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 - vv. \- - 
 
 EMPYEMA. 
 
 A STUDY OF THIRTY CASES FROM CLINICAL AND IIACTERIOLOCICAL 
 
 STANDPOINTS. 
 
 Br 
 
 W. F. HAMILTON, M.D., 
 
 Lecturer in Clinical Medicine, McGill University ; Assistant Physicifin to the Royal 
 
 Victoria Hospital, Montreal. 
 
 Kfprinted from the Montreal Medical Journal, Octoher, li)0(). 
 
EMPYEMA. 
 
 A STUDY OF THIRTY CASKS FllOM CLINICAL AND BACTEUIOLOGICAL 
 
 STANDPOINTS. 
 
 BY 
 
 W. F. HAMILTON, M.D., 
 Lecturer In CliniciU Medicine, McGill University ; Assistant Physician to tin; Uoyal 
 
 Victoria Hospital, JNIontrcal. 
 
EMPYEMA.* 
 
 A STUDY OF THIRTY CASES l-'UOM CLINICAL AM) B> CTElilOLOCICAIi 
 
 STANDPOINTS. 
 
 IIY 
 
 W. !'•. Hamilton, M.D., 
 Lecturer ill Clinical Mediciuu, McUill University; Assistant Plij^ifiiiu to the Royal 
 
 Victoiiii Hospital, Montieal. 
 Cuiiccniing tlio luode of onset of the illnusrf in these cases, but little 
 is iiuteil tii'iit may bo regarded as extraordinary, in tliose tliat have 
 been elassiiied under tiie niet'apneuuionic group, an onset, Ijest 
 described as "pneumonic," prevailed; in some, a crisis occuiTed, in 
 otliei's none is recorded. (It should be noted at this point that not a 
 few of these patients were not brought to the hospital until many days 
 after the period of crisis, if such there were, h'ad passed, and thus this 
 part of .the liistoi7 is lacking). 
 
 A gradual onset was noted in four cases, tlu'cc of which were those 
 of tuberculous patients. I'lenrisy, with a clear sero-fibrinous elfusion, 
 was demonstrated in another ciise. Se\ere, recurrent chills with peri- 
 urethral (abscess, marked the onset of a protracted case. Two ai'c sup- 
 posed to have followed typhoid fever, yet there is but scant support 
 forthcoming for this supposition. The abdomen was the seat of pain 
 so far 'as the complaints of four children indicated. An onset with a 
 eonvulsdon is not recorded.' 
 
 In a general hospital, where patients with the infeetious diseases were 
 not received, one would seai'cely expect to lind that more than -i per 
 cent, of any one class of cases under treatment, were among children; 
 especially would this be rather a siu-prise where the proportion of beds 
 for children is to those for adi.lts as 1 to 8; yet this is about the pro- 
 portion we find in our hospital experience. Of the tliirty patients herein 
 reported, thirteen were under twelve years of age. The youngest of the 
 series was eight and one-half months, the oldest sixty-six yeaxs. 
 
 Under 1 year 1 
 
 From 1 to 5 years 3 
 
 5 to 13 years 10 
 
 13 to 30 years 3 
 
 " 30 to 30 years 7 
 
 Over 30 7 
 
 There were sixteen males and fourteen females. 
 
 ie 
 
 Read before the Canadian Medical Association, Ottawa, September, 1900. 
 
The right side was involved in eleven cases ; the left side in eighteen, 
 while a double empyema was observed but once. Although no refer- 
 ence is made to this subject in text-books, as Dr. Francis Iluber said 
 over ten years ago, he collected from the literature about one dozen 
 cases, and several more have been recorded since. Many of such cases 
 have been cured, yet the one in tliis series terminated fatally. 
 
 Two of our patients showed scars of ^ former operation for empyema 
 over the side again acutely involved. A brief report of these cases may 
 be of interest : — 
 
 A. O. (2577), m., aet. 10 years, became suddenly ill on Jan., 23th, with sharp pain 
 In the left side, chill, flushes. couRh and dyspnfBa ; fever 100" to 102", pulse 100 to 104, 
 respirations 36 to 40. "Within a few days there were sip;ns of fluid in his chest and 
 the exploring needle conflrmed those signs. His mother gave a history of his having 
 pneumonia at the age of seven, and that during this illness his side was opened for 
 pus, and the scar upon the left side conflrmed that statement. 
 
