The discharge of pus in the left side \VDS observed by me in a boy at Annis ton, Ala., in whom a serous pleural ef fusion had been aspirated, and had been treated by medication also. The degen eration of serous exudation into pus was verified in this case. Osier has stated that he has never seen a case of sero fibrinous effusion degenerate into puru lent pleurisy, but, according to W. M. Pirt, literature shows many similar cases, The region at which the pointing oc curred in this ease was in the left inter costal space, immediately below the apex of the heart. I performed the operation of resection of a portion of the sixth costal cartilage on the left side, and se cured drainage with a strip of gauze passed daily through the fistulous tract. The patient made a good recovery, also; and, being young and vigorous, over came the tendency to scoliosis. The last report from hiin showed that there had been no redevelopment of pus, and that the fistula had been closed. J. Me FADDEN GASTON.] The -..11arshall and Traube regions are points of least resistance and, although higher than the pus sometimes reaches, may be considered the most available for spontaneous discharge. It is for this reason, and because the region of Traube is least liable to complications with the diaphragni, pleura, and abdominal wall, that Jaccoml, of Paris, selected it for the introduction of a trocar. J. II. Cox has reported a ease in which spontaneous evacuation took place in front between the sixth and seventh ribs. Recover followed. Y The pus may discharg,e through the intercostal spaces, but fail to reach the surface at the point on account of mus cles; then it burrows beneath them. In regard to the spontaneous escape of pus in thoracic empydnia, a case has been re ported in which it took place at the um bilicus. This location of the weak point is a corroboration of the theory that pus escapes at the point of least resistance, and not always at the point of the lowest pressure. (J. G. 'Willis.) [I witnessed the case of a man at the Atlanta Polyclinic, who had a whole quart evacuated from the incision made into an axillary abscess communicating with an empyema. The patient was lost sight of after the first evacuation by me, and it is supposed that he must have been relieved by the use of a gauze drainage and packing at that time. J. McFADDEav GASTON, JR.] Diagnosis.—The diagnosis may be made from the extreme dullness and lack of respiratory sounds, when the tempera ture remains elevated. But an explora tory puncture is advisable to determine definitely a case of empyema.
Subplirenic pyothorax can be recog nized hy the results of high and low aspiration, in a large percentage of all casits. High punctures, in the fifth inter costal space, show a collection of pus or serum, while low punctures, as the eighth intercostal space, yield pus which is always ichorous. Schein'len (Charit6 Annalen, vol. xiv, p. 15S, 'S9).
Two cases of pulmonary abscess simu lating empyema. Kauffmann (Binning ham Med. Review, Oct., '93).
Case of subdiaphragmatic abscess con taining pure culture of bacillus cob communis observed which simulated em pymna. F. Tilden Brown (N. Y. Med. Jour., Feb. 29, 'ri6).
In the New York Foundling Hospital during the last ten years there were 82 eases of cmpyema, and 69 of these were under two years of age. In 28 cases
there was no involvement of the lung. Clinically, it is at times most difficult to diagnose and locate the pus. In oppo sition to the course of empyema in adults, in children the disease is short and critical, some cases dying within forty-eight hours, and the mortality, in all cases of children, is very high. The rational signs are the same as those of pneumonia, and the only positive sign is the finding. of pus with a large ex ploring-needle. Practically all pleural effusions in infancy are either purulent from the be,ginning or soon become so, and when pus has been found drainage is called for. D. Bovaird (.11cd. News, Dee. 23, '99).
Pleuritic effusion and a earnificd or hepatized lung should be borne in mind, and they may be excluded when the ex ploring needle reveals pus.
At times cases of empycma may be confounded with ordinary iiatramural abscesses, as when they occur near the axilla, and are incised. We have found several cases among negroes treated late and who had been neglected. Etiology.—Pleurisy with its usual sequelm of pleural effusion is the most common etiological factor. The matory complications of pneumonia are also among the causes.
There are four main groups of eases of einpyeina in children. The first is the metapneumonic, the diploeoccus pneu monite playing chief role as etiological factor. In the second group the only micro-organism found in the pleuritic ex mlates is the staphylococcus pyogenes or a streptococcus. The third group is due to the tubercle bacillus, and the fourth is the so-called putrid or fcetid empyema. Henry Koplik (Med. Record, Jan. 25, '96).
It is impossible to state with accuracy the percentage of cases in which pneu monia is followed by empyenia, but it is interesting to note that out of 325 con secutive cases of empyema in the med ical wards of Guy's IIospital, there were 41, or 12.6 per cent., in which it ap peared that the ernpyema followed a lobar pneumonia. W. Hale White (Lan cet, Nov. 10, 1900).
Clinical study of one hundred and thirty-five cases. When the streptococ cus is present and is due to suppurative or pymmic conditions outside the chest, it is usually of a virulent type and has a correspondingly bad prognosis. In the inetapneumonic cases the prognosis of streptococcus is little worse than that lanceolatus. The particular organ ism present is a less cogent factor in determining the need of operation than the fever, prostration, chills, the quan tity of pus-eells pre.sent„ and the tend ency to refill after operation. The grad Hal development of pu.s after successive aspirations can usually be predicted from the presence of streptoeocci or pneumococei in the first fluid withdrawn, even though that be a clear serum. But pus may also appear when the earlier tappings are sterile. C. F. -Wallington (floston Med. and Surg. Jour., NOV. (1. 1902).
Trauma may also give rise to the effu sion.
Tubercular empyerna may follow the perforation into the pleural cavity of a tubercular peripleuritie abscess, origi nating in a tubercular osteitis of the ribs or vertebr2.
Tuberculosis is thought to be caused by pleurisy; on the other hand, Germain See and others are quoted by J. C. Cas tillo, of Lima, Peru, as regarding three fourths of all pleurisies tuberculous in their origin.