If the abscess point in a lower intercostal space, so that the chest cavity can be completely drained, recovery may occur without operative interference. I have met with at least one such case where, although there was at first some deformity of the affected side, this entirely disap peared ; but it must be confessed that such a fortunate result is not com mon.
Sometimes the purulent fluid, instead of through the chest-wall, perforates a bronchus and is coughed up the lung. Large quantities of purulent matter may be thus expectorated, but con trary to what might be supposed, no air enters the pleural cavity and the physical signs are not found to have undergone any special alteration. Indeed, if the case terminate fatally, it is very rare to find on the closest examination any direct communication between the lung and the chest cavity. Spontaneous evacuation through the lung is not confined to cases where no operative procedure has been attempted. It may also occur after a part of the contained fluid has been removed by paracentesis. This mode of ending is often followed by complete recovery. If the pleural cavity can be thoroughly evacuated by this means, and the lung is not bound clown beyond possibility of expansion, recovery may take place with out any permanent retraction of the affected side.
A little boy, aged five years, was brought into the East London Chil dren's Hospital for an empyema of six weeks' standing. The effusion occu pied the right side and appeared to be copious, for the intercostal spaces were obliterated and the heart's apex was felt beating to the outer side of the left nipple line. On percussion, dulness was complete over the whole of the right side, both back and front ; there was marked sense of resist ance ; and the breath-sounds, although blowing in quality, were excessively weak. The temperature was normal.
A few days after the boy's admission eleven ounces of thick, greenish, inodorous pus were withdrawn by the aspirator. After the operation the dulness and weak blowing breathing remained the same, but the intercostal spaces had become visible, and the heart's apex had returned as far as the nipple line. A week afterwards the boy coughed up twelve ounces of thick
pus, and in a few days "a further four ounces. After this the percussion note was decidedly less dull ; the resistance was diminished ; and the breath ing was loud and tubular over the whole of the upper half of that side, cavernous below. Vocal resonance was loud and regophonic.
For some weeks the boy continued to spit up several ounces of puru lent matter every few days ; and in the end made a perfect recovery with out any contraction of the chest-wall. The temperature was normal as a rule ; although sometimes it would suddenly rise to 103° or 104°, but never remained elevated more than a few hours. These elevations did not cor respond with or precede the passage of pus through the lung. A year afterwards the boy was readmitted with acute pleurisy of the opposite side (the left) ; and this attack also was perfectly recovered from.
In many cases of perforation of a bronchus there is the same difficulty in completely evacuating the pleural cavity as is found when the discharge takes place through the chest-wall. Sometimes the opening into the bron chus closes, and pus ceases to be expectorated. Retention of purulent matter then occurs, and the chest may become much distorted, or the child, after a lingering illness, may die of asthenia.
Even when the operation of paracentesis is performed and the puru lent fluid is removed artificially, the case is by no means necessarily at an end. Sometimes, after withdrawal of as much fluid as can be made to pass through the aspirator, no further accumulation occurs ; absorption of what remains in the pleural cavity goes on uninterruptedly, and the child is soon well. These cases are, however, exceptional. It is often necessary to repeat the operation several times, and not unfrequently, as the purulent fluid con tinually reaccumulates, other measures have to be adopted as will be after wards described. In prolonged cases, whether a fistula be present in the chest-wall or not, secondary tuberculosis is liable to occur ; and it is not very uncommon to find great enlargement of the liver and spleen from amyloid degeneration.