The duration of the suppuration which follows varies considerably. In favorable cases it will cease in some weeks and leave almost normal conditions; in other cases again it may last for years. This depends almost entirely upon the stage in which we have operated: the earlier this is done, the quicker will the lung re-expand and the suppuration be ended, while in an empycma of long standing the compressed lung will lose its power of expansion and will furthermore be fixed in the wrong place by rigid adhesions.
Thoracotomy should therefore always be done as early as possible and should be combined with the resection of a rib.
In children with a strong constitution and who have passed the second year of life all this is easy; younger children who hive been weakened by the preceding pneumonia may be able to survive the opera tion, but they stand the long-continued. suppuration and the consequent loss of liquid very badly. We have always had the impression that they wither like a fruit which has been cut (see Atrophy).
For these cases we have adopted another method which we would like to call (lie linear puncture.
We insert an exploratory needle about two fingers' width below the upper border of the pus and aspirate the pus which is above this with a syringe. The next clay we aspirate in the same intercostal space. When we no longer find pus, we go down one intercostal space, and so on, until several punctures in the deepest intercostal spaces fail to bring pus. The number of punctures required varies between six and six teen (in twelve cases treated by this method); in one case we had to resort to a resection of a rib after all, owing to continuous fever; this ease ended fatally after long-continued suppuration (streptococei and diplococei).
Of our twelve eases, three with pneumococcus empyema on both sides made a full recovery, and this method has given us splendid results in desperate cases.
In a very poorly nourished child of four years with double em pyenut after pneumonia we succeeded in emptying the chest within one month, as we also did in the other two cases, and we succeeded with this method much oftener in young children than with the more radical operations.
This method is superior to Biilau's siphon drainage, Fig. 142 (see Feer, vol. iii), because by it we remove only a little pus at a time and allow the lung to follow gradually, while a total removal of the pus must he followed by so much more rapid an exudation with a continuous and tremendous loss of liquid into the vacuum if the lung should not be able to follow at once, the same as it does in early resection. We consider the avoidance of this loss of liquid and the creation of normal conditions of pressure as well as of osmosis one of the best recommendations in favor of our method.
In ernpyemas of long standing with suppuration of several years we must examine existing conditions with the aid of the skiagram.
In one case of a fistula which persisted for seven years after the resection, we were able to diagnose a costal sequestrum on t he radiogram several centimetres in length, the removal of which finally ended the suppuration.
Schedc's thoracoplasty, with the formation of a flap and the depres sion of the wall of the thorax, is an operation of such a magnitude as not to be applicable in children, nor is the peeling-out method of Del orme to be considered. The meth
ods of Simon-Kffster or Saubottin, who cut through several ribs to mobilize the rigid thoracic wall, arc preferable. Bayer recom mends the subperiosteal removal of several ribs in order to close the rigid pus cavity by the draw ing in of the thoracic wall.
Considering all the different methods on the basis of more than one hundred cases of empy ema in children, we would advise the following course of treatment: In older and stronger chil dren, early resection followed by conservative treatment, without washing out, at most application of the suction apparatus of Perthes to prevent the formation of a pneumot borax. (This apparatus consists of a suction bell which is fixed on the thorax by rubber valves; by pumping out the air from this we produce a slight nega tive pressure.) After the wound has elosed we institute respiratory gymnastics with suppression of the respiration in the healthy side of the chest; we let the patient wear an elastic belt which brings the shoulder of the well side nearer to the pelvis of the same side, and we thus not only aid the respiratory expansion of the diseased side of the chest but we also prevent the development of a cieatricial scoliosis.
We advise the linear punctures in children under two years of age or in those who are much reduced, and also in double empyema we avoid all major operations on account of their large mortality. • The examination o/ the pus will aid us considerably. Should we find but few bacteria, most of which lie intracellularly, then the abscess is "getting cold," and we will succeed with the linear puncture even in older children in a short time the fever will cease even with the first puncture, because it is caused principally by the reabsorption of the pus which is under high pressure. Should we find many bacteria, continu ously high fever, the exudation reaseending to its former height and the bacteria extracellular, then we will choose resection of a rib in stronger children. In smaller ones we might adopt Bulatt's permanent drainage, though we cannot recommend this popular treatment from our own experiences.
The after-treatment must work towards the prevention of deformity from scars by means of respiratory gymnastics, antiscoliotie measures, one-sided crawling and portative apparatus which have the same effect in a recumbent position.
The walled-off empyema is treated according to the same principles and it is usually carried out easier; exploratory puncture, which has to precede any operation, will guard us against topographical mistakes.
Tubercular pleurisy (see Schlos.smann, Tuberculosis, vol. ii) is rarer in children than in adults. The serous-exudative type will only he considered as a surgical disease when we let the aspiration follow the exploratory The purulent-exudative type is treated according to the rules we have laid down above for purulent pleurisy; we must bear in mind the unfavorable prognosis and the poor general condition and refrain from major and weakening operations (linear puncture, Billatt, thoracotomy with Lloyd's drainage tube).