The temperature is higher on the average than in the serous type, and may attain 40.5-41.5° C. (I05-10,7° F.) in the beginning. It may be drawn out for weeks, may vary in height, and may often be inter mittent. Very frequently, especially in the later course of the disease, fever may be entirely absent. In striking contrast to the afebrile con thtion is the greatly accelerated and small pulse, which is markedly increased on sitting up. Without the life-saving treatment. the disease often leads to chronic invalidism and death, arnyloid degeneration, purulent metastases, retrecissement (contractures), or to rupture of the pus externally or through the bronchi. llettbner describes a multiple, purulent inflammation of the serous membranes.
C'hronic empyema is frequently unrecognized, and may for instance be mistaken for ca.seous pneumonia. It often differs front this, however, by the displacement of the neighboring organs and eventually by retre cissement and diminished frenntus. The great importance of ernpyema during childhood makes desirable a short review of the most important forms which have been studied, especially by Netter.
(a) As stated under etiology, the pnelimococcus empyema is by far the most frequent form. It may occur primarily or secondarily, most frequently as a sequela of croupous pneumonia after many days or perhaps even weeks (inetapneumonia empyema).
Should the temperature in a croupous pneumonia abate gradually in order to soon rise again, should a high temperature set in again a few days after a typical crisis, or should the decline of temperature re main absent for ten or more clays, the possibility- of the presence of an empyerna must be considered, particularly if the patient is less than four to five years of age. With comparative frequency empyerna begins before the crisis (parapneurnonic empyenta).
-With the advent of a pleurisy in an existing pneumonia, dulness is increased, fremitus is diminished, and bronchial breathing and bron chophony are usually still more increased. It is peculiar that at certain times empyerna compEcates pneumonia only very rarely, at other times again more frequently. Netter found the fever of a pneumococcic em pyenia more frequently continuous than intermittent. Fever, however, may be entirely absent, according to Wiirtz, even in half of the cases which received hospital treatment. The disease may quite frequently run a "latent" course, i.e., the patient scarcely complains of pain and dyspnma and cough are slight. Not altogether infrequently a bilateral empyema may be present. At times the effusion leaves the lower por tion of the pleural cavity free, and may be situated only over an upper lobe, or anywhere in the middle of the lung, or even may be interlobular, conditions which must be carefully considered from a diagnostic point of view. The effusion is opaque from the very beginning, and very
rapidly becomes purulent. It frequently contains in large masses coarse shreds of fibrin almost as thick as a finger.
The pneumococci pus often presents a characteristic appearance. It is thick, slimy, greenish, lias an insipid odor, and leaves no sediment on standing. The pneurnococci in the pus are arranged in long chains, and are distinctly lancet-shaped. Sometimes the effusion becomes ab sorbed spontaneously, if it is only small in quantity. Sometimes it rup tures through the bronchi anti appears in mouthfuls in older children as a purulent sputum. In such cases there is often no pneurnothorax, probably because the communicating opening is very small. An empy eina necessitatis often occurs, mostly through the anterior wall, and manifests itself by rederna and fluctuating swelling in from the third to the fifth intercostal space. The purulent inflannnation at times also involves the pericardium, especially in left-sided empyerna or may lead to pulmonary abscess, metastases, in the form of peritonitis, osteo myelitis, arthritis, and skin abscesses (Hagenbach-Burckhardffi. Menin gitis is not seldom observed, and is most apt to occur in cases of protracted course.
The prognosis in pneumococcic empyema is comparatively- good. Most eases recover with timely operative evacuation of pus. During the first two years, the prognosis is more dubious. During early years serious complications, bronchopneumonia, purulent pericarditis, and meningitis, are more apt to occur, and probably always terminate fatally. In isolated cases, a simple puncture may suffice to bring about recovery.
(b) Streptococcic empyema is frequently found in scarlet fever, measles, angina, and erysipelas. It develops very rapidly with high fever, ty phoid symptoms, and rapid prostration. Diarrhcea is frequently present. The effusion ascends to the top in the shortest time, and immediately reaccumulates after evacuation. The pus is thin and shows on standing a grayish deposit covered by a large quantity of serous fluid. Pericar ditis, sometimes peritonitis, and very frequently general septicinia, are important complications. The prognosis is bad; Netter lost seven out of nine cases operated on. As treattnent he recommends thoracot omy anti irrigation with boiled water.