EMPYEMA, OR PURULENT PLEURISY, is to be treated by free incision and drain age. A few cases in children get well after one or two aspirations, but if pus reaccumulates free drainage should at once be effected. If the exudation is very large it is wise to remove much of the pus by aspiration and effect free drainage a day or two later. Even in the most desperate cases free drainage should be resorted to.
In order that drainage may be free it is usually best to resect a portion of a rib. If the exudation is being thoroughly evacuated through the drain, the dis charge diminishes in a few days. The temperature should fall after the dis charge of pus. Should it not do so either the drainage is ineffective or some other disease is present. It is rarely, if ever, desirable to wash the pleural cavity with any kind of fluid. Complete drainage suffices even in fcetid cases; if fcetor remains, the drainage is ineffective and washing out does not help it. Further, injections of even plain water or normal saline solution are dangerous. There may be sudden syncope, or there may be an ulcer on the pleural surface of the lung through which the fluid escapes into the bronchi and causes great shock or suffocation by obstructing the smaller bronchi.
It is superfluous to wash out the pleural cavity. Personally it was found necessary once in 399 operations upon 250 patients. It is a serious and danger ous procedure. H. B. Bowditch (Amer. Lancet, Dec., '89).
Personal method of substituting salt solution for the effusion of pleurisy tried in 52 cases, all followed by marked re lief and prompt recovery. Thoracentesis is first performed, and as the effusion is gradually aspirated it is replaced by physiological salt solution, which pre vents the collapse of the organs into the empty pleura, while the solution is gradually absorbed and exerts a general tonic and local antiseptic effect. Lewas chew (Therap. med. Woch., June 2S, '96).
The so-called incurable cases of puru lent pleurisy can usually be cured by the siphon, as recommended by Revilliod, of Geneva. The suction of the valve
causes expansion of the lung, while the continuous aspiration renders washing out of the cavity less necessary. C. G. Cumston (Boston Med. and Surg. Jour., Nov. 22, '96).
Value of treating cases of empyema, after operation, by submerging the body of the patient in a bath of warm water emphasized. The force of the inflow of water with each inspiration is much greater than that obtained by means of any ordinary irrigator, and expiration drives out many tough, stringy masses which had not been affected by irriga tion previously employed. The bath should be given at a temperature of 100° F., and the water should be ren dered aseptic by previous boiling. In some cases an antiseptic may be added. The quantity of water should be suffi cient to reach a few inches above the wound, and the child should be kept in it from ten to twenty minutes, until the water, with each expiration, returns clear. Adams (Archives of Ped., Aug., '97).
Of 56 consecutive cases of empyema operated upon by primary exsection of a rib, 13 died: a mortality of 33 per cent. Sixteen of the deaths, however, were from causes which apparently had no connection with the surgical proced ure. Scharlau (Archives of Ped., Aug., '97).
Propriety suggested of treating puru lent effusions occurring in pneumothorax in the same way as empyemata, even where the pus is not foetid, as tending to the prolongation of life and the greater comfort of the patient. In foetid effusions there is no choice; such should certainly be evacuated and drained. As for the serous effusions, there are good grounds for thinking that the perfora tion in the pleura has become sealed up; the removal of a portion of the fluid need not be looked upon as inadmissible. Finlay (Brit. Med. Jour., Jan. S, '9S).
The presence of air does not affect the principles of treatment in case of fluid in the pleural cavity. West (Med. News, Jan. S, '9S).