In some cases the amount of fluid is small. This is most commonly seen when the pleural inflammation is secondary to peritonitis, pericarditis, or pneumonia. Sometimes the pleural cavity, instead of forming one large ab scess, may be divided into several distinct sacs by false membrane and ad hesions, so that one of these may be emptied without draining the others. It is not so very uncommon to meet with more than one loculated empyema in the same subject ; and great difficulty is found in such cases in com pletely relieving the chest of its purulent contents.
A large collection of purulent fluid in the pleural cavity rarely becomes absorbed. If not removed by operation, a spot at some part of the chest wall—usually the fifth interspace in the inframammary region—is noticed to be red and very tender. This soon becomes prominent and forms a large superficial abscess, which, if not opened artificially, bursts and the pus slowly drains away. By this means caries of a rib is sometimes produced. The abscess does not always point low clown. It may appear higher up in the chest, as above the clavicle, or in an upper intercostal space ; and I have known it to open in the supraspinous fossa. In some cases, instead of bursting externally, the purulent collection opens into a bronchus and the matter is coughed up through the lung. In others it perforates the dia phragm, and passes downwards like a psoas abscess behind the peritoneum. Steiner in one case saw it open into the gullet.
Whether the fluid be removed artificially or escape by perforation of the chest-wall, it may after a time drain away completely and leave the patient convalescent. Sometimes, however, a discharging sinus is left which remains open for years. In these cases amyloid disease of organs often follows, or the Child may die from general tuberculosis.
Symptoms.—The onset of pleurisy, although sudden, is not often violent. Usually it begins with a feeling of chilliness, or in older children with a rigor, and with pain in the side, followed after an interval by cough. It is rarely ushered in by a convulsive seizure, as is so commonly the case with pneumonia. The pain is often severe. It is felt in the side or is referred to the epigastrium or the stomach. In infants who cannot speak, its exist ence is announced by violent fits of crying, which may be excited at once by pressure on the chest as in lifting the child up. An older child com
plains bitterly of the pain, and often gives evidence of his suffering by the distressed expression of his face, especially if a cough cause any sudden movement of the side. There is also tenderness of the chest-wall over the seat of disease, for pressure is evidently painful. In addition to the above symptoms there is generally headache ; the. tongue is furred ; there may be vomiting, and for the first few days there is always fever, even in cases where the temperature is afterwards normal. The pulse is quickened, and the respirations are more hurried than natural ; but they are not, as is the case with pneumonia, increased out of proportion to the pulse. Conse quently, there is little or no perversion of the pulse-respiration ratio. The cough does not usually begin until an appreciable interval has passed the onset of the illness. Often, for the first twenty-four or forty-eight hours, little cough is noticed. When it comes on it is hard and dry, and the increased movement of the chest-walls by which it is accompanied is a cause of much suffering. The strength of the child fails comparatively little. There is by no means the marked muscular prostration which is so noticeable a feature in pneumonia. On the contrary, if the pain be not severe, the child seldom takes voluntarily to his bed, but will walk about as usual without any pronounced sense of fatigue. If the pain is severe, he is quiet and indisposed to exert himself ; but this inclination to rest is the consequence of pain, which is increased by movement, and is not due to any sense of muscular weakness.
The degree of fever varies. Usually for the first few days the tem perature rises to or 103° in the evening, falling to 99° or 100° in the morning. After the first week the fever may either persist, or the temper ature may fall gradually to the normal level. In a child of perfectly healthy constitution, if the pleurisy be primary and uncomplicated, the fever usually is moderate and quickly subsides. Persistent high tempera ture in a case in which the pleurisy is primary and uncomplicated is usually a sign that the patient is of strumous constitution.