 He was again operated upon along the line of the old incision, and considerable 
 pus was evacuated but no fibrinous masses. 
 
 The recovery of this case was long and tedious, a sinus presenting 
 after 118 days in the hospital. The second report of empyema con- 
 cerns: 
 
 E. B., m. ret. 9 years, who fell ill on Sept. 20th, 1896, with chill, severe pain in 
 right side, shortness of breath and hoad.iche, but signs of pneumonia did not deve- 
 lop for some ten days. After this the pain in the riglit axilla became more severe, 
 a friction rub was heard, while blowing breathing and rusty sputa were the chief 
 signs of pneumonia. In a few days the blowing breathing hart disappeared and the 
 patient's condition was constantly becoming worse. The right side, always flatter 
 than the left, since his former operation at the age of three years, now began to show 
 a small area of bulging over the lower ribs anteriorly, and later, oedema developed 
 just about the scar from the former surgical wound. 
 
 He was operated upon in the usual way and made a good recovery. 
 
 Well recognised among clinicians and often referred to in books, is 
 that form of empyema in which the cavity, once evacuated, may refill, 
 yet this form of recurrent empyema, so far las the writer knows, is very 
 rarely described. 
 
 Two cases in tuberculous patients, began with pneumothorax. Gas 
 in variable qutotity was noted at time of aspiration or resection in three 
 other cases which lack the usual history of the onset of pneumothorax, 
 as well as any f^irther evidence of its presence. 
 
 Streptococci and staphylococci were found alone in cultures from the 
 effusions of these cases, in two of wliich the odour of the pus is re- 
 ported as offensive. There is no evidence to show that a communica- 
 tion with a bronchus existed. 
 
 The Season;— Winter , 11 Summer 9 
 
 Spring 7 September 3 
 
 The Diagnosis:— y\'lnlii the history and physical signs pointed in 
 
moat instaacca to the presence of pus iu the pleurti, an exploratory 
 aspiration was made in twenty-live cases. Jn one of the patients 
 eiiipyoma was indicated by ccdeina and redness about a prominent area 
 at one i>art of a didl half of the thorax. Four patients were admitted 
 for conditions as follows : 
 
 1. (774) Piscliaa-ging sinus having been operated on some monllis 
 before. 
 
 2. (1150) Discharging sinus along the trtick of tiae aispirating needle 
 used some weeks before. 
 
 3. (153()) I'ersiptent sinus from operation two yeara previously. 
 
 4. (4348) Persistent sinus following aspiration six months before. 
 It is the tciiohing of all clinicians that when there is the least doubt 
 
 iibout the quality of fluid in the chest, or even about tho presence of 
 fluid that one should aspirate. But little, if any, harm can come of 
 this operation, and the diagnosis is made thereby very sure. Empyema 
 cannot be di'agnosed in season without resort to tliis means. 
 
 The Prognosis: — Tlie experience derived from these cases would lead 
 one to say that very much depomls upon the nature of the infection. 
 Tliis we think should be first as we believe it is, of the greatest 
 importi^ce. In the second place, the readiness or otherwise with which 
 the compressed or retracted lung returns to fill the cavity, marks the differ- 
 ence hetween a case of favorahle and rapid progress to complete healing, 
 and a protracted one, ending possibly in extensive rib resection with 
 deformity. 
 
 The prognosis of purulent effusion in a tuberculous patient, usually 
 a mixed infection, whether with or without pneumothorax, is very bad; 
 it has been in the«e cases but a question of time, the discharge nevnr 
 ceasing. A pneuimococcie infection, while comparatively benign, must 
 II be regarded in the light of the variability or the virulence of the micro- 
 
 organism. Oaw. Vierordt has recently reported four oaaes of pneu- 
 moeoooic empyema which had a fatal termination, in two of which 
 peritonitis due to the same organism vMs present. 
 
