TUBERCULAR ElIPYEIIA. — A large proportion of the cases of empyema are essentially cases of cold abscess, or, more properly, tuberculous abscess. In these, free incision, free drainage, and excision of a rib are required. Park has resorted to scraping with the sharp spoon, and in some he has cauterized the diseased sur face with a 50-per-cent. solution of zinc chloride. In several cases death would have occurred had it not been for some such radical operation.
In tuberculous cases radical operation indicated—thoracotomy with resection— if exploratory puncture show bacteria of suppuration. If there are no bacteria of suppuration, aspiration advised to relieve pressure and allow the lung to expand. If the case is of long standing, and the compressed lung is inexpansible, palliative measures are indicated. Baum ler (Deutsche mcd. Woch., Nos. 37, 38, '94).
Tuberculous purulent pleurisy has been cured by thoracentesis followed by injections of corrosive sublimate and boric acid through the same needle (or cannnla) of a Dieulafoy or Potain as pirator.
To summarize the treatment of ena pymna, the following propositions seem tenable:— 1. Empyema is best prevented by promptly evacuating all considerable in flammatory effusions.
2. In the diagnosis of these effusions, by means of exploratory aspiration, the skin should be punctured by a tenotome at the point where the needle is to be driven in.
3. Serous effusions are best evacuated by aspiration. If they reaccumulate after the third evacuation, they should be subject to continuous siphon-drainage, the puncture being made by a small tro car and cannula, the latter being of such size that a small drainage-tube may be • slipped through it.
4. Recent empyemata- are best treated by continuous siphon-drainage, the tube being introduced through a cannula of at least the diameter of the little finger.
5. When, because of a narrow inter costal space or because of constant block ing with fibrinous material, siphon drainage thus provided is inadequate, an inch of one of the ribs (usually seventh or eighth) should be reseeted, and a drainage-tube the diameter of the thumb should be used.
6. When the conditions are such that it is obviously impossible for the lung to expand under the influence of siphon drainage and respiratory exercises, De lorrne's operation of stripping the pseudo membrane from the compre,ssed lung should be attempted.
7. When Delorme's operation is im practicable, a resection of the ribs (Est lander) or of the chest-wall and thick ened pleura (Schedc), corresponding in extent to the size of the underlying cavity, is indicated. Edward Martin (Then Gaz., Aug. 15, 1900).
Decortication of the lung. In this operation the thickened pleura is re moved from a lung, which in conse quence of a pleural exudate has been more or less collapsed. It was first per sonally used in 1693. It is indicated for old empyemata, in which there is no tuberculosis of the lung and the patient has sufficient strength to withstand a major operation. It is a better opera tion than Estlander's, as by it there is a restoration of the function of the lung and a closure of the suppurating cavity.
The diseased pleural membrane is dis sected away —not only that which covers the lung, but that portion lining the wall of the thorax and covering the diaphragm. The operation should be made as thorough as possible, and to this end a large opening in the chest is necessary. It should be so made as to affinit of rapid closure after the opera tion, as this facilitates expansion of the lung, which is brought about by respira tory movements. Respiratory exercises should be employed in the after-treat ment. G. R. Fowler (Med. News, June 15, 1901).