If the fluid remain serous, recovery is certain unless the fluid accumu late to such a degree as to dislocate the heart and interfere with the passage of the blood through the large vessels. In such cases death may occur un less the child be rapidly relieved by operation. When the fluid has become purulent the prospect is more serious, but less so in childhood than in after years ; for if proper measures be adopted a large majority of these cases recover. A high temperature is an unfavourable sign, and the con tinuance of the pyrexia after discharge of the purulent matter by operation should occasion great anxiety. Still, even in these cases recovery often follows. Again, the sudden sinking of the temperature to a point below the level of health is, as Wunderlich has pointed out, a sign of unfavour able import.
If the empyema burst spontaneously through the chest-wall, recovery rarely takes place unless the opening be seated in a lower intercostal space, or unless an artificial opening be established in a more suitable position. Spontaneous cure is more likely to follow evacuation through a bronchus ; and a large proportion of these cases get well. Still, if the cir cumstances are such that retention of purulent matter takes place, the child, if left alone, may sink exhausted.
Fetor of the pus is a bad sign. Unless prompt antiseptic measures are adopted, these cases always end fatally.
Secondary pleurisy is much more dangerous than the primary form of the disease. The fluid is more likely to become purulent at an early date ; and the child, already weakened by his first illness, is in an unfavourable condition to support the exhausting influence of a chronic empyema upon his nutrition.
Treatinent.—A child attacked by acute pleurisy should be at once put to bed, for absolute rest is of the highest importance. A febrifuge mix ture should be ordered, and the diet should consist of milk and broth. If the pain in the side be severe, a leech or two may be applied if the child is robust ; or a hypodermic injection may be given containing one-twelfth of a grain of morphia for a child of four years of age. A firm bandage round the chest is often successful in giving great relief ; and a thick layer of wadding around the affected side is useful for the sake of warmth. Some physicians advocate a careful strapping of the chest over the affected lung with broad strips of adhesive plaster. I have made use of this plan, but cannot say I have noticed any distinct advantage from its,employment. In diaphragmatic pleurisy where the pain is severe, a firmly applied bandage to the abdomen, so as to limit the action of the diaphragm, often affords ease. The bowels, if confined, must be relieved by mild aperients, such
as the liquid extract of rhamnus frangula or the compound liquorice powder ; but violent purgation is hurtful and should be avoided. Mer cury, the favourite remedy in former days, is now seldom recommended. Still, in some cases, one grain of gray powder given twice a day, with an equal quantity of quinine, or with five grains of the peroxide of iron, has sometimes seemed to me to be beneficial. Iodide of potassium is, however, usually to be preferred, and this salt, given in full doses, I believe to be of distinct advantage to the patient. I am in the habit of ordering for a child of four years old, five, eight, or ten grains of the iodide, to be taken every six hours, and look upon the remedy given in such doses as a valu able promoter of absorption. The internal remedy should be always sup plemented by counter-irritation of the chest-wall. Directly the tempera ture falls, or earlier if effusion appears to have ceased, the liniment or tincture of iodine (according to the sensitiveness of the skin) should be painted over a limited surface every night. This application is most use ful if applied over an area of two or three inches in diameter—repainting the same on each occasion. When the skin begins to look dry and cracked, another spot is selected, and the process is repeated regularly as before.
If, after a week, the fluid remains stationary, without sign of absorp tion it is better to change from the iodide to a chalybeate, or to add five or six grains of the tartrate of iron to the mixture. In scrofulous children, when effusion has ceased, it is advisable to improve the diet ; and pounded meat, strong meat broths, yolks of eggs, and moderate quantities of stim ulant are usually required.
If at the end of a fortnight the effusion has been unchanged in amount, it is probably purulent. An exploratory puncture should be made with a fine needle syringe, and if pus be withdrawn, measures should at once be taken to evacuate the chest. If the fluid is found to be serous it is ad visable to wait for a few days, for this small operation and the abstraction of even the limited quantity withdrawn by the test puncture, may act as a stimulus to absorption and be followed by the rapid removal of the fluid by natural means. At the same time the quantity of liquid taken by the child should be restricted ; for a dry diet in such cases by stinting the blood of fluid often greatly promotes the action of the absorbent vessels.