 While the first condition of prognosis relates to the patient's life, the 
 second condition has to do more with health of the subject aJid the 
 length of time of his return thereto. Of those patients who lived and 
 were under observation until healing was complete, that patient of whom 
 it is recorded that "•the lung expanded with a fit of coughing just as 
 the tube was being inserted" at tlie time of operation, made the shortest 
 recovery. She went out of the hospital in twenty days from date of 
 operation, healed. Where the lung was found far from the wall of the 
 thorax 4p.d (adherent, recovery was slow, forty, fifty, sixty, seventy, and 
 
fi 
 
 in one case one luindrcd and twenty days, wore spent before healing 
 was satisfactory. 
 
 TAULE SHOWING DURVT'ON OF ILLNESS IN RELATION TO OPERATION. 
 
 (Not inclmliiijj; tliose dead or wlio wt'iit out before recovery.) 
 
 Hist. 
 No. 
 
 No. of di.ys 
 before opera- 
 tion. 
 
 Date operation. 
 
 No. days after Operation. 
 
 8<)2 
 
 20 
 
 Auk. lOtlJ, 1H!'5. 
 
 20 
 
 llu2 
 
 48 
 
 Jan. 18th, 18!l(i. 
 
 ■'2 
 
 looli 
 
 40 
 
 .July 30th,' 18U0. 
 
 72 
 
 1557 
 
 28 
 20 
 
 
 52 
 
 l(t!)l 
 
 "o'ct.'i-iiYi'Lsim." 
 
 47 Recurrent empyema. 
 
 2084 
 
 21 
 
 May 27tii, 1807. 
 
 120 Pregnant, large pleur. cav., healed. 
 
 2150 
 
 14-10 
 
 .JlHlC, 1807. 
 
 225 Sinus slow in closing. 
 
 2205 
 
 20 
 
 Auk. 30tli, 1807. 
 
 20 
 
 2.577 
 
 10 
 
 Feb., 1808. 
 
 118 Heiunent empyema. 
 
 a 175 
 
 20 
 
 April 13th, 1895. 
 
 21 Went home with tube still in. 
 
 3575 
 
 2(i 
 
 Mav 25th, ISOi). 
 
 ■10 
 
 ai02 
 
 37 
 
 Juiio 8th, 1S09. 
 
 34 
 
 3707 
 
 L.-i 
 
 July 17th, 1899. 
 
 30 
 
 41.58 
 
 15 
 
 Jan. 2rKl, 1!X)0. 
 
 70 Small sinus soon closed. 
 
 4330 
 
 22 
 
 Feb. 19th, lilOO. 
 
 71 .'^mall sinus. 
 
 4348 
 
 539 
 
 Feb. 2(irh, 1001). 
 
 77 Empyema nectssltating extensive 
 
 4412 
 
 37 
 
 Mar. 20tli, 1900. 
 
 74 [resection 
 
 '4601 
 
 20 
 
 June loth. 1900. 
 
 48 
 
 The Treatment: — There is no case of empyema reeoi-ded in this series 
 in which cure followed a simple aspiration. It is interesting to note, 
 however, that in one patient (1150) the pleura was aspirated, more for 
 a di»agnosis than otherwise, after the patient had been ill for about three 
 months. The wound made by the exploring needle did not close. Pus 
 continued to discharge through this track for aboujt five weeks in such 
 quantities that tlie dressing needed to be changed from four to five 
 times daily. Shortly after the cessation of this flow the cough became 
 worse and pus was oxjieetoratod in large (cupful) qua.ntities. \Vlten 
 admitted to the hospital the dull area on tho right side was explored 
 under ether, with small and large needles, in the eighth and tenth spaces, 
 without finding pus. She made an uneventfid recovery. 
 
 In another patient (3475) in Avliose history, personal and family, 
 there appears no evidence of tubercidosis, and in whose pleural fluid 
 pnouraococci and also strcptocoeci were found, the te'jiration method 
 had a fair trial. lie was aspirated on March 26th, April 6th and 11th, 
 and on April 13th ho was operated on, a portion of the 9th rib being 
 resected; at time of operation, the lung could not be felt. He made a 
 rather protracted recovery. 
 
