The Diagnosis and Treatment of Empyema

Few diseases conform so seldom to their classical book diagnosis as empyema or purulent pleurisy in its various types. If even the majority of cases showed consecutive layers from below upwards on one side of the chest, of dullness with absent breath sounds and increased vocal resonance and fretnitus, aegophony, and then tubular breathing, with displacement of the heart to the opposite side, there would be little difficulty in differential diagnosis, nor should we see the tragedies of long-standing chronic empyema which are still admitted to our hospitals. The reason is that it is very unusual for empyema to be anatomically complete. It may, of course, be so found in infections with malignant haemolytic streptococci where the onset is acute and limiting adhesions are not present. In most cases, however, the effusion is so tied down by adhesions that division can be made into types according to the position of such restricting bands; for example, interlobar, mediastinal or diaphragmatic empyema.