THE PLEURA I45 



with free contamination of the membrane and its contents, and in 

 those due to the rupture of very foul tuberculous vomicae, contain 

 vast numbers of organisms of all kinds — bacilli, cocci, etc. — mixed 

 together. These fluids usually smell badly, and are of very evil 

 omen. 



Lastly, in a few cases other organisms, such as the typhoid 

 bacillus, may be found. 



Having these facts in view, the practitioner is recommended to 

 proceed to examine cases of purulent pleurisy in the following 

 manner : The pus is to be withdrawn with a hypodermic needle 

 or exploring syringe, and a few drops deposited at once on the 

 surface of a culture-tube of agar, spread well over the surface with 

 a platinum loop, and incubated at the temperature of the body. 



The microscopical examination is made in the manner described 

 for pus, a simple stain and also Gram's stain, with dilute carbol 

 fuchsin as a counterstain, being used. The presence of strepto- 

 cocci, staphylococci, and pneumococci will be revealed ; bacilli 

 may be present, and in this case it should not be forgotten that 

 the tubercle bacillus stains by Gram's method. If no organisms are 

 found in these films, or if there are organisms which resemble the 

 tubercle bacillus in general appearance, another specimen should 

 be submitted to prolonged staining in hot carbol fuchsin and de- 

 colorization in dilute sulphuric acid, and thoroughly searched for 

 the tubercle bacillus. If the result is negative, several other films 

 should be searched. 



The cultures are to be examined after twenty-four hours' incu- 

 bation. The pneumococcus will produce tiny colourless colonies 

 on the surface of the agar ; the streptococcus forms similar small 

 colourless colonies, but these are distinctly more opaque in the 

 centre; staphylococci form opaque white or yellowish colonies 

 which, after long incubation, spread out, coalesce, and cover the 

 surface of the agar with an even film like a streak of paint ; and 

 the tubercle bacillus does not develop. Films should be made 

 from the cultures, stained and examined. The cultural examina- 

 tion is of great value, but much can be made out by the examination 

 of stained films made directly from the pus. 



Vaccine Treatment. — It is not advisable to trust to vaccine treat- 

 ment alone in empyema. The pus should in all cases be removed, 

 either by aspiration or resection of ribs and drainage. After this 

 has been done the use of vaccines may confer great benefit, and 

 lead to more rapid healing. 



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