 Having but little faitli in the curative cfTcct of but simple aspiration, 
 the pleural elTiision in these cases, not admitted for closure of sinuses, 
 etc., was evacuated by rib resection and opening the sac. 
 
 In fourteen dases a portion of the 8th rib was excised, usually at the 
 
 1 
 
1 
 
 lower scapular aii^^Io or a little anterior thereto; in eight cases the 9th 
 rib; in one the ;tii and 8th; in one the 8th and 9tli; and in one the 9th 
 and 10th. In two cases no rib was excised, as in one of these the pus 
 pointed and was evacuateil by inck'on only when the patient was in 
 extremis; the other is (1150) already described. A rubber drainage tube 
 was used witli but two exceptioi's, when a silver tube was inscrtc<l. 
 Washing out of the cavity wtis adopted a few times in one case only. It 
 wlas a tuberculous cast\ originating as a pneumothorax, in which the 
 odor was very offensive. No untowsml effects followed this process. 
 
 A solution of cocaine was used in one case of rib resection; all other 
 eases wore operated on under gencn-al anaesthesia, induced by ether or 
 chloroform. 
 
 Fatal Cases;— Four patients died in the hospital and ^ fifth died a 
 few months after going lionie.* The percentage of deaths, then, in these 
 cases, so far, may be put do^vl^ as IG. Of these five, two were tuber- 
 culous, the sinus resulting from the opoMion never healed. The 
 patients were the sTibjeets of well marked phthis-is. One was the 
 victim of a double empyema due it would seem to a streptococcus 
 infection, and one, an old patient aged GG years, succumbed shor':ly 
 after an incision was made into the pleural sac whicli contained foul 
 smelling gas und pus. Then case of F. N., No. 3571. whore appcndi- 
 <'itis and poriionitis complicated the empyemic condition, completes 
 the number. 
 
 Considering the gravitv ■" those rtxscs we tliink the results may be 
 put down as very good . -ed. Where a simple infection with the 
 pneumoooocus was found, no deaths are recorded. 
 
 1. (.T).'?2). ;. A., a't. (1(), 111., was taken ill May 1st, 1S!)0, witli pain in lower part 
 of rifi;ht thorax. lie remained at work till May Ii4th, when lie took to heth Dnlness, 
 <liniini,sliecl hreathin.ii and .swellinji from 7th rih downward on I'iuht side, wer(> tlie 
 ehief sij^ns made ont ; lieart dulness could not he distini.'ui.shed. Juno l.")lh, incision 
 made over swclliivj near right costal marjjin, foul sniellinfi gas > scapiid and limits 
 of the cav'ty were not ascertained. A ruhher drain was inserted when pus flowed 
 on coughing only. 
 
 On 17th, ISth and 20th, attempts were made to localize the pus. punctures heing 
 made in 8tli and !)th spaces hut without result. Patient died 20th .Tune, 1.45 p.m. 
 (No note of bacteriological examination ; post-mortem and cultures, not nuide.) 
 
 The clinical history in this case is obscure, the finding suggests 
 rather a latent localised pyopneumothorax. 
 
 2. (3571). r. N., a't. ;{7. (See chief facts in this case under Bacteriology.) 
 
 3. (1S5.5). A. Ti., 'ii't. '20. In A i, gust. 1890, patient sutlered from right sided 
 pleurisy, and on Jan. 10th, 1897, conijilained of pain in left side, cough, shortncHs of 
 
 * Another patient died a few days after leaving the hospital, 
 culous case. 
 
 His was a tuber- 
 
8 
 
 breath, fever and sweating. Feb. Uth his right pleura was aspirated and one ajad a 
 half quarts of pus were withdrawn. Feb. 6tli, over a slightly bulging area and 
 without anjvsthesia, the Otli intercostal space was incised and a metal tube inserted ; 
 Fob. 15th tube removed and li inches of 9th rib excised in postprior axillary line to 
 secure better drainage. 
 
