Pus is probably present whenever the patient in question is less than five years of age, if the pleurisy has joined a croupous pneumonia and the fluid rapidly fills the entire half of the chest. A serous effusion is almost always present whenever the patient is over ten years of age, or if the pleurisy has become associated with pulmonary tuberculosis or acute rheumatism. In order to determine, exploratory puncture is to be done (see below). An encapsulated empyema in an unusual situa tion renders recognition difficult, and may also give rise to confusion wi t h peri cardi tis.
Often pleuritic thickening cannot be distinguished from a fluid exudate because the same may also Calise resistant dulness and dimin ished vesicular breathing. Freinitus frequently reappears in pleuritic thickening. The diagnosis is generally made certain by the course and narrowing of the affected side; frequently, however, only by an exploratory puncture.
Exploratory puncture is to be undertaken where an extensive dul ness does not permit the decision whether a consolidation of the lung or a serous effusion is present, and where the longer duration of this dulness might inake evacuation desirable in case of an effusion. Exploratory puncture should always be done as soon as well grounded suspicion of empymna is present, since it demands the immediate removal of the pus. in practice infantile empyema frequently remains unrecognized for weeks. For this reason children's hospitals often have the experience of receiving eases only when they are in a desperate condition. I3y timely exploratory puncture and operation good health could again be given to many a child that perishes miserably from exhaustion, metas tases, etc., the result of an unrecognized empyrina. Very frequently, the exploratory puncture is the only measure to distinguish small effu sions from pulmonary consolidation; the splenopneumonia of Graneher is scarcely to be recognized in any other way.
-With antiseptic. precautions exploratory puncture is entirely with out danger. The probability of sometimes infecting a healthy pleura by puncture of a bronchiectatic or tuberculous cavity is extremely slight. The Pravatz syringe must not be employed for puncture be cause the pus and shreds are often so thick in metapneumonic empy ema as not to enter a fine cannula, leading the physician to believe that he is not dealing with an effusion. For this reason one must use a larger and well fitting sy-ringe, the cannula of which has a diameter of one milli metre. A spot at which dulness is the greatest and where fremitus and increased breathing if possible is absent is chosen for puncture. The
child is held firmly in the sitting position by the mother. For instance tlte position on the table as shown in Fig. S9 is a favorable one. With the index finger of one hand the intercostal space is carefully found in order not to encounter a rib with the needle, the skin having been disin fected. The needle is plunged in to the depth of about 1-2 cm. If on -withdrawal of the piston no fluid is obtained the needle is pushed in somewhat deeper. The puncture is closed by adhesive plaster. The aspirated fluid permits the unaided ey-e to determine the diagnosis, not only wbether a serous or purulent pleurisy is being dealt with, but often also what is the nature of the empyema (see above). The exact diagnosis is made with cover-glass preparation respectively by culture arid eventu ally by-inoculation. The serous effusion has a specific gravity of 1.016 to 1.024; one drop of acetic acid produces opacity and a flocculent sm-fiment, in contrast to the transudation in hydrothorax which also has a lower specific gravity. a smaller, sacculated, or interlobular, empyema with extensive thickening of the pleura the first puncture often does not yield any pus. A second puncture is then made at another point, and is repeated if necessary after several days. It is well to point out to the relatives from the start the possibility of a negative puncture. Consid erable pleuritic thickening is manifested by the greater resistance encountered in the introduction of the needle.
The prognosis in pleurisy is on the average niuch better than in adults. Serofibrinous pleurisy usually terntinates in complete recovery in a comparatively short time, except when it is of tuberculous origin. If a larger exudate lasts for a long tirne without being removed by medi cal skill, lasting contracture may remain. In individual cases tempera ture, pulse, ancl dyspnoca, are criterions, and the tape measure indicates the increase and decrease of the effusion. Enmyema also furnishes a better progno.sis than in the adult because it mostly depends on pneumo cocci, and the pneurnococcus pneumonia offers the best chances and almost always terminates in complete recovery, if operation is performed sufficiently early. Other empyernie, especially those dependent upon strep tococci, have a much more unfavorable prognosis. The bacteriological examination of the pus may therefore be utilized for prognostic purposes.