EMPYEMA, THORACIC.—Empyema: Gr., ,tintiCi".1,, tO suppurate.
Definition.—Empyema is an accumu lation of pus in the pleural cavity inde pendent of the lung-tissue.
Varieties.—The various kinds of sup purating pleurisies are pulsating em pyema, multilocular empyema, tubercu lous erapyema, double empyema, putrid empyema, and interlobular pleurisy.
When a collection of pus is so situated as to be synchronous \vith the heart-beat, it is denominated pulsating.
In cases of pleuritic adhesions and the circumscribed diaphragmatic pleurisy, we often have encysted collections, which are usually many in number. Tubercu lous empyema occurs in scrofulous sub jects and is often localized, with caseous masses. Double empyema occurs simul taneously on both sides, while interlobar pleurisy is the inflammation in the vis ceral pleura, or that .covering the lung, and pymic exudation a.ccumulating in the interlobar fissures.
The interlobar empyemas are not pri marily abscesses of the lungs, but of the pulmonary pleura; but necessarily as sume the form of abscesses of the lung if not circumscribed by adhesions or evac uated early. The putrid empyema is a form resulting from neglect and long ex posure to the various pyogenic micro organisms, such as saprophytes, and the streptococci and staphylococci, resulting in pymmia and septicmmia.
Symptoms.—In most cases of empy erna there is a history of exposure to dampness or overheating. A. chill comes. on, then fever, and pain in the side. The. disease may not have been regarded as: serious or a relapse may have occurred!. In a few days dyspncea and unusual/ restlessness call the attention of the pa tient again to his chest. In a month or two the clinical picture has gradually changed; the patient, perhaps florid and plethoric, may have become emaciated and morose, a short loose cough suggest ing the presence of consumption, which apparently becomes confirmed when night-sweats are noticed. The aspect of the face and the posture is that of ex treme exhaustion. The physical signs are pain in the side affected. This may be one of tbe first symptoms; but the most marked of these is discomfort due to dyspnma and to the absorption of pus.
The skin may be clammy and bathed in a cold perspiration. The respiration is about 40 to the minute; temperature from 103° to 105°. There is dullness on the affected side, with change of sound under auscultation and percussion when sitting, when lying down on the back, or if the patient be turned on one side.
Twenty patients examined with spe cial care in regard to the change of level of a pleuritic exudation as the patient's position is altered. Anything that might, by acting as a damper upon the thorax wall, give rise to apparent dullness, such as pillows, mattress, supporting hands placed against the back, etc., was avoided, many of the apparent changes in the level of dullness being due to these agents. The thorax-wall must be set in vibration and give character to the per eussion-sounds. If a damper is so ap plied as to stop these vibrations, a dull note results. A normal thorax, if per cussed in the position a pleuritic patient assumes. will give a dull note on certain lines. In only one case out of the twenty (lid the examination reveal any change in the line of dullness. Stranch (Virchow's Arehiv, June 1, '89).
By far the most important aid in diag nosing that enipyerna has followed pneu monia is the temperature. The usual thing, if einpyeina follow, is for the tem perature to fall when the crisis takes place, for it to remain down two or three da.ys. for it then to rise again, so that it soon becomes from 2 to 4 or 5 degrees above normal in the evening and about 1 or 2 degrees in the morning; this con tinues until the pus is evacuated. Some times the apyrexial interval is only one day. sometitnes it is four or five days, and sometimes there is not 'strictly an apyrexial interval, for the temperature (loes not fall at the crisis to normal, but only to nearly normal, and then soon begins to rise again, so that instead of apyrexial interval we have an inter val of lower temperature. There is a fall of temperature at the pneumonic crisis with a subsequent rise in about a third of all the eases in which empyenta fol lowed pneumonia.