 Patient succumbed June 4th. Cultures gave streptococci in pure growth. Post- 
 mortem— Ulcerative Pulmonary TubcrcAi'osis ; Tubercular Ulceration of Epiglottis 
 and Intestines ; Adhesive Pleuritis of right side ; Intersticial Myocarditis. 
 
 ■t. (4454). L. M., iBt. 12, was taken ill about Jan. 2oth, 1900, with what was 
 regarded as pueumoMia of left side. She was ill for four weeks, then she improved 
 for a whili'. On March 24th it was found that there was tenderness and fulness 
 below the left nipple, her general condition having recently failed. 
 
 April 4th, pus was demonstrated by aspirating needle ; two days later resection 
 of 8th rib below angle of scapula, gave exit to a large quantity of yellow pus. 
 Some days later, however, the discharge lessened, and on this account it was decided 
 to resect n portion of the 10th rib, thus opening the cavity at its lowest level, April 
 12th, ana a tube was inserted. The patient's condition continued extremely bad ; 
 fever, restlessness and dyspna'a characterising it. She succumbed on April 19th to 
 a double empyema. Bacteria, streptococci. 
 
 Post-mortem— Bilateral empyema, numerous pockets of pus ; collapse of both 
 lungs. Bronchitis. Some pulmonary interstitial changes. 
 
 When we review the tables showing the length of time required to 
 complete the cure of these patients, one naturally asks, whether any 
 better method than those adopted can be devised by which the retracted 
 and adherent lung may be released and tallowed to fill the pleural sac. 
 We think yet earlier reeo^piition of an empyema is the first step, then a 
 prompt evacuation of the pus seems indicated. Theoretically, the use 
 of the valvular drainage tube that keeps the pleura a closed sac, so far 
 as atmospheric pressure is concerned, appears to one as a means of help- 
 ing toward greater lung expansion. Nicholas Senn suggests laspirating 
 the chest as a means of securing pulmonaiy expansion, a day or two be- 
 fore the operation which admits air. Can not something be done in 
 these cases where adhesions src firm and the lung retracted ? Perhaps 
 Delorme's operation or some otlier new operation for breaking down 
 the pleural adhesions «nd stripping the lung of its contracting fibrous 
 Covering, may give more satisfactory results. 
 
 The BacferioJogij : — Jakowski states that every form of pleural in- 
 fl'a.mmation is of bacterial origin, although one does not always succeed 
 in demonstrating the l)acteria in the exudate. Negative results in the 
 examination of pleural effusions are frequent, and especially so in those 
 of the serous of sero-fibrinous form. A. Fracnkcl says, in summing up 
 his article on the baoteriologidal examination of puirulent pleural 
 effusion, that when in such an exudate, the microbic examination of a 
 largo numbea* of preparations is negative as well as the cultures, one 
 m(ay conclude that the condition in the highest probability is of tulier- 
 culous origin. 
 
9 
 
 In our series of thirty cases, examinations of the pleural effusion were 
 made in twenty-three with the following results : — 
 
 Miuro-organisma. 
 
 Frequency . 
 
 Pure. 
 
 Mixed. 
 
 Sureptococcus . . 
 
 Diplococcus Pneumonia;. 
 Staphylococcus 
 
 7 
 
 
 
 
 4 
 
 4 
 
 4 
 1 
 1 
 
 .. .... 
 
 3 : i. Staphylococci. 
 
 ii. Pneumococci. 
 
 iii. Tubercle Bac. 
 
 f2 : i. Streptococci. 
 
 t ii. B. Coli Com. ct Staphylococci 
 
 Bacillus Ramosus 
 
 Bacillus Pyocyaneus 
 
 Tubercle Bacillus 
 
 Bacillus Subiilis 
 
 2. Streptococci : Diplococci Pneuni 
 
 
 
 
 
 1. Streptococci. 
 
 Sterile 
 
 
 
 
 
 
 The two main features as shown by this table, which may be em- 
 phasized, are the comparative frequency of staphylococci and the rarity 
 of the diplococcus pncirnionife. 
 
