Treatment.—The satisfactory results obtained by Murchison in the treatment of pleural effusions by incision would seem to point to the surgical treatment of many cases, before empyema has set in, as a valuable measure. For this pur pose also the use of blood-letting, blis ters, and medication may be employed to abort the inflammatory process suffi ciently early in the prog-ress of pleurisy that an empyema need not follow. Blis ters and purgation with salines and mer eurials should be actively employed, in order that the parts undergoing inflam matory changes may be relieved of the fibrinous element of the blood, tending to retard resolution. Opiates, and espe cially the camphorated tincture of opium, may be used to relieve pain and hasten the resolution. Carbonate of am monia, turpentine, and digitalis are all also of value.
[I would strongly urge, especially in children, of an early recourse to the fol lowing preparation:— Hydrargyri chloridi mitis, 1 grain. Pitlv. ipecac. et opii, 10 grains. Qui»inte sulphatis, 10 grains.
Ptilv. eampliorce, 1 grain.
.M. Divide into powders No. x. Sig.: One powder every two hours.
In adults:— 136 Ifydrargyri ehloridi mills, 6 grains. Pulv. ipecac. et opii, 30 grains. Quininw sulphatis, 30 grains. Pulv. camphorce, 6 grains.
M. Divide into capsules No. xij.
Sig.: Take one every two hours in day-time, and two capsules at intervals while awake at night.
This should be followed with two tablespoonfuls of oil and one teaspoon ful of turpentine.
The bowels are thus emptied, and the turpentine has a beneficial effect upon the bronchial tubes.
I have seen many cases of incipient pleurisy aborted in this way, and the most alarming symptoins of high tem perature and rapid respiration controlled. J. Mc:FADDEN GASTON, JR.] The full and free evacuation of the pleural cavity is not expedient when the pressure has been great, and the lung is pressed upon in such a manner as to displace the heart. In such a case the o-radual evacuation by aspiration is pref erable.
Aspiration should be limited to one or two trials, for empyvinas of the meta pneumonic type, as seen in children and adolescents. For all other eases free in cision and drainage are indicated. Ran solioff (Ohio Med. Jour., Aug., '93).
Cases in which pus contains large masses of lymph, or pus, thick and creamy, heal best. Offensiveness of pus does not much influence healing. Delay is advisable when there is negative press ure in the pleura. and when expansibility of the lung and contact of layers of pleura can be induced by simple aspira tion and cure effected. Otherwise harm will result from dela.y. Resecting a piece of rib, free incision of pleura, and con tinuous drainage indicated. Pollard (Brit. Med. Jour., Nov. 2, '95).
In children chloroform is the prefer able anmsthetic, but deep narcosis is contra-indicated, owing to the danger of pus being drawn into the other lung from a ruptured bronchus. In adults with general empyema two inches of the seventh and eighth or eight and ninth ribs in the posterior axillary line should be resected. In children the same lerigth
of the seventh rib. Simple incision, with our present knowledge, is rarely ad visable. The operation is indicated as soon a.s diagnosis is made. Irrigation of the abscess-cavity with bichloricle so lution, 1 to 5000, or carbolic acid, 1 to 100, is indicated, unless drainage is per fect and no sepsis. is present. In chil dren the solutions may be weaker. The mortality from the empyenta proper was 15 per cent. in personal cases. Earlier and more radical treatment would re duce it to one-half that proportion. J. A. Hartwell (Med. News, July 13, 1901).
The best method. of securing counter pressure and antisepsis at the same time is by the injecting of a saline solution through the one tube Injections of peroxide of hydrogen in 50-per-cent. solution puts a rapid stop to the formation of pus in the thoracic cavity, and has been strongly recom mended as an injection in empyerna whenever injections must be used. Edi torial (Jour. Respiratory Organs, Sept., '89).
The safest method of procedure con sists in replacing gradually the pleuritic exudate by an innocuous fluid: a solu tion (0.06 or 0.07 per cent.) of sodium chloride (common salt). After with drawal of a small portion of the exudate the same quantity of salt solution is introduced into the pleural cavity. By repeating this operation several times, entire exudate may be replaced by saline solution. The injected liquid dis appears by reabsorption as fast as the lung dilates, and the consequences of a sudden diminution of the intrathoracic pressure need not be feared. S. Lewa chew (Times and Ilegister, Apr. 11, '93).
Immediate relief to syncope has been secured by the reverse action of the as pirator and the injection of the same fluid which has been drawn out.
The practice of aspiration in cases of empyeina has still a great number of advocates, and it is probable that an at tempt to evacuate the pleural cavity in this way is attended with good results when resorted to early in the progress of suppuration.
The packing of the cavity with iodo form or plain gauze in order to secure drainage has been advocated by Ranso hotT, Laplace, and other surgeons. The experience of most practitioners is that a pleural sero-fibrinous effusion.does not often degenerate into a purulent collec tion, and many attribute the pus to the failure of antiseptic precautions in as piration.
In several cases the following points of interest were noted: Although the pleura had been full of fluid for twelve months, rapid re-expansion occurred. After thirty-seven tappings the fluid be came as clear as at first, in spite of admittance of air. The advice given in text-books to abandon paracentesis after two or three trials should be modified. There is no risk if the operator is careful to keep the instrurnents aseptic. West (Brit. Med. Jour., Apr. 27. '95).