EMPYEMA.
Immediate removal of a purulent secretion in the pleura is imperative even in the absence of all symptoms, chiefly on account of the risk of the lung becoming so fixed and bound down by adhesions that expansion may never occur.
In children the pus is commonly the result of pneumococcal infection, and aspiration of the contents may effect a permanent cure without resorting to a free incision. The needle of the aspirating apparatus should be inserted through the sterilised and anmsthetised skin anywhere in the mid-axillary line from the fourth to the eighth rib, selecting the middle of an intercostal space or close to the upper border of a rib. The fluid should be slowly pumped or siphoned out as the patient lies upon the sound side, with the head slightly raised. Should severe coughing occur the aspiration may be suspended without withdrawing the needle till the pulmonary embarrassment passes off. Should the fluid return a second tapping may be tried before resorting to incision.
In adults, whether the exploratory puncture proves that the empyema is pneumococcal or due to the influenzal or other pyogenic organism, a free incision should be made, unless when, owing to a very extensive collec tion of fluid, the heart is greatly displaced and there is much pulmonary embarrassment, a slow tapping may be done to relieve immediate distress, with the intention of opening the chest 24 or 48 hours afterwards.
The Operation by general will usually be neces sary; the skin having been previously sterilised, the patient is placed on his back and the operation is carried out partly from below, a high table if available being used. Since purulent accumulations are sometimes localised, or adhesions of the pleural surfaces may shut off or divide the abscess cavity, the surgeon should invariably before making the incision introduce the needle at the exact spot which he intends to incise. If this be done there need be little hesitation in the selection of a site; the best for most purposes is the sixth or seventh space in front of the posterior axillary line, or in the eighth or ninth in the line of the scapular angle if the ribs be not too close together. The incision should be free, and should run
close along the upper border of the rib for at least 2 inches; after the cavity has been entered the lips of the wound should be widely dilated by dressing-forceps, and after the evacuation of the pus the finger may be inserted, when this is possible, to break down adhesions and prepare for the insertion of the drainage-tube. This should be as large and stout as possible. and should have a flange or collar to prevent its slipping back wards into the cavity. It is often advisable to insert two such tubes side by side.
Resection of one or more ribs will be necessary if these are so close to gether as to prevent the insertion of a drainage-tube with walls of sufficient thickness to prevent the tube being nipped. Most surgeons prefer to resect a rib as a routine step at the beginning of the operation. There are several advantages obtained by this procedure. Thus it permits of the incision being made farther back and thus affords a better drainage ground, and the opening being larger the finger can be used to break down adhesions and large fibrinous flakes or masses can be readily evacuated through it. Aloreoyer, by deciding on resection the original incision, which should he about 3 inches, may he made directly over the rib and, its periosteum being divided, I" or 2 inches of the rib may be resected before opening the pleural cavity without dividing the intercostal artery. After incising the pleura the finger should be thrust into the opening so as to partially block it and retard the flow of pus, so that syncope or dyspncea may be avoided by a too sudden fall of intrathoracic pressure. After the evacuation of the purulent collection a large drainage-tube with a flange or a piece of rubber tubing with a large safety-pin fastened at its external orifice should be left in situ and covered over with several layers of antiseptic gauze or wool to absorb any further discharge, and the patient should be made to lie on the affected side.