 From the clinical history, one is clearly justified in including thirteen 
 of these cases under the class of metapneumonic empyema, althoiLgh 
 the bacteriological findings do not correspond in every respect. The 
 pleural efftision Avas examined ir eleven instances and in but four was 
 the diplococcus lanceolatus found alone, once it was found with staphy- 
 lococci and the colon bacillus. In two cases streptococci were present; 
 staphylococci were found in three cases, once alone and twice associated 
 with the colon bacillus; two cultures proved sterile. 
 
 Tlie following table presents at a glance the metapneumonic cases 
 with those also in which ihe pneumococeus lanceolatus was found and 
 where a history of pneumonia was not clear : — 
 
 Case Report 
 
 No. 
 
 Age. 
 
 Month . 
 
 Cultures. 
 
 Results. 
 
 1.520 
 
 9 
 
 Admitt 
 
 ed for persistent sinus 
 
 2year.s. 
 Cured. 
 
 1691 
 
 9 
 
 Sept. 
 
 No cultures. 
 
 1102 
 
 5 
 
 Dec. 
 
 Diplo. Lanceo. 
 
 Cured. 
 
 2084 
 
 20 
 
 May 
 
 Sterile. 
 
 Cured. 
 
 20! K) 
 
 8 
 
 April 
 
 Staphylococci. 
 
 Cured. 
 
 22(i.5 
 
 2 
 
 Aug. 
 
 Staphylococci et B. Coli. 
 
 Cured. 
 
 2720 
 
 46 
 
 Jan. 
 
 Diplo. Lanceo. 
 
 Cured. 
 
 3707 
 
 8 
 
 .July 
 
 Sterile. 
 
 Cured. 
 
 4330 
 
 6 
 
 Feby. 
 
 Strepto. Pyo. 
 
 Cured ; Small sinus. 
 
 4412 
 
 3 
 
 Jan. 
 
 Diplo. Lanceo. 
 
 Cured. 
 
 44.54 
 
 12 
 
 Jan. 
 
 Streptococci. 
 
 Death double empyema. 
 
 4601 
 
 23 
 
 May 
 
 Diplo. Lanceo. 
 
 Cured. 
 
 .3571 
 
 37 
 
 May 
 
 f Diplo. Lanceo. B. Coli Com. 
 1 Staphy. Aur. and Alb. 
 
 Death. 
 
 3475 
 
 22 
 
 March 
 
 Diplo. Lanceo. Streptococci. 
 
 Discharged ; tube in. 
 
 rt will be seen from the table that but six cases gave evidence of the 
 presence of the diplococcus lanceolatus, and thirteen are of the meta- 
 pneumonic type ; clinically, we thus have a positive bacteriological re- 
 
10 
 
 suit in only 45 por cent., supporting tlie view that the diplococcus pneu- 
 monia} was active in producing the empyema. 
 
 This view is now well established ; the percentiigc in our cases how- 
 ever falling rather below tliat of other observers. It may be that as 
 some would account for tlic sterile cases l>y the suggestion of the deatli 
 of the organism of whatever form, so the same suggestion might huvc 
 equal, if not more, force as applied to the diplococcus lanceolatus. 
 
 All cases of pneumococciis infe<^tion terminated favorably, Avith one 
 exception. In tliis connection it may be well to review the chief points 
 in the history of this case : — 
 
 F. N., ivt. 27, was taken ill about the 1st of April, 1899, with Roneral pains, 
 thoracic an<l alidoniiniil, associiUed with some cliarrlia'a. A few clays later lie hail 
 coush, blood t insed expectoration and definitely left sided thoracic (axillary) pain, 
 aggravated by cough ; ho had also some sweating at night. 
 
 On April 19th, over two weeks after theonset, he experienced a sharp pain in the 
 right iliac region followed by tenderness and vomiting. The history thereafter 
 until his admission is not recorded. 
 
 When admitted on May 22nd. the left chest was aspirated and pus containing 
 the diplococcus lanceolatus was withdrawn ; the chest presented a bulging on the 
 left of the 3r(i, 4th, 5th and 7th intercostal spaces, with a faint trace of cedcma at 
 one part. 
 
