After-treatment is conducted upon the general surgical principles applicable to any large abscess, the utmost precautions being taken to prevent infection of the wound or pleura by any germs introduced from without during the changing of the dressings. These may have to be replaced frequently during the first 4S hours, and at a later stage every or every second day. The patient should be directed to take deep inspira tions for several minutes at a time in order to assist in expanding the lung, or the simple spirometer may be used for this purpose. Irrigation of the cavity is seldom required and may he fraught with serious dangers if the outflow should become blocked. After the discharge has ceased to be come purulent, the tube should be removed, and the cavity and wound permitted to heal by granulation.
In cases where operation has been too long delayed and the lung has become permanently bound down by adhesions, and especially in empyemas of tuberculous origin where the pleura is greatly thickened a large un yielding space is left, which fails to fill up by granulation. the more serious operation of thoracoplastv is indicated; or this may be demanded in rare cases of failure after the ordinary resection method. The Est'ander Schede operation consists in the subperiosteal resection of several inches of a number of ribs (from the third to the seventh as needs he and removal of the thickened parietal pleura, periosteum and intercostal muscles so as to permit of the parietes falling in and obliterating the space. In very chronic cases where the lung is found to be firmly hound down in the vertebral groove its thickened visceral pleura will require incision and peeling off; Delorme peels off the thickened visceral pleura from behind forwards in order to secure as full expansion as possible of the collapsed organ. After the peeling forwards of as much of the thickened pleura as can safely he accomplished, the cavity is packed with antiseptic gauze and covered over with the large skin flap reflected in the first stage of the opera tion, the loosened pleura being secured to the margins of the skin wound.
Linenthal's new operation is a more rational procedure, and consists of a long incision through skin and muscle in the seventh or eighth space from the angle almost to the rib cartilage. by which means, with the aid of a special retractor or rib spreader the intercostal space can he widened to the extent of four inches, giving ample room for exploration of localised abscess, and by dividing the thickened exudate on the pulmonary pleura by the knife or scissors and the introduction of the fingers or hand the imprisoned lung may be freed so as to effect expansion and avoid the permanent deformity following the Estkinder method.
During the slow healing process after ernpverna operations the patient should as soon as possible be wheeled out into the open air when the climatic conditions are favourable, and a change to a warm seaside resort when practicable should he insisted upon. He should he fed on a dietary such as is indicated in the treatment of chronic phthisis.
Autogenous vaccine treatment is of value in some cases by hastening recovery, and is especially indicated when the lung has been perforated and where large quantities of pus are being expectorated. The c,ld sinuses left after the operation. especially in chronic tuberculous empye mata, often heal up completely upon resorting to the injection of Beck's Bismuth Jelly.
The older methods of Reyilliod. Fagg and Biilau by tapping and keeping up continuous siphonage through a rubber tube whose end was dropped into a basin of antiseptic solution placed under the patient's bed have given way to resection and incision : they are still occasionally employed in the treatment of pneumococcal empyema in children, but should be abandoned, though this siphonage method of once emptying the pleural sac in young subjects and then closing the punctured wound may be often advantageously resorted to instead of aspiration.