In many eases there is no apyrexial in terval, and probably in some of these pus is present from quite early in the illness. W. Hale White (Lancet, Nov. 10, 1900).
Empyema in children usually follow lobar pneumonia, after a varying, inter val. The infection is usually with the pnetanocoecus. Spontaneous cure, even when aided by tapping, is rare. Opera tion should not be delayed, as time los is strength lost, and the issue is largel3 one of nutrition. The best form o operation is in general the stibperiosteal resection of an inch of the eighth oi ninth rib in the posterior axillary line the evaeuation of pus and fibrin masses nd tube-drainage. Irriga tion a t ot after operation is not usually advisable Routine after-treatment in fresh ease should be tube-drainage. the tube bein progressively shortened. and remove( when the cavity is nearly healed. \Viler failure to heal seems to depend OD fail tire of the lung to re-expand, treatmen by valve or suction apparatus is ball voted. This is especially of value in th more chronic eases. The inortality i about one in seven; in small ellildrei it is much greater than in those over five years. The causes of mortality are, in the main, beyond our control. The great majority of eases heal even when the healing is delayed for many months. Chronic empycina, in the stria sense, i: rare in children. The closure of the cavity depends mainly on nutrition and on adeqtmte drainage. Recurrence may take place from faulty drainage at any time, and it may oecur years after ap parently sound healing. 'without obvious eanse. Deformity of the chest is usually temporary, and yields to treatment. Long-continited discharge from the eav ity is not infrequently followed by chest deformity- and scoliosis of a severer type. permanent, and sometimes extremely se vere. Cotter (Boston .Med. and Slug. Jour., July 17, 1902.).
fremitus On the affected side. If a finger-tip of the left hand is held in an intercostal space over the region and a finger-tip of the right hand is held in a corresponding intercostal space on the sound side, and the patient is told to count audibly, no sound-waves seem to be transmitted to the finger placed in the intercostal space on the affected side, and the finger on the sound side feels the im Skodaic resonance is a term used to indicate Skoda's discovery of an area near the clavicle which is always free from the extreme flatness found in em pyema,--unless this area be also invaded in cases where the dullness is found in all portions of the chest, in which case the cavity is full of pus. This is also accom
panied by a disappearance of the vocal pact or vibratory motion communicated through air by the sound-motion. The symptoms of serous effusion vary slightly, and yet this wave-motion may be com municated better by serum than by pus.
The variety of sounds heard in the early stag,es of pneumonia upon ausculta tion is followed by a complete loss of sound on the affected side in empyema.
The respiratory murmur is nil. The bronchial murmur above may be per ceptible.
The most-marked cases are the only ones in which all of these signs and symptoms obtain; for, with a small ac cumulation of pus, very little more than the rise of temperature and dyspncea exists. The final termination of a case not recognized and treated would be a pointing and rupture externally or in ternally. The most usual points of rupt ure have been the weakest and least re sistant: i.e., internally, above into the bronchi or trachea; and, externally, at the free spots of Marshall or of Traube. The point on the right side which is com paratively free from muscular covering is called the free spot of Marshall, while that on the left side, as in this case, is called the region of Traube. (See wood cut.) [The spontaneous discharge of em pyema without any untoward results WaS observed by me in the case of a young girl, aged 8 years, who had been attacked with influenza, and, later, with severe pleurisy, accompanied by hig,h temperature, weak and rapid pulse, night-sweats, and hectic, showing great absorption of pus. In the course of time, a prominence about the size of D. ben's egg was noticed on the right side near the costal cartilage. After a simple incision the pus was fully evacuated through the opening, which remained patnlons for about three years. The examination of the patient now shows a slight lateral curvature of the spine, with a lack of development of the mam mary gland on the right side, but with a considerable chest expansion and very slight impairment of the lung. The pa tient is rapidly developing into woman hood and has regained her health and strength.