THE PLEURA 125 



It separates into two layers, the upper transparent layer being 

 much more abundant than is the case with pneumococcic pus. 



This form of empyema is rare in children, but is perhaps, on 

 the whole, the commonest one in adults. The prognosis is much 

 worse than in the pneumococcic cases, and thorough drainage and 

 resection of the ribs is essential. 



Staphylococcic empyemata, according to Netter, are very rare ; 

 the single case in which he found the staphylococcus alone was 

 secondary to ulcerative endocarditis. He also states that when 

 this organism is found in the pus tubercle bacilli are often present as 

 well. The prognosis of these cases, therefore, appears to be bad. 



The tubercle bacillus is responsible for a comparatively small 

 number of cases, and the results of operative interference are 

 not gratifying. The prognosis is worse than in any other form of 

 the disease. 



The pus is usually white in colour, and thin and watery. It 

 may contain small masses of white caseous material. The leuco- 

 cytes which it contains are nearly all lymphocytes, unless a 

 secondary infection with pus organisms has taken place. 



The diagnosis may be made from a careful microscopical 

 examination, but to this end it must be careful, as the bacilli are 

 present in but scanty numbers. 



If no organisms are found after a thorough microscopical ex- 

 amination, the inference is that the case is tuberculous. If a 

 cultural examination is also negative the inference becomes 

 almost a certainty. 



The empyemata arising from rupture of the oesophagus, stomach, 

 intestine, etc., into the pleura, in those due to an external wound 

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 manner : The pus is to be withdrawn with a hypodermic needle 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



