Especially is an incision necessary in cases where numerous punctures have been necessary to find the pus. It should be made where the needle is and before it is withdrawn. A groove may be made in the needle of the aspirator, as suggested by Kebbel, so that the blade can be started from this exact point as guided to the pus by the groove. All such incisions should be near the upper border of a rib.
There arc five classes of cases in which surgical interference is to be considered: 1. Large cavities in which the lung, fastened to the vertebral column by thick false membrane, is entirely and permanently collapsed. In these eases the operation is useless and dangerous.
2. Large cavities in which the lung, though condensed, still preserves a slight vesicular murmur. Intervention is then sometimes useful, particularly in young patients and when the cavity does not extend beyond the third rib. 3. Cavities from eight to twelve centimetres in diameter; these present the most favor able conditions for cure. 4. Simply fistulous tracts of greater or less length; if short and straight, the results will probably be good; the prognosis be comes less favorable when the fistuhe are long and tortuous. 5. Cases in which there are moderate-sized cavities with fistulous tracts communicating with them; in these the prognosis is favor able. Bouilly (Revne Chin, Apr. 10, 'SS).
The method of simple incision in the intercostal space parallel with the ribs has been sufficient often to allow a drain age-tube to be inserted, and in this way many have found that the resection of ribs is unnecessary.
Free incision when done early is very successful; the removal of a portion of Ft rib iA never necessary in acute eases, and a fatal issue at any age is rather a. result of the neglect to recognize the true nature of the case than of the op eration itself. Lewis Marshall (Lancet, Dec. 21, '95).
Below the age of 23 it is unnecessary in empyetna to remove portions of ribs, but above that age it is essential in or der to insure contraction of the abscess cavity. In urgent empyema it is best to use no chloroform, but to freeze the skin with chloride-of-ethyl spray. In pa tients above 23 portions of ribs may be removed whenever the breathing is suf ficiently relieved to bear chloroform. J. C. Renton (Practitioner, Jan., '96).
Simple incision of the raeotonay, may be employed, the site of the incision being determined according to the position of the collection of pus. An opening iu the lowest part of the pleural cavity is not the most suitable. It, is not advisable to wash out the cavity, at the time of operation at all events; such a procedure is not devoid of danger. The more efficient way of
treating an empyema, especially in chil dren, is to incise and remove a portion of a rib. A. Primrose (Canadian Pract., Afar., '90.
Empyemata healed by expansion of the lung, ascent of the diaphragm, and con traction of the chest-wall. In all recent cases there is more or less complete re-expansion of the lung on the with drawal of the pressure which has been exerted by the fluid. Full expansion in the lung should, therefore, be main tained at the time of the operation. .1. E. Winters (Prac. Med., Mar., '96).
Valved tube successfully used for draining the pleural eavity after incision in empyema, with the object of prevent ing the falling in of the chest-wall and diminished expansion of the lung. W. Af. Dutton (Lancet, London, Feb. 6, '97).
lieport based on seventy-live eases. observed chiefly in St. Mary's Ifospital for Children. ht simple CaSVS the treat ment was as follows: Excision of ab011t 10»C and one-half invites of the seventh or eighth rib in the posterior axillary line; light ether amrsthesia is usually employed; the purulent eoagula are re moved; short rubber tubing. cut partly across, doubled and held by large safety pins, is iised for drainage; ablindant 4gatize dressing. is applied and changed when saturated. If the patient's von dition contra-indicates general anzesthe sia, an incision into the chest may be made between two ribs under ericaine nutestlie.sia. Aspiration is only used to give temporary relief to patients who are in great distress from the pressure of the fluid, or temporarily to relieve the second side of a double empyema after the first side has been opened. The patients are allowed out of bed as soon as practicable. and the expansion of the lung is encouraged by forced expiration. irrigation is only used where there is a foul-smelling discharge from necrotic lung-tissue. Secondary operations are not done until good opportunity has been given for healing—usually three or four months should have elapsed after the primary operation—and if there should have been no noticeable improvement for a month. In the sec ondary operation the expansion of the lung should be encouraged by incising. stripping. back, and, if necessary, re moving- portions of the thickened pul monary pleura. The examination of forty-four cases at long periods after operation indicates that reeovery is usu ally complete in the simple eases, and that there is surprisingly little deform ity in most. of the severe eases. Dowd (.)ledical News, Sept. 13. 1902.).