 Under ether, the patient underwent a double operation for empyema and 
 peritonitis. The appendix was gangrenous at the tip ; there was an omental abscess 
 and a considerable amount of pus in the lower part of the abdomen. The pus from 
 the pleural cavity is described as thick with numerous fibrinous masses. The walls 
 of the pleural sac could not be reached by the exploring finger. The pus from the 
 peritoneum contained the bacterium coli ; that from the chest at time of operation 
 is reported containing staphylococci. 
 
 The history of this case suggests a general infection manifest in gen- 
 eral pains, diarrhoea, etc., and a primaiy localisation tat least of that in- 
 fection in the lungs, Mith bronchitis, pneumonia of what form we cannot 
 say, and pleurisy of purulent type due to the diplococcus pneumonia;. 
 Upon this followed signs of peritonitis. 
 
 Concerning the results found in the bacteriologidal examinations 
 made in these cases, it may be said that some dotibt must remain a^ to 
 the exact relationship which the bacteria bear to the production of pus. 
 This applies especially to the forms of, sHaphylocooci, the bacillus coli 
 com. and the bacilhis pyocyaneus, ramosus and snbtilis. 
 
 We have in this series but three cases occurring in tuberculous 
 patients, i.e., patients in whom tuberculosis is undoubted. In one of 
 these the eulttires showed pure streptococcus growth, no tubercle bacilli 
 were found in the pleural effusion. The others were the subjects of 
 pneumothorax with shrunken and intim'ately adherent Itmg. 
 
 The examinations for tubercle bacilli Avere positive in one case on two 
 occasions by two observers, while in the other there is no record of a 
 test having been made. While it is rare to find tubercle bacilli in cases 
 
1( 
 
 oi' empyeinata in tuberculous subjects, yet where u pneumothorax ex- 
 ists one can readily understand how nuicli more likely one would be to 
 secure a positive result in examinations for that organism. We may 
 note in passing, too, that among these cases there is one which shows 
 how 'an empyema in tuberculosis may origiuate in a pim'e streptococcus 
 infection. 
 
 ■'. the four cases of i)urulent pleurisy, staphylococci were found alone. 
 In one of these one need not wish for a more typical history of lobar 
 pneumonia than is to be found in this case. There was crisis on the 
 ytli d'ay and afte/ *n-o or three days the teniporature rose, and for five 
 weeks ran a septic course. JL is recorded that in the act of exploring, 
 air escarped; yet at the lime of resection of the rib some days later no 
 evidence of pneumothorax was detected. 
 
 The role played by this micro-organism in the c^-'se of empyema is 
 yet very uncertain. Fowler considers it as still doubttul whether it 
 should be regarded as a causative agent, ami Xctter remarks upon the 
 rarity of its being found alone. That it may render purulent a serous 
 or sero-llbrinous fiuid is admitted, and the recent c*ases recorded by Lop 
 land Monteux confirm this teaching. 
 
 Many regard an infection with staphylococci as far more common in 
 tuberculous patients. Yet in reviewing tlie histories of these patients 
 so infected, but little if any evidence is forthcoming to show that these 
 were tuberculous subjects. 
 
 The bacillus ramosus and the l)iu-illii8 pyncyanous were found in one 
 case where some weeks before 'about eiglity ounces ol' clear fiuid had 
 been withdrawn. In this case a sinus piu'sisted and fluid discharged 
 along the track of llie cxploratoi'y needle. 
 
 The bacillns subtilis was found in one case. Tlie patient's chest had 
 been 'aspirated uiuler very unfavoural)le cireumsitances to relieve the 
 ui'gcni dyspiKiM some days licforc; the I'ib was excised. 
 
 'I\> l)i'. .lanu's I Jell and Dr. (laiiDw. under whose care these ca.«e8 
 (iiiaJly cauu', I a\n greatly indebted for the ])i'ivilege of making this 
 study, and 'also to llie memlicrs of IJic Resident Medical Stall who luive 
 so kindly assisted in uiakiiiL;' the analysis of the reports.