portion of the upper lobe, which has contracted 
adhesions at that point. 
The tension of the pleural cavity, which, shortly after the removal 
of the first drainage tube, produced flatness on percussion below the 
area of the adherent lung, is only explicable upon the hypothesis of a 
persistent rent in the pulmonary pleura. 
Pulsating pleural effusion appears to be an extremely rare condition. 
Comby1 collected twenty-seven cases ; Kepler2 added to the list eleven 
cases, only two of which were reported by the American authors, 
making the number thirty-eight. Comby,3 in a recent review of the 
subject, gives references to seven more cases, bringing the number up 
to forty-five. Osier4 adds to this list a very carefully reported case of 
his own, and brief notes of three other cases from American sources. 
These, with my case, make a total of fifty thus far reported. 
The condition is almost invariably encountered in left-sided effu- 
sions ; in three instances, however, was the empyema on the right 
side.5 The effusion has in every instance, save one reported by 
Kepler, been purulent. For this reason, Comby suggests that the 
1 Archives Generates, Nov. and Dee. 1883. 
2 Deutsches Archiv fur klin. Medicin, pp. 220-240, 1887. 
3 Archives Generates, April, 1889 
4 American Journal of the Medical Sciences, January, 1889 
Vide Osier’s paper. PULSATING EMPYEMA. 
7 
term pulsating empyema should be employed, instead of pulsating 
pleurisy. 
The cases may be referred to two general groups: 
1. Intra-pleural pulsating effusions. 
2. Pulsating empyemata necessitatis. 
The latter is the more common. The external tumor is usually 
single, but in several instances there have been two or more tumors 
present. The pulsating tumor may often show itself at some distance 
from the thorax. Thus, it has been on two occasions observed in the 
lumbar region.1 In a small proportion of the cases the pulsation has 
been observed in recent effusions; as a rule, however, it does not 
appear until the fluid has been present for some time. 
The diagnosis is unattended by difficulty. It is true that the site 
of the pulsation and its cardiac rhythm suggest aneurism of the tho- 
racic aorta, especially when the pulsations are sufficiently strong to 
move the hand visibly in palpation or the head in auscultation. Here, 
however, we must note the absence of aneurismal pulsatile expansion, 
of murmur, and of thrill. Osier proposes, in cases of doubt, explora- 
tory puncture with a very fine nypodermic needle. 
Among the theories that have been advanced to account for this 
condition, that of Comby, which rests upon three post-mortem exami- 
nations, has much in its favor, though it cannot be invoked to explain 
all the cases. Having found the left lung firmly flattened and adherent 
to the pericardium, Comby thinks that this anatomical disposition 
plays an important part in the transmission and amplification of the 
movements of the heart. It is true that this theory is open to serious 
objections, especially since the lung has not been found in all cases in 
a condition of atelectasis. Comby declares himself, therefore, ready 
to accept some less questionable pathogenic theory. 
The theory of Fereol2 is a modification of that of Comby. He holds 
that the presence of pneumothorax in connection with a large pleural 
effusion is the condition sine qua non of pulsating empyema, and he 
supposes that this pneumothorax is closed, and that it forms an elastic 
cushion between the heart and the wall of the chest, to which the pul- 
sations are communicated after the manner of the rubber air-cushions 
of Marey’s cardiograph. 
In the case that I have reported, the condition fully responded 
to the requirements of Comby’s theory, the lung being, in part, 
1 Vide Comby, Kevue Critique, Archives Generales, April, 1889. 
2 Contribution a l’Etude des Pleuresies pulsatiles (Acadijmie de Medecine, 5 fevrier, 1884 ; et Societe 
Medicale des Hopitaux de Paris, 14 mars, 1884). 8 
WILSON — PULSATING EMPYEMA. 
fully compressed and adherent to the pericardium and communi- 
cating the cardiac pulsations with distinctness and some degree of 
force to the finger introduced into the pleural cavity, and to a probe 
brought in contact with it through the pleural wound. The wide 
extent of the perceptible pulsations during the period immediately 
preceding the last operation at a time when the pleural cavity was 
tensely distended with air, but containing no fluid, demonstrates the fact 
that, under certain conditions, the cardiac pulsations are capable of 
being transmitted through a tense pneumothorax to the surface of the 
chest. And the persistence of distinct pulsation in the second inter- 
costal space, to the left of the nipple line, at the present time, after 
the pleura has been freely opened, justifies the conclusion that pulsa- 
tion may, under certain conditions, be transmitted through a consider- 
able extent of compressed and airless lung. What these conditions 
may be must be determined by further investigations. 
It may be affirmed, in conclusion, that no one of the theories hitherto 
advanced is adequate to account for all the cases, but that there are 
several distinct conditions which favor the development of pulsations 
in pleural effusions. The difficulty in formulating any comprehensive 
theory arises from the fact that every condition hitherto invoked to 
explain this curious phenomenon is frequently present in left-sided 
pleural effusions that show no pulsation whatever.